‘Menu of neglect’: the long-term health problems being ignored in US amid pandemic
Many routine measures are being skipped, such as childhood vaccinations and lead screenings, as experts warn pandemic is likely to widen health inequalities
Last modified on Mon 26 Apr 2021 07.09 EDT
Health resources diverted to fight the Covid-19 pandemic have caused a major drop in critical preventative care including childhood vaccinations and lead screenings, sexually transmitted disease testing and substance abuse services.
In short, many of the routine measures meant to keep Americans healthy – and keep American health from slipping further behind that of other developed, peer nations – have hit a worrying cliff.
As attention has focused on the immediate crisis of the pandemic and the hundreds of thousands of lives lost in America, this other hidden crisis represents another layer of disaster that also has profound implications.
“This is either the second or first worst pandemic in modern human history,” said Dr Howard Markel, a pandemic historian and pediatrician at the University of Michigan. “We knew there would be repercussions and unintended consequences.”
Now, there is a “whole menu of neglect” to address as a national vaccine campaign allows people to slowly emerge from a year of lockdowns and social distancing. “There is no historical precedent for this,” added Markel.
In the first few months of the pandemic alone, at least 400,000 children missed screenings for lead, a toxic heavy metal. Doctors and nurses ordered 3m fewer vaccines for children and 400,000 fewer for measles specifically.
For the first time, clinics were forced to ration lab tests for sexually transmitted diseases as lab capacity and supplies were diverted to test for Covid-19. Contact tracers were also re-deployed from tracking chlamydia, gonorrhea and syphilis cases to finding people in contact with Covid-19 patients.
Data from one large commercial lab showed 669,000 fewer HIV tests were processed. Compared to 2019, the lab diagnosed nearly 5,000 fewer cases of HIV. Delayed diagnosis can lead to people unwittingly transmitting the virus.
Last year, more than 87,000 Americans died of drug overdoses as substance abuse clinics shuttered – the highest death toll since the opioid epidemic began. Some of those clinics never fully reopened, as funding dried up.
While some of these metrics have rebounded since the most severe lockdown in March and April 2020, most have failed to fully catch up as health services remain stretched due to ongoing Covid outbreaks and budget cuts. Meanwhile millions of Americans have lost employer health insurance, slipped into poverty or had lives thrown into upheaval.
Importantly, experts warn that the pandemic is likely to widen health inequalities for those who already had disproportionately worse health – including racial and sexual minorities, the poor and the rural Americans.
“Just as this has accelerated all of the disruptive movements of American society, this has really exposed vulnerability based on poverty, poor access to healthcare, housing issues – the social determinants of health we’ve been talking about for years,” said Markel.
Lead testing
Lead is an invisible and odorless toxic heavy metal found in ageing water pipes, contaminated soil and old peeling paint – hazards found in an estimated 3.6m homes with young children nationwide, according to the Department of Housing and Urban Development.
Most lead exposure is believed to occur when babies crawl across contaminated surfaces, which is why the Centers for Disease Control and Prevention (CDC) recommend children be tested for lead at 12 and 24 months old during routine primary care checks.
As clinic visits plummeted during the pandemic, an estimated 10,000 children with elevated lead levels in 34 states went undiagnosed between January and May 2020, according to a CDC study. The fall in testing also happened as children spent more time confined at home in potentially toxic environments because of school and day care closures.
Lead is highly toxic to the brain and nervous system, as well as most other organs. There is no safe level, but the higher and longer the exposure, the worse the range and severity of the consequences.
The testing decline will probably have a disproportionate impact on Black, brown and poor families who are more likely to be living in older housing which still have lead-based paint, and have suffered the highest rates of economic distress which increases the risk of ending up in unsafe housing.
In Ohio, preliminary reports suggest testing fell by more than 30% in some cities such as Cleveland, where older housing stocks and housing instability are associated with an elevated risk of lead poisoning.
The fall in lead testing didn’t happen in isolation, according to Aparna Bole, a pediatrician in Cleveland and associate professor at the department of pediatrics at Case Western Reserve University School of Medicine.
“Development and nutritional assessments, vaccinations, child abuse and neglect, parental depression … We assess for lots of things during primary care visits which have been deferred or delayed, so kids weren’t getting diagnosed or the early interventions they needed for many things,” she said.
Childhood immunizations
Childhood immunizations to prevent potentially fatal disease fell across the US in the spring and summer of 2020, mostly due to lockdowns and diversion of resources and workers to fight Covid-19, as well as avoidance of healthcare settings as public fear spread.
In Michigan, immunizations plummeted to the lowest levels in a decade, significantly increasing the risk of outbreaks of measles, mumps and whooping cough. Vaccine coverage in all milestone age groups dropped from about 67-70% in the five years before the pandemic to less than 50% in 2020, according to state health officials.
