Ep. 37: Spillover Effects of the Pandemic with Harvard’s Dr. Ateev Mehrotra
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In the U.S. and Canada the public-health response to COVID-19 discouraged people from visiting hospitals or seeking care from MDs, prompting cancellations for childhood vaccinations, colonoscopies and mammograms. How will such decisions affect overall wellness? And what should we learn from these effects? To discover the answers, host Shaun Francis interviews Dr. Ateev Mehrotra of Harvard Medical School, who tracks large data sets of doctor visits. In public health emergencies, Dr. Mehrotra says, spillover effects “can have a larger toll than the actual thing that triggered that emergency.”
PULLQUOTES FROM DR. MEHROTRA:
“I've really had the focus of trying to look at the impact of the virus on non-virus-related care… I don't think we think enough about that, which is that people's response to the virus has led to people not getting care for stuff, [and] other problems. And that is going to compound the harm that the pandemic has had on the American population. We've already seen evidence of that.”
“We found that during that first, early part of the pandemic, we saw an overall reduction in roughly 50% of healthcare spending.”
“On the adult side, the things I'm particularly worried about are colon cancer, and the drop in colonoscopies that we had, as well as breast cancer and mammograms… The drop in visits and the reduction in healthcare that we've seen nationally and worldwide, is going to likely lead to increased exacerbations of those illness and a worsening of that disease. And so that's obviously also a substantial concern.”
“I think that we have ample experience from other public health emergencies that the this spillover effect… is sometimes much larger. I think [about] the example of the hurricanes that affected Puerto Rico. Obviously, some people unfortunately died from the hurricane and the damage. But in that particular case, the deaths that came from people who lost their homes unable to get health care, were way above and beyond the deaths that actually came from that hurricane. We see that in other public health emergencies, where infectious diseases and other things can have a larger toll than the actual thing that triggered that emergency. So this is not a new phenomenon. I think we have never seen it, at least in my lifetime on such a national scale, for such a prolonged period of time.”
LINKS AND HIGHLIGHTS
News stories mentioning some of Dr. Mehrotra’s research:
New York Times: Missed Vaccines, Skipped Colonoscopies: Preventive Care Plummets
Boston NPR: They’re Back: Harvard Study Shows Outpatient Visits Returning
Voice of America: The Doctor Will See You Now, But By Video Chat
Please subscribe and rate us on your favourite podcast platform. Eat Move Think host Shaun Francis is Medcan’s CEO and chair. Follow him on Twitter @shauncfrancis. Connect with him on LinkedIn. And follow him on Instagram @shauncfrancis. Eat Move Think is produced by Ghost Bureau. Executive producer is Chris Shulgan. Senior producer is Russell Gragg. Social media support from Emily Mannella.
Spillover Effects of the Pandemic with Harvard’s Dr. Ateev Mehrotra final web transcript
Christopher Shulgan
Eat Move Think executive producer Christopher Shulgan here. Preventive healthcare, it entails all the things that people do to ensure that they don’t get sick—and if they do get sick, they catch it early. That includes childhood vaccinations for things like measles, mumps and rubella. It also entails cancer-screening measures like mammograms and colonoscopies.
Chris
In the spring and summer of 2020, as coronavirus spread, rates of preventive care plummeted. What are the long-term effects? What happens to all those kids who didn’t get vaccinated? All those people who missed their cancer screening?
Chris
That’s what we’re investigating in this episode, which sees our host Shaun Francis interviewing Dr. Ateev Mehrotra, an MD and academic at Harvard Medical School who uses enormous medical insurance databases to track the way people are consuming their healthcare. Here’s their conversation.
Shaun Francis
Hi, Ateev. Welcome Eat Move Think listeners to our podcast today. We have Dr. Ateev Mehrotra from Harvard University Medical School joining us today, and we're going to delve into an aspect of the pandemic that, you know, we've touched on in previous podcasts, but want to dig in more today, and that's really the impact on preventive health, and really chronic disease as a consequence of COVID-19. And I want to dig into it, not just from a consumer perspective but also how is this affecting the world? Because I don't know that we always take this into account when we are very locally focused. So with that, I'm going to launch into it. How's this gone for you over the last several months as a physician and public health official?
