By David Shaywitz, National Review
COVID-19 has altered how we think about health and medicine — but will these changes outlast the pandemic?
Gripped by the COVID-19 pandemic, we now wash our hands obsessively; hand sanitizer has been out of stock for weeks. We are grateful for the hospitals in our communities that take care of us if we’re struck down, and for telemedicine approaches that try to keep us healthy and out of harm’s way. We’re hopeful drug companies will come up with something to fight this terrible virus and that data scientists will be able to warn us where the disease will strike next.
But, to paraphrase the Shirelles, will we still feel this way tomorrow? Will the health behaviors and attitudes we developed during the pandemic persist after the danger has passed — and should they?
Let’s start with hospitals. Pre-COVID-19, there was a big push to reduce the total number of hospital beds in the country, especially in community hospitals. In 2014, for example, Cleveland Clinic CEO Dr. Toby Cosgrove said the country had too many hospital beds, noting an occupancy rate of about two-thirds. That remained steady over the next several years.
Hospitals pushed back, of course, arguing that they provided critical value to the community. But the megatrends were clear. As Dr. Penny Dash, a McKinsey senior partner, put it in 2019: “We probably need fewer hospitals.” The reason, Dash continued, was an evolution in need from acute to chronic care, and the opportunity to provide more of this care outside of hospitals, in settings more convenient for patients. Dash explained,
“[W]e are having a different burden of disease than the burden of disease that we would’ve seen 20 years ago and certainly 50 years ago and 100 years ago. What we are now seeing is that people don’t tend to die as children of infectious diseases. They don’t tend to die during their adult years of infectious diseases, they don’t tend to have accidents as much. If they have a heart attack, we can usually treat it and cure it and people survive. As a result, the diseases that we’re seeing are chronic diseases associated with aging populations, but also with poor lifestyle behaviors.”
Now we are in the middle of a pandemic, watching with dread as our hospitals fill up with patients acutely ill with an infectious disease. We cry for more beds, not fewer. While this singular, searing experience may be enough, in the short term, to offset the powerful broader trend toward fewer hospitals and more care closer to the patient, the reprieve may prove short-lived.
Next: How will this crisis affect telehealth, or the provision of medical care remotely by technology? The urgent need for telehealth has sent related stocks soaring. Privately held Aledade, a startup led by Dr. Farzad Mostashari, the former assistant commissioner of the New York City Department of Public Health and the nation’s health-IT coordinator under President Obama, has shared data reporting that the use of telemedicine in primary-care practices shot up in mid-March.
Yet the increased use of telemedicine now is at least partly due to the temporary lifting of a slew of barriers concerning its regulation and reimbursement. Jonathan Bush, a health-technology entrepreneur, reminded me that in 2014, the Texas Medical Society “actually voted to make telemedicine illegal, despite having many rural patients to serve.” While the specific effort was overturned, Bush says, “it was difficult to make a business out of delivering this type of care” before the COVID-induced change in reimbursement and regulation. Yet these policy changes are only temporary; if the original cumbersome restrictions are reinstated, it will impair the growth of telehealth once more.
The pandemic has also put pharmaceuticals in the limelight. Some (but not all) critics have suspended their reflexive hostility while waiting to see if the industry can develop and deliver something that will cure, or at least reduce the severity of, this illness in a way that will help everyone. A number of pharma companies are driving hard to advance potential therapeutics or vaccines toward the clinic. The entire industry seems to be participating in the multiple large, high-profile consortia that have developed. Perhaps they will prove catalytic. Still, I’d bet more on individual company efforts than the industry mega-consortia. Ultimately, we’ll likely get the therapeutics and vaccines we need. But it might take longer than we’d like. Drug development is intrinsically difficult because biology is complex and domesticating it is hard; the urgent need for an effective medicine doesn’t alter this uncomfortable reality.
