By Danny Yarnall
Social distancing is in effect across the United States in an attempt to prevent further infection of the COVID-19 virus, especially among more vulnerable populations, and ease the burden pressing on the healthcare system.
The images of children and grandchildren separated from their loved ones in nursing homes and eldercare facilities through panes of glass illuminate the pain of isolation under social distancing. In a hospital setting, that isolation can result in truly dangerous outcomes for vulnerable patients, said Penn Memory Center Co-Director Dr. Jason Karlawish.
Dr. Karlawish joined a panel of national experts to discuss the benefits and harms of social distancing, its potential mental health effects, and what relaxation measures would eventually look like as a part of a webinar series form the American Public Health Association and the National Academy of Medicine.
The webinar was the second in the series. The first examined the science behind social distancing and how past pandemic responses could inform the current response.
With Dr. Karlawish on the panel was Anne Schuchat, MD, Principal Deputy Director, Centers for Disease Control and Prevention; Sandro Galea, MD, MPH, DrPH, the Dean and Robert A. Knox Professor at the Boston University School of Public Health; and Jennifer Nuzzo, DrPH, SM, a senior scholar at Johns Hopkins’ Center for Health Security. The panel was moderated by Sharon Inouye, MD, MPH, a professor of medicine at Harvard Medical School.
The webinar began with Dr. Schuchat examining sources from cellular data usage and navigation apps to describe how Americans are following social and physical distancing guidelines over the course of the last two weeks. 30 million Americans have been asked to stay home under “unprecedented” circumstances to stop the spread of COVID-19.
She presented a model of social “pauses,” reducing work and school contacts to blunt the peak of the virus as to not overwhelm an already thinly stretched healthcare system.
And while those benefits of social distancing are apparent and necessary, it also adds the kind of collateral damage that cannot be afforded when lives are at stake.
“The question I have is who is made vulnerable by the act of social distancing,” said Dr. Karlawish.
He posited three groups of people who are unable to advance their rights, interests, or well-being due to social distancing: those that require closeness care in order to survive, those whose services require physical closeness such as caregivers or food service workers, and those whose services facilitate social or physical closeness, like workers in adult day programs or restaurant suppliers.
The risks posed to these vulnerable groups include extreme social isolation, lack of regular care, multiple paths of exposure to the virus, or delirium. Delirium is a condition often seen in hospital patients or nursing home residents causing confusion irritability, hyperactivity or complete inactivity. It can have an alarming effect on cognition and often result in re-hospitalization or death.
Dr. Karlawish offered a basic principle of justice as a way of thinking around these compound vulnerabilities.
“We need to treat equal people equally and unequal people, unequally…someone who is vulnerable merits or deserves more to be treated differently than someone who is not,” he said.
This thinking, Dr. Karlawish explained, allows necessary exceptions to be made. It allows exceptions for caregivers to receive proper personal protective equipment in order to administer vital care and consult with doctors on behalf of loved ones living with dementia and diagnosed with COVID-19 while in the hospital. It allows for exceptions to the unemployed to receive financial assistance to support themselves when laid off due to closures. It allows for exceptions to access to health insurance to protect the uninsured population put at risk due to the spread of the pandemic.
Even after addressing these vulnerabilities, there will still be people left out, Dr. Karlawish noted, making it all the more necessary to allow those individuals access to PPE and healthcare. He took special notice of what are considered total institutions like nursing homes and prisons, where individuals will have severely restricted freedom and access to these solutions, all while in close quarters for months on end.
“They are ground zero for this attention because they are ground zero for this pandemic…We need to think about how to get them access to the resources they need, such as personal protective equipment,” Dr. Karlawish said.
The webinar continued with Dr. Sandro Galea speaking on the mental health effects of similar crises and how we can learn from past events on what to expect in the wake of the COVID-19 pandemic in order to manage its mental health ramifications. Dr. Jennifer Nuzzo examined the long-term plan to move away from social distancing, looking at countries like South Korea and Singapore as models for what is needed to reduce the time spent in shutdown.
Dr. Karlawish ended his presentation with a nod to the necessity of care. “Caregivers are like the influenza vaccine, the vaccine we desire for COVID…social distancing can impede the need for care and this is the national dilemma we have to face.”
Slides and a recording for past webinars are available at covidconversations.org.