Dr. Ateev Mehrotra
Yeah. So Shaun, I mean, it has been a crazy last six to eight months for obviously everyone in this world. For me, it has been a seesaw of changes clinically, going from early in April when I worked in the hospital to every single one of my patients having COVID, and having many of my patients die, unfortunately. To now, more recently, at least in the summer, when I was working in the hospital where we had very few. And it really felt like night and day in terms of that side of my life. And then obviously from the public health side, trying to understand what the impact of the pandemic has been on our patients has been such a critical issue. Um. But I've really had the focus of trying to look at the impact of the virus on non-virus-related care, because that's been a major concern for me. I don't think we think enough about that, which is that the people's response to the virus has led to people not getting care for other problems, and that is going to compound the harm that the pandemic has had on the American population. We've already seen evidence of that.
Shaun Francis
Obviously, we had the April-May severe lockdowns and, you know, I think, gosh, that was the maybe the first time that became an official public health intervention. And it extended beyond even normal businesses being shut down, we actually shut down healthcare. Had that ever been contemplated before?
Dr. Ateev Mehrotra
You know, certainly obviously, in very local circumstances, we've had lockdowns or also we've obviously had circumstances where through weather events, we've had certain areas of the country kind of shut down. But this on a national scale is something we've never seen. And as we all witnessed, you know, we all were in our homes, and the use of healthcare just plummeted across the nation, not surprisingly. Something I've never seen in my lifetime.
Shaun Francis
I guess part of it is, you know, like, literally hospitals were closed to non-COVID patients in some instances, and other instances, people chose not to come in for fear of getting COVID.
Dr. Ateev Mehrotra
The thing that we got very worried about, and I think we're seeing that impact already, is that patients for heart attacks, strokes, abdominal pain, appendicitis, all these conditions, which we know people were having, they were so scared to get care, they weren't coming in. You know, one doc—just as an anecdote said, you know, she was trying to encourage one of her patients to come in for chest pain, and she's—the patient was very, you know, point blank and said I'd rather die at home from a heart attack than come into that hospital. They were so scared of going in, understandably.
Shaun Francis
It seems at home deaths have increased. And the question is, is that because of somebody had COVID? Or is it because they didn't come in due to some other condition?
Dr. Ateev Mehrotra
Right. And that's the evidence that I have. So first, we have the evidence from the substantial reductions, very large reductions in people coming in for life-threatening problems. That obviously is a concern. And then we also have the death data, unfortunately, that's coming in. And that if we count the number of people who died of COVID, and then we see the number of people who died, the excess deaths are way above and beyond. Some of that is likely patients who had COVID that was undiagnosed. But I think, at least my hypothesis or guess is that the majority of those cases are patients who had a problem, they decided not to come in for care, and that led unfortunately to their demise.
Shaun Francis
I mean, maybe we should have foreseen this. You know, because I think isn't one of the tenets of public health to do no harm?
Dr. Ateev Mehrotra
Yeah. No, I think that we have ample experience from other public health emergencies that the this spillover effect, if you want to call it that, is sometimes much larger. I think I would just give the example of the hurricanes that affected Puerto Rico. Obviously, some people unfortunately died from the hurricane and the damage. But in that particular case, the deaths that came from people who lost their homes, unable to get health care, were way above and beyond the deaths that actually came from that hurricane. We see that in other public health emergencies, where infectious diseases and other things can have a larger toll than the actual thing that triggered that emergency. So this is not a new phenomenon. I think we have never seen it, at least in my lifetime, on such a national scale for such a prolonged period of time.
Shaun Francis
So there's obviously a linear relationship for people not seeking medical care and how that might affect your mortality. But you just touched on potentially too as in Puerto Rico, the devastation that something like that can cause and that might also influence mortality. So in this example, we have economic devastation. Has there been much research on how that might influence longer-term all-cause mortality?
