The hidden side of the coronavirus tragedy

The Journal of the Brazilian College of Surgeons has contributed to better inform surgeons about the different aspects of COVID-19 since the time when the coronavirus pandemic reached Brazil¹. In addition to the terrible repercussions for the health of the population and catastrophic economic repercussions, the pandemic has a hidden side that we need to discuss immediately. While almost all the effort and investment aims at combating COVID-19, thousands of people with other diseases are in poor health. Perhaps, at the end of the pandemic, this reality will be one of the worst consequences of this whole process we are living.

The fight against the novel coronavirus suddenly caused millions of patients to lose their appointments, tests, surgeries, many of them scheduled for months. All of a sudden, hospitals have become fearsome places. Frightening, continuously repeated headlines contributed significantly to the configuration of this hidden side of the pandemic. It is a collateral damage, a bitter price to be paid by the vast majority of the population.

The famous Southern thoracic surgeon José Jesus Camargo discusses this topic in a chronicle published in the newspaper Zero Hora². Camargo argues that health authorities should guide the population without it seeming like oppression or brainwashing, and not allow fear to multiply the risk of disease. Camargo stresses that “fear, which so often protects us, can itself become a serious disease, rapidly spreading like a pandemic, also without treatment and without the prospect of a vaccine, since it is embedded in our fragile and suggestible nature”. The author emphasizes, “it is almost impossible to prevent the information to be misunderstood and, if not enough, even be distorted when traveling from mouth to mouth, exposed to personal interpretations often marked by the fatalistic spirit of the messenger”. Camargo also highlights the change in people’s perception of hospitals: “When health authorities recommended people with mild signs of flu not to run to emergencies because they would be exposed to contact with really sick patients, they were, without meaning to, demonizing the hospital environment. And, with that, causing patients with chronic diseases to get worse due to delay in medical care”. Camargo ends touching on another facet of the problem in the state of Rio Grande do Sul and in most Brazilian cities: “the Emergency Rooms, with half the capacity, as well as the empty hospitals, are already causing preventable deaths, which will certainly not be mentioned in the television bulletins, which do not account for this collateral lethality of the coronavirus”.

The New England Journal of Medicine, in a recent editorial³, questions as to how to best care for people with diseases unrelated to COVID-19. The article warns about the overall reduction in patients with coronary syndromes due to social mitigation measures, which cause patients to delay seeking medical attention, even in emergencies. Patients with acute myocardial infarction that finally access the hospital have their treatment altered due to the concern of health services and doctors themselves with the exposure of interventional cardiologists to coronavirus. Diagnostic and therapeutic conducts based on invasive procedures (cardiac catheterization and placement of stents/CABG) are replaced by clinical therapies (thrombolytics). The treatment of cancer, usually involving immunosuppressive therapy, resection of tumors, and hospital admission, is being disproportionately affected by changes in the protocols of chemotherapy and radiotherapy and in the type of therapy, operations being avoided during the pandemic. The question is: are we protecting ourselves at the expense of worse patient outcomes?

Nevertheless, not only these two areas that suffer from this COVID-19 “collateral damage”. Constraints in the care of less urgent cases also cause problems to many patients. For many operations, the line between urgent and non-urgent can be drawn only in retrospect. In another article, published in the British Journal of Surgery⁴, the authors also maintain that patients are being deprived of surgical access, with uncertain loss of function and risk of adverse prognosis as a side effect of the pandemic. The authors state, “Surgical care that is not essential or time-critical can be delayed and deferred to a later date when the pandemic subsides. However, even in the midst of a pandemic certain procedure types must be performed, including appropriate cancer treatment, emergency surgery and urgent transplantation…”. Situations that are theoretically more benign, such as abdominal wall hernias and gallbladder calculous disease, should also receive attention to avoid the need for emergency treatment or serious complications associated with disease progression. The negligence with certain surgical needs would increase the number of deaths and years of life lost due to the COVID-19 pandemic.

Another finding is that patients, in addition to surgeons, have also preferred to postpone elective operations for fear of contracting the disease in the hospital, the same fear that also leads them not to seek care for conditions that would be treatable or curable. Functional loss and reduced life expectancy may result from the delay in presentation and in late diagnosis, and this burden will increase with the duration and severity of the pandemic.

The inevitable global economic recession caused by the pandemic also directly affects both the public Unified Health System (SUS) and the private one. Many people, when lose their jobs, automatically tend to lose their health insurance plan, further burdening the SUS. Supplementary health care, with fewer customers and less financing, tends to go into crisis, just as private hospitals tend to suffer very significant financial losses. The SUS will suffer from lack of public funding due to a decrease in tax revenues in an economy in recession, mostly affecting the poor and marginalized.

When the governor of Rio Grande do Sul celebrates a 70.6% occupancy rate of the state ICU beds, with only 10% of COVID 19 confirmed patients⁵, he forgets that the low occupancy rate (compared to historic ones) demonstrates how people with other diseases are being set aside at this point. Although the pandemic can force difficult choices, a careful, transparent decision-making helps patients feel cared for. It suffices to follow the fundamental principles of medicine. We must not forget that the world does not stop and life goes on, just as acute and chronic diseases should continue to receive attention, prevention, and treatment. The need for surveillance of viral transmission does not diminish an equally important message: “COVID or not COVID, we are still here to care for our patients”.

REFERÊNCIAS

• ¹
  Correia MITD, Ramos RF, Bahten LCV. Os cirurgiões e a pandemia do COVID-19. Rev Col Bras Cir. 2020;47:e20202536.
• ²
  Camargo JJ. Quando o medo atropela a razão. Jornal Zero Hora. 2020 Abr 23. Disponível em: https://gauchazh.clicrbs.com.br/colunistas/jj-camargo/noticia/2020/04/quando-o-medo-atropela-a-razao-ck9bknpx500br017ng9im0d3a.html Acesso em 23 de abril de 2020.
  » https://gauchazh.clicrbs.com.br/colunistas/jj-camargo/noticia/2020/04/quando-o-medo-atropela-a-razao-ck9bknpx500br017ng9im0d3a.html
• ³
  Rosenbaum L. The Untold Toll - The Pandemic's Effects on Patients without Covid-19. N Engl J Med. 2020;382(24):2368-71. Epub 2020 Apr 17.
• ⁴
  Søreide K, Hallet J, Matthews JB, Schnitzbauer AA, Line PD, Lai PBS, et al. Immediate and long-term impact of the COVID-19 pandemic on delivery of surgical services. Br J Surg. 2020 Apr 30; 10.1002/bjs.11670.
  » https://doi.org/10.1002/bjs.11670
• ⁵
  Governo do Estado do Rio Grande do Sul. Secretaria de Saúde do estado do Rio Grande do Sul. Monitoramento COVID-19 [Internet]. Disponível em: https://covid.saude.rs.gov.br Acesso em 12 de maio de 2020.
  » https://covid.saude.rs.gov.br

• Funding source:

  none.

Publication Dates

• Publication in this collection
  04 Sept 2020
• Date of issue
  2020

History

• Received
  18 May 2020
• Accepted
  22 May 2020