As the United States enters its third full covid winter, a top administration official is warning that the permanence of the coronavirus in the disease landscape could mean brutal and long-lasting seasonal surges of cold-weather illnesses for years to come, resulting in hospitals struggling to care for non-covid emergencies and unable to give patients timely, lifesaving treatments.
Winter has traditionally been crunchtime for hospitals because of influenza and another seasonal pathogen, respiratory syncytial virus, or RSV. Now SARS-CoV-2 has joined them to form an unholy trinity of pathogens that surge in the cold months.
White House covid-19 response coordinator Ashish Jha said the American health-care system may not be able to withstand the continued viral onslaught, straining the system’s ability to care for other serious illnesses.
“I am worried that we are going to have, for years, our health system being pretty dysfunctional, not being able to take care of heart attack patients, not being able to take care of cancer patients, not being able to take care of the kid who’s got appendicitis because we’re going to be so overwhelmed with respiratory viruses for … three or four months a year,” Jha told The Washington Post.
He described a scenario in which the typical winter logjam of patients begins much earlier than usual – in August or September – because of the coronavirus. It’s a darker scenario than the administration has portrayed in the past, and one Jha said most Americans have yet to realize.
“I just think people have not appreciated the chronic cost, because we have seen this as an acute problem,” Jha said. “We have no idea how hard this is going to make life for everybody, for long periods of time.”
James Jarvis, a senior executive at Bangor-based Northern Light Health, the second-largest health system in Maine, shares Jha’s concerns. He said hospitals now expect to see patients who are sicker, including people with long covid, children more at risk for diabetes because of covid-19 infections and patients suffering from heart conditions related to previous bouts of the disease.
Jarvis, who also works in a small family medicine practice, had a patient who was hospitalized two months ago for covid-19, and then again for influenza. He was discharged to an acute rehabilitation facility but then suffered a stroke. There was no bed available at Northern Light’s flagship hospital, Eastern Maine Medical Center, so he was treated in the emergency room for four days.
“He never left the emergency room,” Jarvis said. “I felt horrible. I’d see him and say, ‘I’m so sorry that you’re still in the emergency room.'” The patient received the care that was needed and eventually returned home, but Jarvis was frustrated that the patient never got a hospital bed.
These warnings come at a moment when public health officials are still waiting to see how bad the current winter surge in viral infections turns out to be. So far, this covid winter in the United States has been challenging, though not nearly as disastrous as the past two. But most of the winter still lies ahead, and covid-19 hospitalizations have risen significantly since October.
Hospitalizations remained generally flat during the early part of January, with about 45,000 inpatients suffering from covid-19 as of Wednesday. The national numbers can mask geographical surges: States along the East Coast have been hit hardest so far, while the West has been largely spared.
Public health officials are closely monitoring the spread of XBB.1.5, an omicron subvariant that is the most transmissible form of the coronavirus yet seen. It has already become the dominant lineage in the Northeast and will probably, at current rates, take over everywhere, outcompeting other omicron variants.
Despite its transmissibility, XBB.1.5 does not appear more likely than earlier forms of omicron to cause severe disease, and as it spreads in a population with significant levels of immunity, it has not managed to create the same devastating surge of hospitalizations seen in the past two years.
In January 2021, more than 3,000 people a day were dying of covid-19, because almost no one had immunity at that point and vaccines had just started rolling out. Last year, the situation was only marginally better. The U.S. population had much more immunity from vaccines and previous infections, but the omicron variant was leaps and bounds more transmissible than previous ones. Omicron was less likely to be fatal for an infected patient, but so many people got sick so quickly that the nationwide death toll in January 2022 spiked to more than 2,500 a day.
This winter, the “tripledemic” of the coronavirus, the flu and RSV has not been as terrible as feared. Pediatric hospitalizations for RSV rose sharply in the fall but have dropped recently. The flu started its cold-weather assault relatively early in the fall, rose quickly and has declined steadily for the past five weeks.
The big unknown now is what will happen as the health-care system feels the effects of holiday gatherings.
