The storm overhead
By Larry Kravitz, MD, and Tuyet Tran
Swirling down with the suddenness of an unheeded prophecy, a storm descends on us, threatening to strip away our comfortable manner of practicing medicine. We are losing our templates for ordinary living. Everything has shifted. The pandemic is upon us, and it is the tip of the spear for the revolution of our future medical world.
As I record this reflection, I gaze out upon an unfamiliar landscape, a vast white blanket spreads over the fields behind my house. A polar vortex of climate change origin has descended to latitudes never before so compromised. Electric power is gone. Phone service is spotty. The Internet is dead. Water, little that there is, must be boiled. The gears and engines of my city’s infrastructure have slowed to a cold, eerie, and silent halt. The roads are impassable. I can’t get to my office. I can’t reach my patients by phone. They are hurting today. And it’s not just the homeless under the bridges. This unprecedented vulnerability will stretch its menacing fingers to the apartments of our blue-collar underclasses, and even seep into comfortable suburban mansions. This week, almost no one will escape this tide of disruption. People are going to suffer. Some will no doubt die today. Some will die alone.
Here is the writing on the health care wall, as we recede from the first world of the 20th century, the so-called American Century. The scope of medical threats is daunting, and they are not in control. It was enough that out of a population of 29 million in Texas, 5 million went without power, 12 million had disrupted water service, and over 70 people died during the February ice storm. But on a larger scale, life expectancy has declined in the U.S. since 2010, and we have now sunk to 35th in the world. Since the March 2020 start of the pandemic in the U.S., about 527,000 (17% more) additional Americans have died than would have in a normal year. Now consider that a rising 31% of the U.S. population has no health insurance, one-tenth of the total population.
With that, we are facing an increasing aging population; the world population of elderly will be tripling from 500 million to 1.5 billion by 2050. But our resources to pay for this are dwindling. Social security surplus will run out in 2035, which will result in payments decreasing to 79% of previous levels. The national debt has skyrocketed in the last four years, reaching $27 trillion, 129% of GDP. It increased by $3.3 trillion in this pandemic year alone.
And the cost of health care keeps going up. Drug prices are rising at a rate that outpaces other health care services; drug prices have increased by 33% since 2014. The toll of obesity is ahead, with the latest federal data showing that nearly 40% of American adults were obese in 2015-16, up from 34% in 2007-08. With the opioid crisis, the death rate from drug overdoses doubled from 2007 to 2017. The number of gun murders rose 32% between 2014 and 2017. Then there are the anti-vaxxers; as many as three in 10 Americans think vaccines should not be mandatory. Half of American households use largely unproven nutraceutical agents. The public has also fallen prey to an epidemic of e-cigarettes and scarier products like K2.
Doctors had their own disillusionment, when medical record keeping became oppressive. The EMR seemingly made the problem worse, although the ultimate problem is the same: medical information is vaster than the human brain can capture. There are emerging diseases to cope with. Zika, HIV, and Ebola were the pandemics before The Pandemic. And there is the threat of invasive disease changes. Dengue coming up with climate change from Latin America, and invasive species like fire ants moving north, or poisonous Death Cap mushrooms, a migrant from Asia.
Our tools in this battle are threatened. A report by the CDC noted that every year, more than 2 million people in the United States become infected with organisms that are resistant to antibiotics. And medicine supply chains have become threatened with “back orders” along with 4,500 product and medication FDA recalls a year.
Of course, hovering over these issues is the encroachment of climate change and its severe weather events. In Texas, Hurricane Harvey claimed 63 lives, and more than 30,000 people were evacuated. Besides the 2,975 deaths caused by Hurricane Maria hitting Puerto Rico in 2017, the devastation wrought by the storm disrupted supply chains for the high percentage of critical intravenous fluid bags and medications made in Puerto Rico for the rest of the country. For Texas, we can expect the yearly longest dry spells to be one to four days longer by 2055, and the stiflingly hottest day will be 4 to 5 degrees hotter. No matter our efforts to control it, 700,000 to 1,000,000 climate migrants with their health care needs can be expected to migrate from Central America to the United States between now and 2050. These are the burgeoning cracks in our health care system, and America has itself to blame for not addressing the warning signs we have all seen coming.
It is time for us to buckle down to some serious health care. Our patients need every one of us to be their safe harbor in this storm.
And imagine the polar vortex and pandemic through the eyes of our fledgling medical students, who were removed from their classroom and clinical sites. Shrouded by a cloud of uncertainty and isolation, they were crippled with remote learning, and were faced with an uncertain future as to what their place would be as prospective medical physicians. Before the pandemic, as many as 27% of medical students suffered from depression, 11% with suicidal thoughts. The prolonged social isolation and anxiety surrounding the pandemic resulted in a further stark decline in student’s mental health, and the snowstorm made it even worse. The emergence of telehealth became the silver lining of the pandemic, and a safe platform for medical students to join in. But it was not what they signed up for; the medical world of their dreams had been turned upside down.
So here we are now. Even as the snow has melted, many of the coming changes remain. I am recovering from the COVID-19 infection that afflicted me from some frontline work in the homeless community in Austin. I receive a call that my hundred-year-old patient has succumbed to hypothermia, and life-support has been withdrawn. In my first post-vaccination travel visiting family in California, I watch to keep our dog away from Death Cap mushrooms that grow along the park path. Working at my home computer late into the night, I field insurance authorizations for costly diabetes medication and switch out hypertension medication, unavailable due to factory contamination by carcinogens. My medical student receives word that her 70-year-old neighbor, who shepherded her street play as she grew up in Houston, has passed from COVID-19. She wasn't able to go home to share this with her family over Christmas, not wanting to risk spreading coronavirus.
As our declining United States life expectancy reminds us, perhaps the best we can hope for is to be fighting a prolonged war of attrition against the monstrous threats to our medical world. Now, in a time of post-COVID vaccine renewal, we can get back on a righted path, a time to open our eyes to our fragile, vulnerable Texas, and reset for the post pandemic world. We have survived. We need to foster a new generation of doctors handpicked for resiliency and adaptability. I have faith in turning our medical future over to them, bleak as it may be at times. We need a keen perspective of the changing dystopian landscape. We can fix things, but we need to respond like never before.
Larry Kravitz, MD, is a family physician in Austin. Tuyet Tran, is a third-year medical student at UT Southwestern Medical School.