Covid-19: The defining disease for the next generation of physicians?

For my generation it was AIDS. In fact I remember my first case as an intern--a thirty something blonde male who we admitted to the ICU. It was the first time I saw the purple skin lesions of Kaposi sarcoma. A year before I had spent 3-months at NIH as a medical student and recall Dr. Anthony Fauci's lecture on what we knew about AIDS and the immune response in 1984-5. He was headed out for a run over the noon hour with his fellows and residents; trim, short, with lots of energy, but less gray hair.

The epidemic as it was called back then forced discussions about safe sex, needle exchanges, how to ask about sexual preference and expanded research in immunology. Billions of research dollars were earmarked to study what became HIV/ AIDS. Research colleagues retooled their interests to follow the money. Our understanding of viruses and a whole new slew of medications (ant-viral) were identified, tested and introduced. A global response was birthed as the virus tore through Africa infecting women and children and not just gay men or IV drug users.

Personally, the decade was marked by the diagnoses and death of colleagues and friends--addresses and phone numbers deleted from my address book at that time paper. I can recall ripping out whole pages. And then it became a chronic disease--not curable, but treatable. HIV positive no longer carries the death sentence it once did.

It feels strange to look over my shoulder, realizing that I am over 60 and in the at risk group for Covid-19. This won't be my fight. I probably shouldn't be on the front lines now that I've just completed my 2-week self-quarantine after returning from Palestine. I can't help thinking about the defining events of previous generations: Penicillin, the polio vaccine, employer based health insurance in the 1960s . . .

What are the learning opportunities from Covid-19?

The well funded US health care system's inability to reorganize and respond quickly shows the problem with the under-funding of public health, the lack of universal health insurance, the disconnectedness of what we have and do versus what we need and should be doing, and the problems with the for-profit incentive in health care.

Public Health funding has been woeful for decades. This Himmelstein/Woolhandler article, the longtime proponents of Single Payer Health Care, does a nice job of summarizing these realities.

Lack of health insurance: Thankfully the bill that recently passed congress has some provisions for the uninsured but gaps remain. While tests costs are covered, treatment coverage for hospitalization is limited. (See point 4 in the link above.) This means patients who survive days in the ICU will likely have astronomical copays. More needs to be done here. Can we do it without bankrupting future generations?

Disconnected: Electronic health records don't share information easily. No organized approach about how to ration limited resources, leaves decisions to clinicians which risks inequity and incredible pressure on individuals. (See Link to New York Times article.) Here, different health systems that interact with the young residency doctors in a local program give different guidance on how to use protective equipment. Talk about crazy and non-collaborative! That said, physicians have put on the protective equipment they have and cared for patients. Medical students who have been pulled off their clinical rotations here have organized to support physicians with child care, meals and running errands. The professionalism is wonderful to see. The essential commitment and goodness of people is being underlined.

The For-profit motive likely amplified the dwindling funding for public health. Clean water isn't sexy, but we hear about it when we don't have it: Think Flint Michigan and Milwaukee Wisconsin. And I wasn't surprised to read that the effort to plan for and produce adequate backup ventilators was dropped when a smaller company was bought by another company who had a different business model. (See NYT article.)

And finally, the virus itself is a huge unknown. Will it fade with the season change? What waves of virulence with we see? Can a vaccine be developed? Will people accept the vaccine? What health issues will those who survive the days on a ventilator face?

It is my hope that the disruptive change points to the need for universal and better coordinated health care. One that allows for planning and coordination of the precious resources we have and does not steal from the other essentials--education, clean air and water, safe roads, sustainable energy. And I wish the next generation of physicians the stamina and will to mount the effort and persistence it will take.