Jha told The Post that he compares the health-care system to a sea wall, holding back a certain level of water. In winter, when case numbers pile up, the water splashes over a little. Hospitals staff up temporarily and try to make it through until the water recedes. That’s the old normal.
But SARS-CoV-2 has dumped new water in that sea, and the flood of patients has cascading effects on other types of medical care.
Anne Zink, chief medical officer for the Alaska Department of Health, said Jha’s sea wall analogy accurately describes the stress of the pandemic on America’s overall declining health.
“The sea wall was crumbling before the pandemic, and the waves of the pandemic created great holes, and that continual onslaught will degrade the wall and make it worse,” said Zink, an emergency room physician who is also president of the Association of State and Territorial Health Officials.
In addition, uncertainties in the medical supply chain have become the new normal, said Jarvis of Northern Light Health. Medication and supply shortages happen with greater frequency. Critical shortages for nurses and other staff are expected to worsen as physicians and nurses retire but aren’t replaced in the same numbers. More than 7,000 nurses at two major New York hospital systems walked off the job Monday after labor talks broke down over staffing and workloads, though tentative deals were reached Thursday enabling them to return to work.
Before the pandemic, the hospital system had always had some flexibility and had been able to manage its shortage of acute-care beds, Jarvis said. “But that flexibility is now gone,” he said. “There is no wiggle room or expansion room that we would have for anything in reserve.”
Since the start of the pandemic, experts have warned that covid-19 is not the only killer when health-care systems are under stress. People with ailments may delay tests and screenings, they may be more reluctant to go to the hospital for fear of catching an infection, and patients may wind up waiting hours for an examination when minutes count.
“Delays of care will result in people having either more severe disease or, unfortunately, dying, and there’s little that we can do to prevent that,” Jarvis said. “You know, that has always happened, but never to the extent that it’s happening now.”
As for the future, “it’s only going to get worse,” Jarvis said.
Hospitals are already under financial stress because of rising labor costs, physician burnout and the trend toward outpatient treatment. The added coronavirus strain is likely to push some facilities over the edge, noted Robert Wachter, a professor and chair of the Department of Medicine at the University of California at San Francisco.
“With all of this, you’ll see hospitals … begin closing at a faster pace, leaving some rural/suburban communities without a hospital, and fewer hospitals in urban areas,” Wachter said by email.
So far, Congress and the federal government broadly have not taken concerted action to address these chronic challenges. There is no cavalry on the horizon for the health-care system.
Some officials in the Biden administration aren’t sure the scenario will be quite as grim as Jha outlined.
“It’s not an unreasonable hypothesis,” said one senior administration official involved with the coronavirus response, who was not authorized to speak publicly and spoke on the condition of anonymity. “But I don’t think we have hit a steady state of disease to be able to say for sure what we will see year in and year out. … It’s very dynamic.”
“We all agree that the virus is evolving faster than we thought. We just don’t know where the virus is headed. We don’t even know what the next three weeks are going to hold.”
As always, the unknown factor in predicting the coming months and years is evolution: Viruses mutate. There is no way to predict what the coronavirus will do next, but experts do not think it has run out of evolutionary space.
Still, for more than a year, all of the new circulating versions of the virus have been subvariants of omicron and have not shown signs of making people sicker.
“If XBB.1.5 had the virulence of delta, we would be in deep weeds,” said Ross McKinney, chief scientific officer for the Association of American Medical Colleges.
McKinney and other experts stress the importance of improving vaccine uptake to reduce the respiratory disease burden – to ward off severe covid-19 cases, as well as other diseases like the flu. Despite all the pain and suffering inflicted during the pandemic, vaccine acceptance remains dismayingly low, experts say.
“The willingness of the public to accept vaccines to limit the spread of these respiratory diseases is very limited,” said William Schaffner, an infectious-disease doctor at Vanderbilt University School of Medicine. “If the public doesn’t accept them, there’ll be more people sick and greater stress on the health-care system.”