To meet the challenge of enduring spread in the years to come, we must prioritize primary care and community health over the profit-driven status quo.
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The beginning of Omicron’s retreat, while welcome, is certainly not the end of our fight with COVID-19. Yes, most Americans have probably (and unfortunately) been infected with SARS-CoV-2 at least once. As of last September, the Centers for Disease Control and Prevention estimated 147 million infections in the United States since the beginning of the pandemic, and we have seen about another 30 million reported cases since then (with tens of millions more likely unreported)—all at the unfathomable toll of over 890,000 lives. On the positive side, more than 60 percent of Americans have now been “fully” vaccinated against COVID-19, gaining good resistance against severe disease without risking death. Yet even though a solid majority of Americans has some protection against COVID-19 via vaccination, infection, or a combination of the two, the promised land of “herd immunity” does not lie before us, at least not as typically envisioned.
A great deal of public discussion in recent weeks has suggested that “endemicity”—a state where the virus continues to circulate in the population like scores of other respiratory viruses, with more predictability albeit probably still with seasonal surges—is around the corner. The Europe office of the World Health Organization (WHO), for example, recently stated that the continent may be entering the “plausible endgame” of the pandemic. But if long-term circulation is unavoidable, nihilism isn’t, and the number of lives lost annually to COVID-19 in the years to come depends in large part on actions we take today. As others have argued, there is an ongoing role for public health interventions to reduce transmission of the virus during surges, together with a need for massive investment in our nation’s underfunded public health infrastructure—for a “New Deal for Public Health,” as health law scholar Amy Kapczynski and epidemiologist Gregg Gonsalves outlined in these pages nearly two years ago. Yet less has been said about improving our medical care response itself, particularly in the new era. There should be little doubt: minimizing harm in an era of endemic COVID-19 requires us to reimagine key aspects of our medical system.
Since the pandemic began, many have hung their hopes on a misguided notion of “herd immunity,” implicitly assuming that at a certain threshold, immunity from infection and vaccination within a population could all but eradicate COVID-19, as it has for smallpox or measles. (The political right’s let-it-rip strategy is based on the idea that prolonging this process is futile, and we may as well rush to the endgame phase.) Clearly, this isn’t happening: instead COVID-19 is behaving, unfortunately but not surprisingly, much like other common respiratory viruses, which intermittently infect and reinfect people throughout their lives.
Respiratory viruses that behave this way—including influenza, respiratory syncytial virus (RSV), and four seasonal coronaviruses—tend to function as universal childhood illnesses that continue to beleaguer us throughout adolescence and adulthood, causing recurrent colds, flu-like syndromes, and sometimes even pneumonia. Influenza, for instance, infects 100 percent of children by age 7 yet even in adulthood infects 1 in 10 (or maybe more) of us each year, although vaccination helps. RSV and the seasonal coronaviruses act similarly, infecting virtually all of us as children yet continuing to cause respiratory infections through our lifespans.
In other words, even with repeated infections, none of these viral respiratory infections produces what scientists call “sterilizing immunity,” or durable protection against future infection—unlike brushes with (or vaccination against) measles or smallpox. All the evidence today points to SARS-CoV-2 being in the same boat. This is not to say vaccines or infections provide no protection at all, of course: immunity to viruses like SARS-CoV-2 certainly appears to durably reduce the risk of severe disease, making pneumonia—the syndrome that actually kills most people—less and less common. This phenomenon, in fact, is the basis of one theory of why the 1918 influenza pandemic “ended” even though the virus itself never really went away: its descendants still circulate today, but with sufficient population immunity the pathogens trigger more colds than bouts of pneumonia, rendering it indistinguishable from other influenza strains. Ultimately, this too is a type of “herd immunity,” albeit a less desirable one.
But if we can reasonably envision the broad outlines of COVID-19’s trajectory, we still don’t know the critical specifics. We can’t assume that SARS-CoV-2 will behave exactly the same as these other viruses or reach an equivalent level of virulence, and there’s not enough evidence at the moment to say how quickly we should expect that to happen, even if we think it will. And today, mass death is still ongoing. COVID-19 is now killing more than 2,000 people a day in the United States—a death rate simply incomparable to seasonal influenza. Two years into the pandemic, with a substantial majority of the population with some immunity, we still see COVID-19 patients with severe pneumonia coming to the Boston-area ICU where I work as a critical care physician. So while it is possible that at the endemic endpoint, the risk of severe pneumonia from SARS-CoV-2 infection could (happily) fall to that of the four seasonal coronaviruses now in circulation, or (less happily) to that of influenza, it’s also plausible that the human toll of COVID-19 will remain double or even triple that of seasonal influenza indefinitely (or even worse). And even if the novel coronavirus does eventually come to mimic influenza in its annual impact thanks to increasing levels of population immunity, it would still cause a large amount of additional illness and death, disproportionately borne by chronically ill and elderly people.
This should not be seen as acceptable or “natural.” In the years to come, a key defense against it should be a robust primary care–based medical response.
