Lessons Learned in Lockdown: The Impact of COVID-19 on a Health Care System

What’s it like going to work every day in the health care field during a pandemic? How has providing health care during the middle of a global infectious disease emergency affected you? These are questions that I anticipated one day having to answer. During medical school training at the University of Arizona, we were warned that an infectious disease pandemic akin to the 1918 Spanish Flu pandemic was due, and was somewhere in the horizon.

I now work for a Federally Qualified Health Center in San Diego, and on January 24, 2020, we received our first California Health Alert Network (CAHAN) advisory regarding a novel coronavirus outbreak in China causing a potentially deadly respiratory illness. The first case in the United States had already been identified 3 days prior in a traveler returning from Wuhan, China in Washington State. The virus was here, but the importance of that did not register at the time. As a health care provider in San Diego, CAHAN advisories are a fairly common occurrence. I don’t think many of us realized at that time the impact that this particular virus would have on our society and the world, and that this was the global infectious disease outbreak that we had been warned about. Still, this virus is unique from many of the viruses that preceded it in many ways, and scientists are still trying to dissect it in an effort to understand how it behaves.  

One of the characteristic of this virus that is astonishing to me as a pediatrician is that in general, it causes relatively few cases of the severe respiratory illness COVID 19, in children. Furthermore, relatively few among those cases have died. The fatality rate is highest among those aged 60 and older. The pediatric sector of health care, to date, has dodged a bullet. Instead of widespread panic resulting from a pandemic which kills both young and old indiscriminately, what we have is a situation where kids are not readily dying, and government-mandated measures have been put into place to slow the spread of the disease and give health care systems a chance to prepare. We face a global infectious disease outbreak- with training wheels…but not without challenges.

So, what measures have health care systems implemented to stem the spread of this novel disease while addressing its impact on the acquisition and provision of health care? I work for a health care system whose mission is “to improve the health and well-being of the communities we serve with access for all,” and thereby provide access to healthcare for those persons who are marginalized and resource challenged: those persons at greatest risk to be multi-impacted by this virus. I have been privileged to be part of a team of people who have met the challenge of the novel coronavirus with creative ways to maintain the goal of providing health care to those who otherwise might not get it.

Our objectives were clear: Separate the healthy from the sick, minimize the congregation of people, maintain essential in-person access to health care, and educate the public. These objectives were met in a variety of ways, many of which, I  believe, are here to stay.

As part of the objective to separate the healthy from the sick, while decreasing the congregation of people, the health care system had to quickly determine which services were essential enough to maintain an in-person visit component, and which could be addressed via distance medicine using phone or video technology. Clinics were closed and consolidated, buildings were separated by floor into Well Visit versus Sick Visit locations, and whole clinics were given “Telehealth Only,” “Well Visit Only” or “Sick Visit Only” designations. Through this, we have learned that the separation of sick from healthy and the provision of health care through telemedicine (though not new concepts), have worked so well during this time of forced implementation, that these modifications to the provision of medicine are from now on going to be more largely incorporated into how medicine is provided.

Once essential services and the locations to preform them were determined, the health care system developed protocols and processes to safely maintain in-person access to health care. Pandemic or not, babies will continue to be born, infants and young children need developmental surveillance and immunizations, chronic disease needs monitoring, and the aged, mentally ill, and disabled persons need supportive care. In order to do this, screening takes place on many different levels, prior to admittance into the clinic. Screening helps determine which kind of appointment would best address the presenting need, in order to deliver care to patients with the least exposure risk possible. These provisions also included protecting providers who are at higher risk for morbidity if exposed to the virus from patients. Providers who are over 60 years of age, pregnant, or have certain underlying health conditions were reassigned to telehealth clinics. Once a readily obtainable medication is on hand to treat the novel coronavirus, or a vaccine becomes available, we can perhaps go back to delivering medical care in many of the more traditional ways. In the meantime, we have developed protocols and processes to address this modern-day pandemic. The lesson here is that these protocols and processes are being streamlined so that they can be quickly implemented, should the need arise again.

Wash your hands. Cover your cough. Avoid congregating. Stay home when you are sick. We used to be reminded of these important safeguards which help prevent the spread of viruses every winter during flu season, but many generations have passed since implementing these measures was so closely tied to one’s actually staying alive. Placing a strong emphasis on teaching and disseminating these public health messages was an important part of the health care system’s response to stem the spread of the novel coronavirus. Hopefully, we have all now been indoctrinated into seeing germs everywhere. I used to be particularly conscious of unseen living organisms on the surfaces of exam rooms, in medical offices, or in medical buildings in general. Now, I think twice before picking up a cucumber at the grocery store. The first thing I do now when I arrive at work is disinfect all frequently touched surfaces in my workspace. Meticulous and compulsive hand washing, social distancing, and staying home when sick are now mainstream, new normal elements of American society. People are no longer welcome in public spaces without a face cover, let alone if visibly ill. The take away here is that these simple, yet lifesaving educational public health messages – wash your hands, cover your cough, stay home when you’re sick – are components of age-old wisdom which have finally taken their place among the standard way of life in America to prevent the spread of disease.  

How has the pandemic affected me as a medical provider overall? First off, I’m extremely thankful to still be working and serving the community. I do feel the impact of the fear that the virus causes. People assume that doctors are closer to the virus and therefore should be given a greater measure of social distancing. We nearly lost our child care provider to that thinking.

I also have a great deal of respect for the unknown aspects of the biology of this virus. It makes me uneasy to know that we are heading into a time of relaxing social distancing measures when we don’t have a vaccine, proven pharmacologic treatment, widely available testing, or public health measures in place for ongoing disease containment. Even though we have gone through an indoctrination period of awareness of how to prevent the spread of disease as pertains to this virus in particular, if we relax prematurely, the very thing we have been trying to prevent (rapid spread of this virus and a shrinking senior sector of society) might very well become a reality, even after everything we have already sacrificed. Let’s give our doctors, scientist, and public health sector just a little bit more time.  Ultimately, what we are trying to prevent is the loss of life on a grand scale, and as a society, I hope we do not have to learn that lesson the hard way.