Understanding collateral damage: introducing a series on Primary Care and Public Health in the Wake of the COVID-19 Pandemic
When I first met Dick, he was a 74-year-old man recovering from back surgery who came to the office to report dizziness; I did not find a cause for this symptom. He had diabetes that was then well controlled on insulin (hemoglobin A1c was 6.3), atrial fibrillation for which he was on digoxin and warfarin, and a defibrillator that had not recently fired; his ejection fraction had risen from 25% years before to 45% months prior. When I saw him next 3 years later, he was slated to have back surgery again, for the fifth time; he had been found to have obstructive sleep apnea but did not tolerate continuous positive airway pressure (CPAP). The procedure did reduce his level of pain, but by the next year (in February 2020) he had been offered additional surgery, which he declined. He was able to work for 12 hours at their restaurant and only wore his back brace when he was going to get on his tractor.
The first time I saw Dick during the coronavirus disease 2019 (COVID-19) pandemic was in May 2020. He did have back pain that limited sleep, but he could walk to his barn one hundred yards away, or down the road. He again had dizziness, and had fallen when he was not particularly careful getting out of bed or going to the bathroom. In September he was seeking a second opinion for constant back pain, having found out that a screw in his spine was broken; dizziness was triggered by bending at that time. And in February 2021 he was pending cardiology input ahead of lumbar surgery intended to mitigate pain that brought him to tears—retrospectively, the last back procedure had reduced pain for 1 year. This arthrodesis only relieved pain for months; corrective surgery was planned for July 2021 to address a dislodged screw.
Unfortunately, Dick lost a daughter to COVID-19 in October 2021. He obtained medical care as before with the help of his wife and surviving daughter; a myelogram was pending as he mulled (repeat) neck surgery. However, about 2 weeks after his loss he presented with slurred speech and confusion; icterus was noted. Computed tomography of the brain showed no infarct, and abdominal ultrasound did not reveal a cause of his new elevation in alanine aminotransferase (from 10 to 514 units/L) and mild elevation in total bilirubin (to 1.8 mg/dL). Ultimately, the cause of sudden hepatic derangement was not found—in retrospect, Dick may have had stress-induced liver injury (1)—and he was discharged home with palliative care. He responded to symptomatic care over the course of months, until he suddenly died at home in April 2022, days before he would have turned 80.
Although Dick had COVID-19 in February 2022, his death was not related to direct effects of coronavirus; he had received three vaccines against COVID-19. The life expectancy of some Americans dropped significantly in 2020 and 2021 compared to prior years (2); it is however not known how many extra deaths occurred during the pandemic because of grief or stress attributable to losing family members to COVID-19. A good ‘family history’ gets updated regularly; I believe it remains important to ask patients about the health of family members and offer health maintenance tips where indicated.
The articles following this preface make up the special series “Primary Care and Public Health in the Wake of the COVID-19 Pandemic”. The collection will highlight the intersection between primary/ambulatory care and public/population health amidst the ebbs and flows of COVID-19.
Acknowledgments
Funding: None.
Footnote
Provenance and Peer Review: This article was commissioned by the editorial office, Journal of Public Health and Emergency for the series “Primary Care and Public Health in the Wake of the COVID-19 Pandemic”. The article has undergone external peer review.
Peer Review File: Available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-35/prf
Conflicts of Interest: The author has completed the ICMJE uniform disclosure form (available at https://jphe.amegroups.com/article/view/10.21037/jphe-23-35/coif). The series “Primary Care and Public Health in the Wake of the COVID-19 Pandemic” was commissioned by the editorial office without any funding or sponsorship. V.O.K. served as an unpaid Guest Editor of the series and serves as an unpaid editorial board member of the Journal of Public Health and Emergency from April 2023 to March 2025. The author has no other conflicts of interest to declare.
Ethical Statement: The author is accountable for all aspects of the work in ensuring that questions related to the accuracy or integrity of any part of the work are appropriately investigated and resolved.
Open Access Statement: This is an Open Access article distributed in accordance with the Creative Commons Attribution-NonCommercial-NoDerivs 4.0 International License (CC BY-NC-ND 4.0), which permits the non-commercial replication and distribution of the article with the strict proviso that no changes or edits are made and the original work is properly cited (including links to both the formal publication through the relevant DOI and the license). See: https://creativecommons.org/licenses/by-nc-nd/4.0/.
References
- Joung JY, Cho JH, Kim YH, et al. A literature review for the mechanisms of stress-induced liver injury. Brain Behav 2019;9:e01235. [Crossref] [PubMed]
- Schwandt H, Currie J, von Wachter T, et al. Changes in the Relationship Between Income and Life Expectancy Before and During the COVID-19 Pandemic, California, 2015-2021. JAMA 2022;328:360-6. [Crossref] [PubMed]
Cite this article as: Kolade VO. Understanding collateral damage: introducing a series on Primary Care and Public Health in the Wake of the COVID-19 Pandemic. J Public Health Emerg 2023;7:23.