The lion’s share of the health benefits delivered by modern medicine comes from the practice of primary care in outpatient settings. Primary care clinicians’ provision of preventive care, along with their diagnosis and management of common chronic diseases like hypertension, probably has a larger health impact than anything else in medicine—including what I do in the ICU, along with the organ transplants, robotic surgeries, and sub-sub-specialties often seen as “cutting-edge medicine.” Primary care clinicians provide a personalized entry point into the health care system, offering preventive services including vaccinations, evaluating and mitigating the innumerable symptoms that pester and plague us throughout our lives, and serving as a long-term trusted source of counsel on health matters.
Unfortunately, for decades the balance between primary and specialty care has been growing more and more distorted in the United States. Per capita visits to primary care physician physicians have been declining for years, while the provision of specialty care is rising. One in four Americans lacks a primary care physician altogether, while the proportion of health spending devoted to primary care is shrinking. Relatedly, the number of primary care physicians per capita has been falling as the ranks of specialists continue to grow. These trends speak to the underlying profit-oriented dynamics of American medicine: capital-intensive forms of care tend to be the most lucrative. This is unfortunate for many reasons, including the fact that a far stronger primary care system could prove a powerful tool to minimize loss of life from endemic COVID-19.
Take COVID-19 vaccinations. In the future, annual COVID-19 booster shots may prove useful, as is the case with influenza vaccination. Yet even today, in the midst of a giant surge of death, a quarter of adults remain unvaccinated, and about 55 percent of fully vaccinated adults have not been boosted. Political polarization and misinformation explain some of this situation, but our fragmented, exclusionary, for-profit health care system that marginalizes primary care is also to blame—along with the weak response from the federal government, which has chosen to rely more on privatized vaccinated distribution through pharmacies like CVS and Walgreen’s instead of more robust public vaccination campaigns. A 2021 survey found that Americans rated their own physicians as their single-most most trusted source of information on COVID-19 vaccines. Yet longstanding relationships between patients and physicians are increasingly rare in our corporatized health care landscape, with ever-shifting insurance networks, onerous cost barriers, or the rapid expansion of for-profit urgent care centers and drug store “Minute Clinics.”
We could all greatly benefit from a trusted, committed, long-term primary care clinician who advises us when we have misgivings or fears about a booster and reaches out to remind us to come in when we forgot to be vaccinated. A recent study colleagues and I completed sheds some light on this possibility. In early 2021, uninsured people were very slow to be vaccinated against COVID-19, whereas those covered by the Veterans Health Administration (VA)—the integrated, publicly financed and owned, primary-care–heavy health system for veterans—were vaccinated somewhat more quickly, and substantially more equitably, than those with other forms of insurance, even though vaccines were free for all. Notably, veterans are also more likely to be vaccinated against influenza.
The significance of primary care doesn’t only lie on the preventive side, either: it is ideally situated to efficiently distribute therapeutics that prevent a SARS-CoV-2 infection from progressing to severe pneumonia. We now have two oral antiviral medications (molnupiravir and paxlovid), an intravenous antiviral (remdesivir), and one monoclonal antibody treatment that are effective at blocking the development of severe COVID-19 in the Omicron era, but in order to have these salubrious effects, these therapies must be given shortly after symptom onset. Together with vaccines, this suite of preventive pharmacologic interventions could theoretically thwart the development of the vast majority of cases of severe pneumonia after SARS-CoV-2. But their effectiveness requires that people quickly recognize cold symptoms as possible manifestations of COVID-19, get tested, obtain results, consult with a physician, receive a prescription, and make a trip to the pharmacy—all before swallowing the first pill within five days of symptom onset.
For many of the medically vulnerable, disabled, and underinsured people at highest risk of developing severe COVID-19, jumping through all these hoops in rapid succession before the clock runs out is sure to prove impossible in our current fragmented system. It would make an enormous difference if we all had a well-resourced primary care physician to confer with when we developed symptoms that we might otherwise chalk up to allergies—who could administer a rapid turnaround test and provide or administer the appropriate preventive drugs, who would ensure prompt hospital evaluation if things went south, and who could later nag us into that annual booster if it becomes indicated.
Bolstered funding and support for a more robust primary care–based COVID-19 medical response could make a difference toward this goal even today, and it should be a priority for the Biden administration. For instance, increased funding and support for COVID-19 vaccination infrastructure and logistics in primary care practices might help in some locales. Blocking the projected expulsion of as many as 15 million people from Medicaid, as pandemic-related protections expire this year, is urgent. The full and permanent elimination of cost barriers for COVID-19-related care, partially achieved by federal legislation passed in early 2020, could also make a difference. (That legislation required insurers to cover COVID-19 testing and created a system for coverage of testing and treatment for the uninsured, but it also allowed providers to charge uninsured patients for care so long as they did not also partake in the federal system, leaving some with large bills. Meanwhile, private insurers’ voluntary waivers of co-pays and deductibles for COVID-related care are mostly a thing of the past). Other programs—like direct home delivery of antivirals, as New York City is doing—could help bridge gaps in pharmacy access.
