With more than 950,000 deaths and close to 80 million cases in the U.S. alone, few would argue the COVID-19 pandemic hasn’t had a devastating impact on Americans’ health. Yet we may only be just starting to understand the true effects of the crisis.
In particular, the pandemic – now at its two-year mark – has played a pivotal role in changing the health landscape by hindering chronic disease management for many patients, raising the specter of more severe illness for many with underlying health conditions. Such factors are likely contributors to increases in mortality for some of the leading causes of death in the U.S., such as Alzheimer’s disease and diabetes.
“Many of the conditions and issues that need to be addressed with diabetes have been delayed for a really long time,” says Dr. Robert Gabbay, chief scientific and medical officer for the American Diabetes Association. “That’s a significant factor that unfortunately we’ll continue to see the implications of over time.”
The pandemic has placed a dangerous strain on the health care system and undoubtedly disrupted patient care: An April 2021 survey conducted by the Urban Institute found that a quarter of nonelderly adults reported delaying or forgoing care in the past 12 months over fear of exposure to COVID-19. The survey also found adults with chronic health conditions were more likely to report forgoing or delaying care in the past 30 days compared to people without a chronic disease.
Gabbay says the postponement of preventive and routine care visits has led to a rise in people with undiagnosed diabetes and an increase in uncontrolled blood sugar levels among those already diagnosed. Socioeconomic fallout – data depicts struggles with homelessness and debt among diabetic patients during the pandemic – also has affected the ability of patients with diabetes to effectively manage their condition, he says. That process can come with high out-of-pocket costs.
“The pandemic has been a magnifier for some common problems – one of those has been affordability of medical care and treatment for those with diabetes,” Gabbay says.
And though much focus has been on how COVID-19 impacts people who already have diabetes, Gabbay says there is evidence suggesting the coronavirus itself may fuel new diabetes cases as well.
Some new diagnoses, he says, likely stem from individuals who contracted COVID-19 and then discovered their diabetes status after seeking treatment. But a study published last May in the journal Cell Metabolism found COVID-19 can infect beta cells in the pancreas, hindering the body’s ability to produce insulin. The hormone regulates blood sugar in the body, and too little of it can lead to diabetes. A recent CDC study also found a higher risk of newly diagnosed diabetes among children under age 18 who had contracted COVID-19.
Gabbay says such findings are concerning for individuals who were already at risk of developing diabetes prior to coming down with COVID-19.
“This has long-term public health implications,” he says.
At the same time, a study published in February in the Journal of Diabetes and its Complications suggests the impact COVID-19 may have on diabetes onset may be short-lived. Researchers at Massachusetts General Hospital in Boston examined nearly 600 COVID-19 patients who were identified as having diabetes and found approximately 41% of survivors whose diabetes had not been previously diagnosed later regressed to either a normal blood sugar level or prediabetes.
Lead study author Dr. Sara Cromer, an investigator in the Department of Medicine-Endocrinology, Diabetes and Metabolism at Mass General, says the findings suggest new diabetes diagnoses in some patients may be due to inflammatory stress in response to COVID-19 that causes temporary insulin resistance, rather than a permanent inability of the body to produce insulin.
Cromer says such responses have been seen in other infections, but that it appears to be more common in COVID-19 patients. She says the use of high doses of steroids in treating COVID-19 also can cause insulin resistance and blood sugar levels to rise.
“The combination of the severe inflammatory response to COVID and the use of high-dose steroids may kind of cause a perfect storm that leads to those very high blood sugars, but that can improve once someone has resolution of their COVID and is no longer on those steroids,” Cromer says.
It’s well-documented that the coronavirus can cause various lung complications such as pneumonia, blood clots and acute respiratory distress syndrome. For the roughly 37 million Americans who live with a chronic lung disease like asthma or chronic obstructive pulmonary disease, the pandemic has added new levels of anxiety for both patients and clinicians.
“They’re living in fear,” says Dr. Panagis Galiatsatos, a national spokesman for the American Lung Association and director of the Johns Hopkins Tobacco Treatment Clinic. “They know they are a bad cold away from being admitted to the intensive care unit.”
After adjusting for risk factors like hypertension and obesity, a study published last year in the International Journal of Chronic Obstructive Pulmonary Disease found that the mortality rate among people with COVID-19 was more than two times higher among those who also had COPD. At the same time, the number of people who died due to a chronic lower respiratory disease such as COPD declined by about 3% in 2020, while the corresponding death rate dropped by nearly 5%.
Unlike with diabetes patients, Galiatsatos says the pandemic has not really hindered chronic lung disease patients from actively managing their conditions. He says pandemic safety measures like masking have brought the rest of the country around to adhering to the kinds of precautions people living with such conditions have had to practice for years.
“What I’m hoping is that we begin to take airborne viruses really seriously and learn to have a specific culture that allows us to live among these public health crisis-causing viruses without that much disruption,” Galiatsatos says. “I’m hoping we learn our lesson of how to adapt to this.”
A big part of that effort will rely on scientists’ ability to properly convey to the public the severity of future disease threats – an issue that has come to the fore during the pandemic as misinformation or shifts in messaging about COVID-19, mask-wearing and vaccines have strained trust between the public and health experts.
Should similar scenarios arise in the future, Galiatsatos says better messaging will be needed for the public to understand and be more willing to adhere to measures like mask-wearing and social distancing earlier in the progression of airborne disease threats.
“Otherwise the community won’t have our trust and the community won’t have the recognition of how severe these things are,” Galiatsatos says. “Science needs to have these conversations continually, consistently, and not just at times of crises.”
