This article is from the first chapter of Silent Killers, our editorial series on chronic disease.
It’s not only the infected that suffer from the coronavirus.
From cancer to diabetes, Alzheimer, or cardiovascular disorders, the label ‘pre-existing condition’ covers a galaxy of diseases. What everybody with one shares is the experience of having lived for the better part of two years in the shadow of a viral pandemic that they know puts them in special danger.
Now, they risk paying a high price once again as hospitals cut back on crucial doctors’ visits to deal with the new surge in cases of COVID-19.
The rollout of vaccines and the arrival of new treatments have caused coronavirus deaths to plunge — even in Europe, where a fourth wave is raging, mortality rates are below where they were a year ago.
But the lower death count hasn’t prevented intensive care units from filling up, and that means the virus isn’t just a problem for those who catch it. The most vulnerable, who rely on health services for regular check-ups and treatment, are also suffering.
“People are focusing on the virus and not on its consequences,” Bente Mikkelsen, director of the World Health Organization’s Department for non-communicable diseases, told POLITICO. The WHO has observed a drop in access to key medicines like insulin, as well as drugs for cancer, hypertension and others, she said.
With each coronavirus wave, overwhelmed hospitals are forced to put on hold everything that isn’t considered essential. Surgeries that can wait get put on the back burner, cancer screenings get dropped, and physical rehabilitation appointments are canceled.
In the Czech Republic, for example, hospitals are grinding to a halt as they fill with COVID-19 patients and suspend elective procedures. Similar scenes are playing out in Austria and Slovakia.
Across Europe, medical specialists in a range of fields interviewed by POLITICO reported major disruptions to their work. More than one doctor complained that, because of interruptions to health services, they were treating serious cases of the kind “hadn’t been seen in 20 years.”
Now that coronavirus infections are setting new records in many European countries on the eve of winter, doctors worry that hospitals will again go into survival mode. And it will be those who are most sick who pay the price.
Risk factors
Even in the early days of the pandemic when the coronavirus was still a mystery illness raging in Wuhan, the profile of the typical patient at the greatest risk was clear: They were older, but more than that, they were fragile, suffering from multiple existing conditions like obesity, diabetes or cardiovascular problems.
Recent research has confirmed that trend.
!function(e,t,i,n,r,d){function o(e,i,n,r){t[s].list.push({id:e,title:r,container:i,type:n})}var a=”script”,s=”InfogramEmbeds”,c=e.getElementsByTagName(a),l=c[0];if(/^/{2}/.test(i)&&0===t.location.protocol.indexOf(“file”)&&(i=”http:”+i),!t[s]){t[s]={script:i,list:[]};var m=e.createElement(a);m.async=1,m.src=i,l.parentNode.insertBefore(m,l)}t[s].add=o;var p=c[c.length-1],f=e.createElement(“div”);p.parentNode.insertBefore(f,p),t[s].add(n,f,r,d)}(document,window,”//e.infogr.am/js/dist/embed-loader-min.js”,”e6b0c86d-98a8-4e1e-8b96-ac01c46c4ad5″,”interactive”,””);
One study by researchers at the European Centre for Disease Prevention and Control (ECDC) and other disease control experts, which awaits peer review, found that patients suffering common chronic ailments are many times more likely than others to die of COVID-19.
Obesity, and the related disease of diabetes, is one well-known risk factor. Experts link higher mortality rates with inflammation, to which obese patients are more prone. Greater difficulty in breathing and filling lungs with oxygen due to more physical weight on the lungs is also thought to play a role.
Coronavirus infections can cause cardiovascular disorders like thrombosis and myocarditis, said Jose Zamorano, head of cardiology at the Ramón y Cajal University Hospital in Madrid. At the same time, patients who already have cardiac problems “have a worse prognosis if they are infected,” he explained.
It’s the same story with other types of disease.
A U.S. study found that, once infected, patients on dialysis had an almost 20 percent higher risk of dying than comparable patients not on dialysis.
These patients are “really at very high risk,” said Andreas Kronbichler, a kidney doctor who worked in Innsbruck, Austria, during the first wave.
Patients in need of dialysis have to go into the hospital often, and each visit can be deadly due to the risk of catching COVID-19 there. Meanwhile, the process of getting a kidney transplant, which could help get patients off dialysis, gets ground to a halt for weeks.
“You’re not only throwing away potential donated organs … but you have an awful backlog,” explained Kronbichler.
The kidney specialist is now in the U.K., but he said his home country of Austria was experiencing a rerun of the first wave: “There’s no transplants anymore. Patients are dying on the waiting lists.”
The advent of effective vaccines has provided much-needed protection, and vulnerable patients with preexisting conditions have been brought to the front of the line to receive them. But the jabs are not a silver bullet. Transplant patients, for example, can have problems mounting an immune response to vaccines, said Kronbichler — something seen among other patients with compromised immune systems.
Booster doses can help by kickstarting an immune reaction that’s way larger than the first round of vaccinations, and new coronavirus drugs, like the antiviral pills developed by Pfizer or Merck, can also reduce risk.
Meltdown
More than the overt danger from coronavirus infection, patients suffering from non-communicable diseases have been hit by the collapse of routine health services: from prevention to treatment and rehabilitation.