In the longer-term, further-reaching reforms could render our COVID-19 medical response far more comprehensive and effective. For instance, single-payer health care financing in conjunction with development of neighborhood-based primary care health centers could bring the full spectrum of COVID-19–related preventive care—including vaccine outreach, rapid turnaround testing, provision of high-quality masks, and direct administration of early treatment including antivirals and monoclonal antibodies—to every community, all under one roof. Such centers could also work closely with local public health agencies in infectious disease surveillance, the identification of hot spots (including workplaces), launching vaccination clinics at schools or community events, operating mobile vaccine outreach teams, and much more.
All of which is to say: our primary care system should provide “whole population care,” an approach to primary care espoused and practiced by the radical general practitioner and epidemiologist Julian Tudor Hart. In this model of care, the health of everyone within a geographically delineated community is the responsibility of the providers, not only those patients who happen to make an appointment and show up. Such an approach, as Hart famously found in his own decades of clinical work heading a National Health Service practice responsible for a deprived Welsh mining community, can greatly improve management of chronic health conditions, which remain grossly underdiagnosed and undertreated in disadvantaged communities, and improve overall population health. It can be similarly effective in the response to endemic COVID-19 and other respiratory viruses, as well.
As community health physician Wendy Johnson recently noted in these pages, such a radical and expansive vision of primary care was also expounded by the landmark declaration that emerged from the 1978 International Conference on Primary Health Care, organized by the WHO in modern day Kazakhstan. The Declaration of Alma-Ata called for “urgent action by all governments” in the realization of a sweeping vision of comprehensive primary care that brought “health care as close as possible to where people live and work,” and once inspired a whole generation of progressive health activists. Such a spirit could inspire us, once again, today.
Of course, improving primary care in the United States is not enough. Even with far more comprehensive community-based prevention and management of COVID-19, many patients will still require hospitalization. While most countries have faced supply strain during surges, much of the dysfunction in the uniquely well-funded U.S. system (which has some of the highest ICU beds per capita in the globe) has been unnecessary. Some important improvements can be achieved under our current financing system, but, again, others would require deeper reform.
For one thing, the fragmentation and privatization of our health system has impeded a more organized, integrated, and equitable operational response by hospitals to surges. In the United States, when hospitals are overloaded, we have relied on physicians to make relentless calls to every hospital they know of to track down a scarce bed, a ritual that colleagues and I have resorted to throughout the pandemic. A recent article in the New York Times describes an overloaded rural facility that made some 200 phone calls to track down beds, including to hospitals as far as 400 miles away. In contrast, other nations have used high-speed trains and collective air transport to bring patients from more to less overrun regions, together with centralized systems of bed management and allocation within regions to achieve “load balancing.” We could do much of the same today without overhauling the health care system, but it would require embracing a spirit of cooperation and planning rather than competition, which is far too often the motivating force in American health care. Such an approach would also require state and federal support to establish regional systems capable of real-time bed tracking across all hospitals and able to redistribute patients to available beds during surges and provide critical care consultative support to smaller institutions.
A harder to fix problem is our maldistribution of health care infrastructure. Our profit-oriented health system encourages investment where it produces dividends while neglecting communities with high-needs but less potential for revenue generation—an imbalance between health care supply and needs Hart famously called the “Inverse Care Law.” Nearly half of low-income communities, for instance, have zero ICU beds, as a recent study found. So unsurprisingly, during the winter 2020–21 COVID-19 wave, the odds of critically high ICU occupancy (greater than 90 percent) were more than double for the most socially vulnerable counties compared to the most affluent. As part of our longer-term medical response, financing reform could ensure that we expand health care infrastructure—whether ICUs or primary care neighborhood health centers—where it is needed, not necessarily where it is most profitable.
Such reforms are possible under single-payer financing arrangements that socialize (and separate) expenditures on health care infrastructure from those used to cover providers’ operating costs, as is the case within the VA and Canadian national health insurance. In a far more limited (and inequitable) way, the 1946 Hill-Burton Act, which subsidized hospital construction in the United States in wake of World War II for several decades, was undergirded by the same basic idea. Such real-world policies and programs demonstrate that short-term reforms and longer-reaching transformations are indeed possible. The challenge going forward is to marshal the political will to make them a reality.
Acknowledging the endemic future of SARS-CoV-2 shouldn’t lead us to turn our backs on the medically vulnerable and embrace a “return to normal.” Instead, we must collectively insist on an effective, ongoing, and sustainable policy response—not only to support and protect those who are most at-risk for developing this particular disease, but to shore up the provision of medical care for us all.
The central lesson we should draw from our experience with COVID-19 is not that the U.S. health care system has been poorly equipped to respond to a crisis: it’s that it has been poorly equipped to serve many critical functions in the provision of meaningful and equitable health care to all Americans. In addition to public health measures outlined by others, the expansion of community-based primary care, the redistribution of health care infrastructure, and greater operational integration in our hospital system could form the backbone of a medical response that both minimizes the havoc wrought by COVID-19 and improves the provision of care for all conditions for decades to come.
Adam Gaffney, MD, MPH, is Assistant Professor of Medicine at Harvard Medical School, a pulmonologist and critical care physician at the Cambridge Health
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