The recent spike in COVID-19 hospitalizations tied to the omicron variant led to bed shortages and made it increasingly difficult for hospitals to address the needs of non-COVID patients with serious conditions like cancer, says Dr. Arif Kamal, chief patient officer for the American Cancer Society.
Kamal also says decreases in patients receiving diagnostic services like cancer screenings have occurred during each major wave of the pandemic, and some health systems have been forced to redeploy supportive care personnel from their cancer centers to other areas to address hospital staff shortages.
“We’re starting to see folks who play sort of a preventative role – for example, checking in with cancer patients regularly to see how they are doing – there may be in fact less of those calls taking place and less access to those support care resources,” Kamal says.
The nursing shortages many health care providers across the country have faced during the pandemic have also been a concern at many cancer centers, Kamal says, while staffing shortages reported in cancer service areas like infusion therapy have led to treatment delays as well. We’ve seen “some shutdowns of in-person clinics and buildings, so that naturally affects a lot of the screening work that’s been happening,” Kamal says.
Such factors have led to a steep decline in the detection of new cancer cases, at least some of which may be found later at a more advanced stage. Dr. Norman Sharpless, director of the National Cancer Institute, last year said new diagnoses dropped by around 50% in months after the pandemic took hold in 2020. And a study published in June that examined the pandemic’s impact on cancer services in Louisiana and Georgia found there were nearly 30,000 fewer cancer pathology reports than in 2019, representing a 10.2% decline.
Internationally, an analysis of data from 2020 that was published in The Lancet Oncology found that 1 in 7 patients in regions where a full lockdown occurred had not received a planned cancer surgery.
In the U.S., early detection has helped spur significant drops in cancer mortality over the past three decades, with the death rate declining by 32% between 1991 and 2019, according to a report by American Cancer Society researchers. CDC data also shows about a 1.5% decline in the cancer mortality rate between 2019 and 2020.
But Kamal fears pandemic-related delays in preventive and treatment services, compounded by reports of supply chain disruptions that are delaying access to supportive medications like antibiotics and anti-nausea drugs, could lead to a reversal of this decadeslong progress.
“Much of the progress over the last 30 years of cancer care delivery has been not just new drugs to treat cancer but also new drugs to support patients going through that treatment process,” Kamal says.
The development of new cancer treatments also has been affected by the pandemic, as concerns over the spread of COVID-19 have created challenges in getting participants for clinical trials, causing some to be delayed or halted altogether, Kamal says.
“Naturally the concern there is that the development of new drugs and the testing of existing drugs will slow, and has slowed down during the pandemic,” Kamal says.
In many ways, the pandemic was a perfect storm that proved deadly for patients living with Alzheimer’s disease.
“COVID-19 was really devastating and continues to be devastating for people living with dementia,” says Beth Kallmyer, vice president of care and support for the Alzheimer’s Association.
Kallmyer points out that people living with dementia often live in communal environments like long-term care facilities and nursing homes – places that have been hit hard by COVID-19. As of Jan. 30, more than 200,000 COVID-related deaths had occurred in long-term care facilities among residents and staff, accounting for at least 23% of all COVID deaths in the U.S., according to an analysis by the Kaiser Family Foundation.
And while people suffering from dementia can face an increased risk of severe illness from COVID-19 itself, the pandemic’s disruption to health care has proved to be a serious threat to patients often incapable of managing their condition without caregiver support.
“Now all of sudden you’re in a nursing home and you have a patient that might need inpatient care, or you’re taking care of an elderly loved one at home who may be in need of inpatient care – the bar to actually go to the emergency room gets a lot higher when you’re worried they could be exposed to something in that setting,” says Dr. Lauren Gilstrap, an assistant professor of medicine at Dartmouth College’s Geisel School of Medicine.
Gilstrap is the lead author of a study published last month in JAMA Neurology that found the mortality rate among Medicare beneficiaries ages 65 and older with Alzheimer’s disease and related dementias was 26% higher in 2020 than it was during a corresponding period in 2019. Among beneficiaries without dementia, the mortality rate was 12% higher.
Gilstrap says mortality patterns in areas where COVID-19 cases were low appear to implicate changes to health care services in higher mortality among dementia patients more than the actual disease of COVID-19. Those changes include decreased access to inpatient hospital services and outpatient clinics in favor of virtual tools like telehealth, coupled with visiting restrictions in nursing homes that likely increased feelings of social isolation and loneliness for many patients, Gilstrap says. Social isolation among older adults has been associated with an increased risk of developing dementia, as well as premature death.
“While COVID may be driving some small proportion of the increase in mortality, it’s probably not driving the bulk of it,” Gilstrap says
Overall, the U.S. death rate from Alzheimer’s rose by 8.7% in 2020 to 32.4 for every 100,000 people, compared with 29.8 per 100,000 people in 2019, according to data from the CDC. The number of Alzheimer’s deaths increased by nearly 13,000, representing a more than 10% surge.
Though it’s difficult to gauge precisely how delays in disease management and other factors will affect the nation’s health in the long term, experts agree a positive that’s come out of the pandemic has been health care’s ability to rapidly transition to provide care to patients remotely.
Still, Dr. Donald Lloyd-Jones, president of the American Heart Association, acknowledges the ripple effects caused by the last two years are likely to last well after the pandemic ends.
Clinicians, he says, likely will have to treat more patients who have experienced setbacks on risk factors such as blood pressure control. Study findings presented at an annual AHA meeting, for example, revealed the average share of adults with hypertension and optimal blood pressure control had declined from 60.5% in 2019 to 53.3% in 2020.
“I fear some of this cake is already baked – the loss of control of some of these risk factors that has happened during the pandemic is something we’re going to continue to pay the price for,” Lloyd-Jones says. “But there’s a lot of this that is in patients’ control, and now we have new ways to engage with them.”