Dr. Ateev Mehrotra
So we know that people who lose their jobs are less likely, understandably, to seek care, and that obviously very related to that is the loss of insurance. And so when we think about the impact of the economic impact, it goes above and beyond just dollars, it does flow on to, unfortunately, deaths. Here in the pandemic, one of the things that I think there's been a lot of interest and focus on is that so many people have lost their jobs. And if those people also lose their health insurance, that's going to exacerbate that. Early on in the pandemic, at least the data that we have and others have through July, luckily, is we have not seen a surge of uninsurance. I think that's because employers, others have been able to kind of use Cobra COBRA benefits and other things to keep their health insurance for that period of time. But now we're going into the fall, a lot of those unemployment cheques have obviously dried up, unfortunately. As well as, you know, the airlines and others are now laying off people more, and so we have the potential and at least my expectation is as we go into the winter months, we are going to see a surge of uninsurance, and that's going to exacerbate the problems I've already described.
Shaun Francis
What about the mental health toll? Is that calculable in terms of these, you know, lack of—well, maybe increased despair that might be caused with uncertainty in economic conditions?
Dr. Ateev Mehrotra
I believe the evidence is there, that there has been a huge surge in anxiety, depression, substance use, domestic violence, all from the pandemic. Some of that is obviously driven by the economic issues, unfortunately, as that's one player in this issue, but it also I think it goes beyond that. I think we've all felt, even for myself, luckily who still has a job and my family, you know, just the being in the home at all this time, the uncertainty, the election cycle, all of these things are compounding each other, and I think are leading to a lot of uncertainty, anxiety, and not surprisingly, those unfortunate issues of increased mental illness ,increased substance use. And you might have seen data on, increases in overdose deaths.
Shaun Francis
I have seen that. I've seen too, the developing world seems to be particularly impacted. So for example Africa, where they may not be as impacted by COVID because they have a younger population, you know, certainly are, through lack of vaccinations, and/or treatments, and/or sort of the major hit on their economy. I think the WHO might take that into account. Do we take that into account when we think about our overarching public health strategies?
Dr. Ateev Mehrotra
I think for those listeners, an issue that's front and centre for them is their schools. When we think about the schools, and the decisions that have been made about opening or closing or hybrid, all these terms we never even knew existed until a couple months ago for school, we've obviously focused on the virus and its impact and the risk for teachers, for students, their families, the community as a whole, but I think we've probably focused too much on those impacts, and not enough on the kind of theme of our conversation, which is the spillovers or those larger impacts. How is that affected our kids' education? And what is the long-term effect of having this loss of education? What is the impact on their social development? Something that's hard to quantify, so it's not easy to track on a New York Times website, but I think is obviously really important.
Dr. Ateev Mehrotra
What is the economic impact, as we're seeing women exit the workforce, because it's hard to have your second grader in Zoom school and having them, you know, working them through, and so that women are deciding to drop out of the workforce because they just—it's too much to handle. These kinds of spillovers, I don't think have come up enough in the conversation when we make that decision about should we have kids physically in person in school versus doing it remotely. And I think that's just one example of a larger societal issue that we don't typically think enough in that kind of public health strategy.
Shaun Francis
I mean, schools are an excellent example, because it is unclear how either the schools or public health are making decisions. I think Harvard might be partly closed at the moment. I have one son, for example, at Wake Forest University in North Carolina, and they're totally open except if the professor considers themselves at risk, the professor protects themselves. The professor beams into class. I have one son at Santa Clara University in California, and they're totally shut. And they don't know when they're coming back. Like, they literally don't know when they're going to open again. And you wonder, like, how are these decisions being made to your point? Is it all cause mortality? Is in the best interest of the kids? Is it—you know, something people get very disoriented with the decision framework.
Dr. Ateev Mehrotra
I think when we, hopefully soon when this pandemic ends and we look back at our what we did well, and what we didn't do well, I think this lack of consistency as you framed it is really very frustrating. Why did every school district, why did every university have to make their own personal decision, weighing the strengths and weaknesses of the evidence and make their decision based on that? And that doesn't make a lot of sense from a public health perspective because, you know, I get it that the caseload may be a little bit different and there are some local phenomena, but at the end of the day, the issues at hand were very similar. I shouldn't use the past tense, are very similar for every university, Santa Clara versus Wake Forest. And I often am—you know, what I see, you know, this is more anecdotal, but what it appears to be is a little more driven by politics. The fact that how people vote in that particular state or community is driving this decision should give us good evidence that this is probably not—the variation that we're observing was not rational, but rather driven by opinion. And that's not typically how we think we should make public health decisions.
