In addition to death, disability and disruption of virtually every aspect of normal daily life, the pandemic is causing millions of people to miss or postpone medical care for non-COVID conditions. The full effect of missed and delayed care may never be accurately measured, but there is a growing sense that COVID-19 is causing extensive collateral harm.
Among the stories of people whose diagnosis and treatment have been delayed by COVID-19, Bill Gardner’s self-told tale of delayed cancer diagnosis is still fresh in my inbox, having been published just yesterday. Dr. Gardner, whose essays appear on the Incidental Economist blog, writes clearly and candidly about his experience and intends to continue to blog through his course of treatment.
Earlier this year, in certain areas of the United States (and Canada, in Dr. Gardner’s case), avoiding exposure to SARS-CoV-2 and mustering as many health workers as possible to care for COVID-19 patients were rational reasons to suspend some medical services. Everyone hoped the disruption would be brief and cause as little harm as possible.
Actions thought to be temporary in March are only now transitioning to a “new normal” pattern. Many clinicians and health systems are working hard to provide a full range of services and procedures, which involves both implementing new policies related to COVID-19 — disinfection, social distancing, screening, etc. — and convincing patients that it is safe to come back.
The need to do what is essentially public relations outreach reflects an irrational component to the disruption. This dynamic seems to have caught health systems and clinicians off guard, as seen in medical journal headlines: Where Are All the Patients? and Where Have All the Heart Attacks Gone?
Although caution in the face of a pandemic is wise, there is evidence that many people in need of care, even emergency care for heart attacks and strokes, are so fearful of COVID-19 they will not risk a trip to their local hospital’s emergency department. The irrational dimension of that reaction relates to “dread risk,” a concept that’s been around for decades, newly relevant in this moment.
I first encountered the idea and term “dread risk” in an article titled “Do Not Stay Home: We Are Ready for You.” The authors, who are the CEO and CMO of a large regional hospital in Germany, explain that the term describes disasters, such as earthquakes, nuclear plant malfunctions and the 9/11 terrorist attack, that suddenly, randomly kill a large number of people and are extensively covered in the media. These events trigger fear that leads many people to avoid things they associate with the disaster. COVID-19 leads people to avoid medical care — we can now add the coronavirus of 2020 to the list of dread risks.
Gerd Gigerenzer, Ph.D., also from Germany, has written extensively about dread risk, including an analysis of the “excess deaths” he attributes to irrational fear of flying triggered by the 9/11 terrorist attacks. In an essay about COVID-19 and dread risk, Gigerenzer argues that better “risk literacy” would allow us to make better decisions in adverse circumstances – including coronavirus pandemics – and navigate the uncertainty around us more confidently. That may be a hard sell at the moment, but it’s a valuable goal going forward. For now, Gigerenzer helps us understand a dynamic that appears to be adding to the collateral damage from COVID-19.
Countering the dread-risk effect of COVID-19 requires an approach different from dealing with the logistical challenges of contacting, prioritizing and scheduling patients who are eager to return. Convincing those who now see medical facilities as places of peril, not places to go for help, is a new challenge in patient engagement and will take time and patience on all sides.