A sea of people sit in the waiting room, anxiously waiting to hear about loved ones. Doctors, nurses, medical technicians rush around methodically going from patient to patient to address everything from broken limbs to chest pain to ear infections. A place typically bustling with life, the emergency departments of many hospitals have become much more tranquil since the beginning of the COVID-19 pandemic. With all eyes on the coronavirus, many patients have chosen to avoid medical care unless COVID-19 related, causing sharp drops in the amounts of people visiting the emergency room and seeking out primary care. 

The United States has failed to adequately control the epidemic, so the novel coronavirus continues to pose an acute threat to the population and the economy. Government officials continue to politicize the pandemic, and stories of the United States’ pandemic failure continue to dominate each news cycle. However, there is a real, human cost to diverting all attention to the ineffective pandemic response; the importance and treatment of consequential medical issues are being eclipsed by recurring narratives. Indeed, essential primary care and other urgent non-COVID related ailments have largely been put on the backburner.

Emergency room visits for heart attack, stroke, and hyperglycemic crisis continue to drop. At face value, this may indicate that incidents of stroke, heart attack, and glycemic crises have decreased; however, public health officials emphasize that these afflictions are not disappearing. Instead, people experiencing symptoms are too scared to seek out medical attention due to COVID 19’s ongoing health crisis. A blocked artery causes death in a matter of minutes, and deferring emergency care for fear of coronavirus poses a greater risk of mortality than otherwise. Additionally, the emergency department often offered healthcare to those who lacked access to primary care options, particularly low-income and Black and brown communities. Those who need the emergency department as their main form of healthcare may be relegated to living with their illnesses rather than seeking care due to fear of infection. Routine screenings are vital to ensuring long term health by catching problems before they are life-threatening. Fear causes these patients to suffer in the long run; these illnesses are life threatening, and it is essential to treat symptoms as soon as they appear.

 The fear of contracting the novel coronavirus is not unique to emergency department visits. Routine pediatric vaccinations have seen a statistically significant decline as well, with parents opting out or postponing appointments for their children. Within the first six years of life, the CDC recommends receiving ten different vaccinations. Meant to prompt herd immunity and prevent resurgences of polio, measles, mumps, rubella, and a myriad of now extinct illnesses, these vaccinations provide important protection for most children. Herd immunity provides protection for the most vulnerable members of society who may not be able to get vaccinated themselves. When a large population does not get vaccinated for these illnesses, they not only put themselves at risk, but those who are at a greater risk of health complications as well including pregnant women, babies, and immunocompromised individuals. It is easy to forget the threat these diseases once posed to everyone, but without maintaining herd immunity these diseases will no longer be relegated to small clusters but can spread on a much larger scale — creating epidemics. In fact, this has happened before. In the 1970s, Japan experienced a strong resurgence in whooping cough cases when the number of children who were vaccinated dropped to just ten percent. Of the 13,000 Japanese citizens infected, 41 people died. After this epidemic, vaccination rates began to rise again and incidents of disease dropped to miniscule levels. While all eyes are watching the warp speed at which the coronavirus vaccine is being produced, Americans must remember the benefits of vaccinating children to prevent rises in high risk diseases in the future. 

Routine cancer screenings, physicals, and other check-ups have largely been postponed or cancelled. However, primary care physicians are adapting to make care safer and more available to address the decrease in visits. COVID-19 spreads readily in indoor spaces and amongst those in close contact, which means mask-wearing and physical distancing are vital to prevent transmission. For patients who must be seen in person, best practices follow the same guidelines put in place for all public locations—wear a mask and stay six feet apart when possible—in addition to temperature checks before patients enter. Additionally, to prevent further spread of the novel coronavirus, the CDC released guidelines for all primary care physicians to follow, including implementing telehealth options for the vast majority of ailments including COVID-19 screening, patient referrals, follow-up post-operations, mental health counseling, amongst a slew of others. Telehealth—the provision of medical care remotely—has become a staple of medical care during the pandemic. 