For measles, a highly contagious virus which can lead to serious long-term complications including death, only 81% of 19- to 36-month-olds and 76% of five-year-olds have been vaccinated. To achieve herd immunity, 95% of the community must be vaccinated or otherwise immune.
“My fear is we’re going to have another pandemic take the place of what we’re experiencing now with Covid,” Bob Swanson, Michigan department of health and human services immunization division director, told the Lansing State Journal.
Nationwide, states are struggling to catch up, with recovery slowest among Black and brown children, according to Anita Shet, pediatrician and senior scientist, director of Child Health at the International Vaccine Access Center at the Johns Hopkins Bloomberg School of Public Health.
“Low vaccination coverage is a country-wide phenomenon, and one that needs a multipronged approach to combat these barriers and get everyone vaccinated,” said Shet. “If children who missed out on their vaccines during the pandemic do not get caught up, measles outbreaks can become common again very soon, and we may even see deaths.”
According to the CDC analysis, routine childhood vaccinations will prevent 8m hospitalizations and 1m early deaths for children born between 1994 and 2018.
Sexually-transmitted diseases
Even before the pandemic, sexual health services were chronically underfunded in the US. After adjusting for inflation, the spending power for STD programs has decreased by over 40% since 2003. Syphilis rates tripled over the same period.
After record numbers of chlamydia, gonorrhea and syphilis for the past six consecutive years, the figures for 2020 are expected to be significantly lower – which is terrible news, according to sexual health experts, reflecting a steep increase in undiagnosed STDs.
Left untreated, STDs can cause serious conditions including pelvic inflammatory disease, infertility, cancer, birth defects and even death. Routine tests are crucial as patients can be asymptomatic.
Accessing sexual health services became much harder last year. Nationwide, four out of five sexual health screening clinics reduced opening hours or shut down altogether sometime during the pandemic, according to a poll by the National Coalition of STD Directors (NCSD). Health departments diverted STD health staff to work on Covid-19 resulting in big declines in contact tracers for chlamydia (28%) gonorrhea (18%) and syphilis (23%). The workforce remains depleted due to budget cuts, hiring freezes and ongoing Covid outbreaks.
Last year, clinics were forced to ration STD tests as manufacturers prioritized coronavirus test kits. In October, more than 70% of labs surveyed by the American Society of Microbiology reported testing equipment shortages.
“The [shortage] situation is resolved now, but for months after clinics reopened public health labs could not find test kits for anything, it was unbelievable, we’ve never been in that situation before,” said Jennifer Mahn, associate director for clinical programs at NCSD.
In fall 2020, several states including California and Michigan reported outbreaks of drug-resistant gonorrhea, in mostly young people, which experts say was probably caused by a mutation of the bacteria that was replicating unchecked due to falls in testing and treatment. The outbreaks forced the CDC to issue new treatment guidance in December.
The rise in undetected infections is likely to disproportionately harm people of color, who have long faced higher rates of STDs and HIV due to gaps in services. In 2019, two-thirds of all babies born with congenital syphilis were Black or Latino, highlighting the stark disparities in testing and treatment, according to the NCSD.
“Historically, sexual health clinics have been the entry point for people from marginalized communities, it’s where a lot of referral to primary care, mental health and Medicaid enrollment happens, but now there are less places for those individuals to go,” said Mahn.
“It’s really scary, the pandemic has led to further cuts in an already crumbling public health infrastructure for sexual health, god knows what treatment resistant strains are out there. We’re trying to sound the alarm but budgets for STDs and HIV are always the first to be cut.”
Opioids
More than 87,000 Americans died of drug overdoses over the 12-month period that ended in September – a 27% rise on the previous year, according to preliminary data recently published by the CDC.
After a slight drop in deaths in 2018, fatal overdoses had started climbing in the months leading up to the pandemic, but went up sharply in April and May 2020 when a nationwide lockdown led to widespread closures in drug treatment and addiction support services, some of which never reopened due to budget cuts.
The states hardest hit by fatal overdoses last year included West Virginia and Kentucky, which have long ranked at the top, but notably also included California, Arizona, Louisiana and Tennessee. Most deaths were linked to synthetic opioids like fentanyl, but stimulants like methamphetamine were also involved in many fatal overdoses as dealers mixed drugs to increase profits.
A decade ago, the opioid epidemic mostly affected white Americans in rural and suburban areas, but now Black Americans are dying disproportionately. The risk of dying from a methamphetamine overdose is 12-fold higher among Indigenous Americans than other groups.
Joe Biden is yet to appoint a drugs czar to lead the charge on tackling the epidemic, but his Covid relief package includes more than $1.5bn for substance misuse prevention and treatment, and a pledge to address racial inequities in access to services.
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