Paola Santalucia is a neurologist and cardiologist who led a stroke unit in Milan during the early stages of the pandemic in Europe, when northern Italy bore the brunt. COVID-19, she said, hit the health system in northern Italy “like a shockwave.”
With a stroke, speed is everything, said Santalucia: It can make the difference between full recovery and permanent disability — or even death
In normal times, a patient can go from calling emergency services to being treated within an hour. That carefully orchestrated system was blown up by COVID-19, said the stroke specialist, who is also vice president of Italy’s association for the fight against thrombosis and cardiovascular disease (ALT). Emergency services were flooded by COVID-19 patients. Milan’s biggest hospital, Niguardia, at one point had a line of 60 ambulances waiting to get in.
Santalucia said things got so bad that there were cases where stroke victims that had “light” symptoms were told to stay at home. Doctors were forced to make excruciating judgments that the danger of being inside of a hospital in which the coronavirus was raging was just too great.
A report by the World Health Organization’s Europe office surveyed 39 countries in the region: Eighty percent of respondents said there had been at least some disruption. Cancer treatment and cardiovascular services had the least disruption, but still almost a third of respondents reported some difficulties.
!function(e,t,i,n,r,d){function o(e,i,n,r){t[s].list.push({id:e,title:r,container:i,type:n})}var a=”script”,s=”InfogramEmbeds”,c=e.getElementsByTagName(a),l=c[0];if(/^/{2}/.test(i)&&0===t.location.protocol.indexOf(“file”)&&(i=”http:”+i),!t[s]){t[s]={script:i,list:[]};var m=e.createElement(a);m.async=1,m.src=i,l.parentNode.insertBefore(m,l)}t[s].add=o;var p=c[c.length-1],f=e.createElement(“div”);p.parentNode.insertBefore(f,p),t[s].add(n,f,r,d)}(document,window,”//e.infogr.am/js/dist/embed-loader-min.js”,”8bdfbf8f-667c-44dd-ba20-937f827ee4a5″,”interactive”,””);
Even with hospital departments up and running again, long wait times and a decrease in patient visits can still delay treatment. In the U.K., for example, hospital referrals for specialist doctors plunged in the first wave — and remain below pre-pandemic levels.
“COVID-19 has created challenges for health systems of a really unprecedented scale,” said Sarah Reed, a senior fellow at Nuffield Trust, a think tank focused on improving health care.
Even the most well-equipped health systems have been forced to delay routine treatments, added Reed, either to avoid patients coming into contact with people infected by the coronavirus, or because they were overwhelmed.
The end result: huge backlogs and doctors working overtime to catch up.
!function(e,t,i,n,r,d){function o(e,i,n,r){t[s].list.push({id:e,title:r,container:i,type:n})}var a=”script”,s=”InfogramEmbeds”,c=e.getElementsByTagName(a),l=c[0];if(/^/{2}/.test(i)&&0===t.location.protocol.indexOf(“file”)&&(i=”http:”+i),!t[s]){t[s]={script:i,list:[]};var m=e.createElement(a);m.async=1,m.src=i,l.parentNode.insertBefore(m,l)}t[s].add=o;var p=c[c.length-1],f=e.createElement(“div”);p.parentNode.insertBefore(f,p),t[s].add(n,f,r,d)}(document,window,”//e.infogr.am/js/dist/embed-loader-min.js”,”db593cb3-fe71-4dfa-bdc5-64c9b745e17f”,”interactive”,””);
The European Cancer Organisation estimates that as many as 1 million diagnoses have been missed in Europe as a result of the pandemic. The NGO has collected data on everything from missed treatments to increased mortality among cancer patients across Europe. It found, for example, a nearly 30 percent decrease in breast cancer diagnoses in France from January to September 2020 from previous years.
“I don’t think we’ll see the full effects of the pandemic for many years to come,” said Reed, who warned of a “ticking time bomb” of illnesses ready to explode after the pandemic. The risk now is that the flare-up of new coronavirus cases will reverse gains made over the summer in cutting the backlog. “That’s why curbing COVID transmission is a core part of recovery,” said Reed.
For Chantal Mathieu, head of endocrinology at the Gasthuisberg univerity hospital in Leuven, Belgium, the initial surge in COVID-19 infections was a dramatic time for diabetes patients. Cases of diabetic foot, an ulcer that can lead to amputation if left untreated, increased as patients fearful of infection stayed away from hospitals. And, lacking regular contact with their physicians, many patients experienced potentially harmful weight gain.
That situation could repeat itself as hospitals fill up and already-stretched health staff come under renewed strain.
“The chronic diseases: hypertension, obesity, diabetes — all of that which is the core business of our primary care is being neglected because [doctors] don’t have time,” said Mathieu, who is senior vice president of the European Association for the Study of Diabetes. “That will backfire.”
A shortfall of staff due to sickness as vaccine immunity wanes means that an increased workload is being borne by fewer doctors and nurses.
Doctors could go on for a couple more weeks, but not much longer, said Mathieu: “Or we will collapse.”
This article is produced with full editorial independence by POLITICO reporters and editors. Learn more about editorial content presented by outside advertisers.