“There have been many plagues in the world as there have been wars,” Albert Camus wrote, “yet plagues and wars always find people equally unprepared.” Both plagues and wars, horrific and tragic, strike the soul of a society, its core beliefs and practices. The battle against the novel coronavirus is already changing the way medicine is practiced.
Although battlefield analogies can go too far, the fact that a crisis forces new knowledge and practices is familiar in military medicine where quick reactions are essential. George Washington suspected the British of spreading smallpox in Boston, leading him to order the inoculation of his soldiers with the dangerous variolation technique, 20 years before Edward Jenner’s much safer vaccine. Civil War doctors treating the combat wounded confirmed theories about germs and infections that had not yet made their way into standard medical practice. They organized early systems of triage and evacuation of casualties.
So many World War II veterans returned with emotional damage that clinical psychology became an established profession. In the Pacific Theater infectious diseases disabled as many as a third of American sailors, accelerating penicillin development and production. The Korean War, and then the Vietnam war, transformed emergency medicine and inspired innovative treatments to save victims in that first “golden hour.” Helicopters flying patients to shock-trauma units memorialized in the TV show "MASH" are common across the country.
Not only do plagues and wars often appear at the same time, but they also have much in common. Both are disorienting events that have biological as well as political and social consequences. Neither microbes nor armed conflicts are respecters of persons or borders. There are no boundaries in a world of chaos and life-threatening stress. Mysterious infections cross biologic barriers and propagate uncontrolled across the globe. The coronavirus pandemic has thrown into sharp relief that health is fundamental to national security. When plagues and war strikes, health takes on new meaning, offering an opportunity to provide healthcare differently.
Modern-day soothsayers predict that the country will see waves of recurrent illness because of Covid-19 for two more years. The pandemic has kicked off a far-reaching global disruption that can potentially reconfigure the world order. We only need to look back to both world wars to imagine the consequences on both domestic and international policy, or the Great Depression to grasp the social upheaval behind the New Deal. The pandemic has already killed more Americans than the Vietnam War, a conflict that fundamentally disrupted the cultural and political fabric of the society. It could change how many countries regard public health and the availability of good medical care to vast segments of their populations.
Like their predecessors in wartime environments, physicians and other health care professionals are confronting a situation that is new to them, one in which previous experience is at best limited. As one doctor has observed, they have all become palliative care specialists. For years, doctors have relied on the findings of standard randomized control trials (RCTs) to guide and assess the efficacy of treatments or drugs, even though acknowledging the limitations. Modern medicine has depended on a vast number of guidelines based on the best available evidence, but there is no good evidence today on how to best treat the coronavirus.
The presumption that only validated science should drive medical decision-making has been overtaken by the exigencies of the flood of very sick patients. In the critical care setting, instead of immediately putting Covid-19 patients in respiratory distress on sedation and a ventilator, they have been found to benefit more from being kept awake, put on oxygen and kept off their backs. This strategy has also reduced pressure on the availability of ventilators and heart-lung bypass machines, avoiding some of the most distressing rationing decisions. The doctors have changed their approaches to treatment as they have learned from their experiences with patients. Time will tell if patients whose respiratory complications from other diseases could also benefit from that approach, reducing the use of ventilators and ventilator dependence more generally.
The rules for telemedicine and related technologies have been modified as more and more medical practitioners are working with patients online. Legal barriers are being set aside in the emergency. That is a breakthrough, as the proponents of telemedicine have been advocating for such changes since the 1990s but confronted bureaucratic and institutional barriers. For decades, innovations like telemedicine were slowed because a “business case” could not be made to show savings and profitability. Practitioners resisted implementing innovative technology as they could not figure out how to get reimbursement for the changes in delivering care. To many practitioners and health business leaders, cutting-edge technology was too disruptive and disorienting to be assimilated into practices.
Beyond the clinic, the pandemic has forced shifts in regulatory oversight. The urgent need to get tests, therapies and vaccines into the field has changed the usual procedures of the CDC and FDA. The FDA has adjusted some procedures but has moved slowly. The looming threat of tens of thousands of patients with serious illness from a new disease requires that these agencies and the institutions working with them find ways to expedite discoveries and validate therapies. However, there is a risk that drugs will enter widespread use based only on anecdotal information rather than rigorous studies. The regulatory system itself could be weakened, and not improved, over the long term.
For the last 70 years, medical practice has been shaped by a bloated, inefficient health care industry. Neither the mental health system nor our loose network of medical practices was prepared for the challenge. As we have learned in the past few weeks, public health preparedness has taken a backseat to an outdated, market-driven business model of health care delivery. The battle against the virus presents an opportunity to recalibrate our health care system as well as advance our practices.
Jonathan D. Moreno is a professor of medical ethics and health policy at the University of Pennsylvania. His most recent book is “Everybody Wants to Go to Heaven but Nobody Wants to Die”. Follow him on Twitter: @pennprof
Stephen N. Xenakis, a psychiatrist and retired Army brigadier general, serves on the executive board of the Center for Ethics and the Rule of Law at the University of Pennsylvania and is an adjunct professor at the Uniformed Services University of Health Sciences. Follow him on Twitter: @SteveXen.