Dr. Sameera Syed of the OBGYN of Lancaster practice is one of many physicians who have had to shift the way they treat patients during the pandemic. Lancaster, which sits in the heart of central Pennsylvania, cradles both a diverse city and rural farmland. But this community, much like the rest of the United States, has been struggling to control the COVID-19 pandemic. As of Monday, August 17, 2020, Lancaster County has 6228 reported cases of coronavirus and a rising positivity rate. Mixed messages from public officials have made containing the spread of the virus much more difficult; for example, local politicians have boycotted PA Governor Tom Wolf’s guidelines for re-opening. Meant to protect Pennsylvania citizens, Wolf implemented a tri-fold plan, with red, yellow and green phases. Moving out of each phase required meeting specific contact tracing and healthcare capacity, but Representative Lloyd Smucker of Pennsylvania’s 11th district alongside various county commissioners openly disregarded the yellow phase requirements and urged citizens to move into the green phase early for economic recovery. 

Amidst a pandemic turned political, Syed has had to ensure safe care to her patients regardless of the opinion on local coronavirus guidelines. Dr. Syed is a practicing obstetrician and gynecologist with 20 years of experience and two residencies in both OB/GYN and Family Medicine.

“Obstetric care is very unique since it involves both maternal and fetal health and well-being. My office was very careful in keeping OB patient access available at all times. We rescheduled the mostly non-urgent [gynecology] patients but tried our best to not reschedule our OB patients,” she said in an interview with The Politic.

For patients who Dr. Syed felt did not require a gynecological exam, she turned to telemedicine to meet with them remotely, responding to “quick concerns like a post-op question or a birth control issue for which one may not need to be seen in an office setting,” Syed explained. By utilizing telemedicine, Dr. Syed allows adequate room for patients who do require urgent exams in her office. Specifically, she has been able to maintain routine in-person visits for expectant mothers. But telehealth does not bode well for prenatal care; obstetric care requires monitoring of both maternal and fetal health. Monitoring the fetus requires in person visits to check on fetal heart rate and movement, which patients cannot do at home. Fetal monitoring is paramount to ensuring a safe pregnancy, without it infant and neonatal mortality rates increase significantly. A safe and healthy pregnancy requires regular surveillance, so as to protect both mom and baby. To catch signs OB patients came first, and her non-urgent gynecology patients were rescheduled as necessary. 

Nonetheless, not all doctors have been able to accommodate patients as well as Dr. Syed. Indeed, care for expectant mothers has been especially affected by the pandemic. This is extremely detrimental, as the American College of Obstetrics and Gynecology and the CDC both emphasize the importance of regular and frequent monitoring of the mother and fetus. Harvard Health reported that, in some cases, patients are monitoring clinical vitals themselves and reporting them to their physicians in lieu of in-person visits if they are at greater risk for coronavirus. Physicians have years of expertise in reading vital signs, allowing them to draw relatively accurate conclusions on a patient’s health. Self-monitoring, while convenient, can lead to excess stress on the part of the patient who may not understand the readings they are reporting and may not understand how to accurately use the given technology themselves. These issues cause room for error and potential harm. Self-monitoring is better than no alternatives, but the in-person reassurance from a doctor regarding the health of both mom and baby is crucial to ensuring a healthy pregnancy. 

Separately, there are innate inequities regarding telehealth. Remote treatment requires access to the necessary technology and a steady internet connection, which low-income and rural patients may not have. And COVID-19 already disproportionately impacts low income Black and brown communities. When primary care can only be offered virtually, it adds another barrier to accessible healthcare for the populations who need it most. In-person care may be the only option for them, but due to fear or preventative measures taken by primary care physicians, these populations are less able to seek out medical help. Balancing the urgency of critical care and the safety of postponing preventative care is difficult, but Dr. Syed believes that current guidelines are sufficient to combat coronavirus if they are followed diligently.  Preventative measures– taken by patients and providers—only work to combat the virus if everyone stays cautious. 