Shaun Francis
And it's so interesting, because the politics—I think you're right, but it doesn't seem to have a party. It's more like in America it has a party affiliation, and especially driven by the election cycle, but when I look at other countries, so for example, I have one son in boarding school in England. I mean, it's just as controversial, to be honest, irrespective of, say, who the party in power is, you know, with respect to—the symmetry, it's political, but it's not necessarily ideological by party affiliation.
Dr. Ateev Mehrotra
I think it's a fair point. I think it's a fair point that you should push back that is not just Republicans versus Democrats, but rather—you know, I was reflecting on some work that had been done during the 1918 flu, and where there had been a huge backlash to wearing masks in San Francisco. And I think it was called the Anti-Mask League where they cornered the mayor and, you know, started protesting. That kind of thing would not be—it sounds very similar to what we're hearing in 2020. And so I don't know, I think you're right to push back a little bit that these kind of phenomena are not new, and we've seen them previously in our history, also.
Shaun Francis
It's remarkable how it's come full circle. Let's talk about preventive health care. From your data just talk about what does your data show about people's preventive-care decisions through the pandemic up until now? Maybe you might speculate, you know, where we're going?
Dr. Ateev Mehrotra
So Shaun, you might be aware that we have been, in some of our work, what we have been doing is been tracking across 50,000 clinicians across the nation from all these different specialties. We've been lucky enough to have access to some scheduling data, which has allowed us to almost have a real-time look on how much care patients are receiving, at least in the outpatient setting, you know, clinics, and so forth. And we've been looking at both in-person visits as well as telemedicine. And the pattern that we've observed across those different providers is that early on in the pandemic, this dramatic drop in care, during the periods of shutdown orders. And so, you know, preventive care has a lot of different components to it. We don't have yet the data more recently, but at least through the middle of the summer, the data that we had is that during that substantial drop in visits and care in general we saw, not surprisingly, corresponding drops in all aspects of preventive care, both from vaccines for kids, well child visits for kids all the way to colonoscopies and mammograms for cancer screening for adults. And so all of those different components of preventive care were reduced. Obviously, there's going to be, hopefully in the next couple months, there'll be a bit of a bounce back as we address some of that pent-up demand, But I think the concern is that in some cases, that care that didn't happen will never come back.
Shaun Francis
Are we going to miss cancers and heart disease as a consequence?
Dr. Ateev Mehrotra
Likely Yes.
Shaun Francis
And do you think we will shut down healthcare—I mean, for lack of a better term, again? Do you think we've learned our lesson now, and won't have such a sort of blunt instrument with respect to how we're dealing with this going forward?
Dr. Ateev Mehrotra
We can probably learn from the experience we saw in Florida, in Texas and Arizona from just a couple months ago when cases surged there. In our data, we did see a drop in overall visits and an increase in telemedicine when cases were quite high in the community, but nothing to the degree that we saw previously. And so it was, if I remember right, just a four or five percent change in number of visits. So, you know, substantial, but compared to what we saw early on in the pandemic, nothing of that magnitude. And so based on that, I think it's reasonable to think that that's probably what we'll see nationally: as cases surge into the winter, we will see a drop in in-person care, we will see an increase in telemedicine, as both providers and patients are more concerned about going in. But it likely will not have that same impact as we had previously, because we've learned from that experience, created new workflows, etc.
Shaun Francis
Let's hope. I mean, I saw something from McKinsey recently, I know certainly in Canada, we have an issue, maybe even of greater magnitude, that it might take years literally to work through the surgical procedure backload.
Dr. Ateev Mehrotra
Certainly there was a lot of health care that didn't happen. In some work that we're just publishing, we found that during that first early part of the pandemic, we saw an overall reduction in roughly 50 percent of healthcare spending. And in the US, where that makes up almost 20 percent of GDP, huge decline in healthcare use. You ask the question and cited the work from McKinsey that it'll take years to go through that backlog. I think my instinct is that it won't take that long, because a lot of those procedures and radiology tests and everything else, just won't happen.