An interesting wild card in drug development involves approaches that may not have been developed specifically for infectious diseases, but which could be quickly adapted to the task. The ability of Regeneron to rapidly develop suitable, targeted antibodies (a technique first used in 1892 against diphtheria and tetanus) holds considerable promise, for example. As does the extensive analytical work of seeking to identify and repurpose already approved medicines that might work against the virus. But proof will require data, not just good intentions. If effective treatments aren’t both forthcoming and accessible, expect frustration with pharma to return forcefully. But I’m confident medical science and the industry will deliver.
Whether the pandemic will change the way biopharma thinks about infectious diseases is an open question. This is an area that (with a few exceptions) has seen a profound retreat within the industry, due largely to a refocusing on areas perceived as more profitable. In 2018, Novartis shut down its infectious-disease unit in California’s East Bay, part of a larger trend that’s included Sanofi, AstraZeneca, and others. Not surprisingly, there’s been a lot of effort — including by Dr. Scott Gottlieb, when he was leading the FDA — to contemplate incentive structures that could more effectively catalyze drug development in this area, which may now assume greater urgency.
Now let’s consider AI and digital transformation. While some champions are eager, if not desperate, to invoke the pandemic as the transformative event that brings digital to medicine, many are less convinced. One senior pharma leader who specializes in digital health bravely wrote a post on LinkedIn titled “COVID-19: The Big Failure of AI and Big Data,” which described how these technologies fell short of their often-extravagant expectations.
Others, though, still hope that despite the rough start, this will prove to be technology’s finest hour. A remarkable number of hackathons and more formal consortia (always the consortia!) have sprung up as engineers and data scientists hope to use their skills against the pandemic. Tech billionaire and founder of C3.ai Tom Siebel — who has championed the concept of digital transformation that’s become inescapable in business — just announced the launch of a long-planned Digital Transformation Institute. It will first address the pandemic, in what board member and Microsoft Chief Scientist Dr. Eric Hovitz described as a compressed moon shot. Optimism about the potential of data and AI to benefit medicine in the long run is warranted. But figuring this out will not be as easy as some techno-optimists hope. The need for a high volume of relevant, high-quality data will complicate matters.
This brings up another set of important policy issues: how to balance potential public-health benefits with intrusions on privacy by emerging surveillance-data collection technologies associated with digital transformation. Some digital-health leaders emphasize that health vs. privacy is a false choice and that we must ensure that the digital tools we use have robust data-governance provisions from the beginning. If not, rights we surrender during this crisis might prove impossible to regain after it’s over.
Finally, I’m curious about the future of hygiene, which has been a cornerstone anti-coronavirus effort. On a recent Politico podcast, Gottlieb identified hygiene as one area likely to be profoundly changed by this crisis:
“This has altered the course of history in the world, this has changed American life and global life. We’re going to have more cleaning of shared surfaces, we’re going to have restrictions on how many people can crowd into an elevator, Ubers and airplanes are going to be averaging the deep cleanings that they do, we’re going to be seeing more ultraviolet light [to kill germs] in indoor settings, we’re going to see copper [also to kill germs] used on shared surfaces.”
Who knows how many of these predictions come to pass; I’m especially skeptical that our handwashing habits will durably change. It has always been a tough sell. Before COVID-19, the CDC reported that “on average, healthcare providers clean their hands less than half the times they should,” despite persistent quality-focused efforts to improve this number. Outside of hospitals, research suggests that hand hygiene is also surprisingly poor. Ten percent of people don’t wash their hands at all after using the bathroom. Another quarter fail to use soap.
Yet if our post-COVID-19 world becomes more hygienic, even this might carry some unintended consequences. For instance, the “hygiene hypothesis” suggests that without sufficient exposure to environmental stimuli, our immune system fails to get properly trained, leading to overreaction via allergies and auto-immune conditions later in life. When I asked Dr. Kari Nadeau, a Stanford physician-scientist and food-allergy expert, about the potential long-term impact of the pandemic, she told me that some allergists think those exposed to the virus will be less likely to develop allergies in the future because of the effect on the immune system. Others worry that the renewed societal emphasis on hygiene could make us see more allergies.
“We still don’t know the answers yet,” Nadeau told me, “but we’re getting there — hopefully.”
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