Obstetrics is a unique case, as many women rely on in-person care to ensure overall well-being, but other forms of urgent, non-COVID related care, have similarly been modified to prevent spread of the novel coronavirus. Dylan Norton, an incoming freshman at the University of Pennsylvania and a Lancaster resident, experienced first-hand the challenges of receiving urgent treatment amidst the pandemic. In mid April, Norton underwent critical lung surgery. Hospitalized for ten days, Norton recounts in an interview with The Politic, “I felt pretty safe most of the time since they took a lot of precautions. Surgery was a little scary since I knew if any of the nurses or doctors had [coronavirus], it could’ve been extremely dangerous for me.” 

Dylan’s experience was characterized by precaution: Norton was tested for COVID-19 upon arrival, medical staff remained socially distanced when possible, and all follow-up visits were conducted virtually.

One important note, Norton emphasized, “It was definitely a little lonelier than I expected as well. Doctors, when possible, had to stay socially distanced from me, and I was only allowed one visitor, so my mom stayed with me the week I was there.” Having an adequate support system to aid in recovery is crucial, but difficult during a pandemic. 

Norton’s experience is not isolated, and demonstrates the danger of modified primary care during the pandemic. 

“Mental health, anxiety, depression, financial and social stressors are certainly sidelined by the pandemic since these don’t manifest as physical complaints usually but are certainly going to show long term adverse impacts on healthcare,” says Dr. Syed. She emphasizes that “the pandemic has forced us to prioritize and take care of the critically ill as opposed to worrying about the long-term implications of mental health and stress of patients and their families.” This may prove to be detrimental. 

 For those who are undergoing serious procedures, an emotional support system is vital for recovery. Necessary precautions to prevent coronavirus strains the ability of patients, like Norton, to have outside contact and help from family, friends, or counselors. In addition to the adverse effects of isolation, some patients have started to feel overlooked, with non-urgent elective surgeries being postponed indefinitely. 

At Dr. Syed’s Lancaster hospital, they tested non-urgent surgery candidates for COVID-19, and, if positive, the risk of receiving surgery was higher than waiting for the procedure. Elective procedures that could be postponed were delayed but not canceled. However, procedures like induced labor and caesarean sections were not postponed in any capacity, as they required immediate attention. 

Though not as sensationalized by the media, the adverse effects of modified primary care will have long term repercussions on global health. Lethal diseases that once afflicted the majority of society are at a high risk of resurfacing if children do not continue to be vaccinated against them. Patients who have postponed elective surgeries and procedures must continue to suffer until they can get the necessary treatment, and, in some cases, this can lead to even worse long-term health impacts for the individual. The longer a problem is ignored, the worse it gets. Additionally, the stress and anxiety that comes alongside the inherent isolation necessary for preventing coronavirus spread has disastrous impacts on mental health, especially for those who may need a support system to fight their health battles. The United States healthcare system is experiencing a reckoning, in addressing capacity, inequities in treatment, and ability to effectively care for all patients. The current healthcare system is being strained by the pandemic, but allowing these issues to persist will cause strain in the future as an influx of patients may require even more serious care. The only way to effectively address these issues is to first  confront the pandemic. Primary care cannot be put at the forefront of the conversation until the pandemic is under control, but time is running low.

To address the issues posed by paused primary care, we must all also be educated on the risks and methods of prevention for this pandemic and follow the health and safety guidelines. Only when community members work together to implement the guidelines will the pandemic be relegated to the past, refocusing healthcare to the everyday needs of patients. Dr. Syed expresses this clearly: “I think any patient now more than ever needs to be looked at as a unit taking their family, social, financial, and environmental stressors into account. Being supportive, encouraging and providing the patient with the most accurate information about how they can protect themselves and their families from this pandemic is the biggest service we can do for the patient.” Protecting oneself from the pandemic is top priority, but one cannot forget the importance of seeking out necessary care. The biggest service we can do for our country is to control the pandemic and catapult primary care to the forefront of the national conversation, so Americans fare better in the present and the future. 

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