Shaun Francis
We'll just—we'll forego them.
Dr. Ateev Mehrotra
Exactly. And let's be clear, I think one thing that we haven't addressed or discussed enough, is that not all healthcare is good. And when I say good, I mean, that is actually providing value. There's certainly lots of evidence, prior research prior to the pandemic that we had, in many cases, tests, surgeries, visits, that were—the use is of low value. Which basically means that that care is not improving people's health sufficiently. And so some of that forgone care, maybe that's a good thing. But I think, given the magnitude of the drop, I would also—I don't have evidence of this, but I'd be pretty confident in saying a lot of that healthcare was necessary high-value care. Unfortunately, that was forgone.
Shaun Francis
And from your perspective, you know, what are your top three, five items from a preventive care perspective that alarm you the most or I guess on the other side is you believe offer the most value?
Dr. Ateev Mehrotra
Yeah. So certainly, it's hard to choose your favourites because I do feel that this idea of preventive care is a good thing. So I'll just highlight some of the things that we feel are most critical. Obviously, the vaccines and the prevention of illness. You know, we've already had problems with measles, mumps, and other forms of infectious disease. And I think that on the—that's mostly on the children's side, but on the adult side, the things I'm particularly worried about are colon cancer, and the drop in colonoscopies that we had, as well as breast cancer and mammograms. So those are the two that kind of just come to mind.
Shaun Francis
And what about heart disease? Are we not—do you think we're not going to catch as many of those? Or are you expecting to see a bump in that?
Dr. Ateev Mehrotra
Yeah, so I appreciate you bringing that up, and I might be kind of focused too much on the choice of words. In the healthcare world, we often talk about primary prevention and then secondary prevention. Primary prevention is the idea that we're going to detect illness before it happens, or detect early illness. And then secondary prevention is we've identified the illness, and now we want to do whatever we can to deter exacerbations of that illness or that illness worsening. And so when I think of secondary prevention, or management of chronic illness, I think a lot of areas such as heart disease, heart failure, diabetes, emphysema, asthma, where the drop in visits and the just reduction in healthcare that we've seen nationally and worldwide, is going to likely lead to increased exacerbations of those illnesses and a worsening of that disease. And so that's obviously also a substantial concern. The visits that I've been seeing more recently in the last couple of weeks, the fact that visits have returned to baseline decreases some of my concern, but what we saw early on in that pandemic, and obviously is quite concerning and probably did lead to some worsening of that illness, maybe some heart attacks, and we'll never be able to recover from that.
Shaun Francis
What would be your advice to patients then, with respect to preventive care, given where we're at? You know, in the ever-changing school framework as we talked about, you know, should I send my kids to school or not? I mean, it's so inconsistent. Should I get my colonoscopy now or my mammogram or not?
Dr. Ateev Mehrotra
In that case, I think deferring to your physician or your care team makes a lot of sense. But I guess the point that I would make is that, in general, given the precautions that have been implemented in healthcare clinics and hospitals, surgery centres, I think they've been quite rigorous. And I think patients in general should feel safe going in to get that that type of health care.
Shaun Francis
Excellent guidance. I appreciate it. Dr. Mehrotra—I want to roll my R when I say that. Dr. Mehrotra, thank you very much for for taking your time. This is super insightful and actionable. And gosh, let's hope we learn from this and have some more consistent guidelines for how we advise people going forward. And definitely encouraging to feel like you're seeing those office visits get back to normal.
Chris
That’s it for this episode of Eat Move Think. Check out the podcast website for highlights and full episode transcripts at eatmovethinkpodcast.com. Eat Move Think is produced by Ghost Bureau. Senior producer is Russell Gragg. Social media support from Emily Mannella. Editorial direction from Chantel Guertin. Remember to rate and subscribe to Eat Move Think on your favourite podcast platform. Follow Shaun on Twitter and Instagram @shauncfrancis—that's Shaun with a U—and Medcan @medcanlivewell. We'll be back soon with a new episode examining the latest in health and wellness.