Op-Ed: Can Primary Care Prevent the Next Pandemic?

The vaccines will end this pandemic, but there’s no one-and-done shot for our collective despair.

I am a primary care doctor. Every day I’m witnessing the emotional, behavioral, physical, and medical fallout of the pandemic. The stacked traumas of COVID-19 are making us sick. The accumulated stress in my patients’ lives has naturally informed how they think, feel, and behave. Grief and loss have directly affected their medical decision-making and health. Widespread vaccination is our ticket to normalcy, but no one is immune to the trauma of the pandemic.

On the eve of reentry, we must sift through the rubble and start an honest conversation about health. What does it mean to be healthy? Where are our patients currently turning for help? How can we reimagine healthcare to meet both the mental and physical health needs of our patients?

The short answer is this: Patients need help navigating mental and physical health in one place. They need tools to dig out from trauma. They need a patient-centered medical home. As we face reentry, patients need better primary care.

We move forward as if everything is fine, but it isn’t. Not yet. Getting vaccinated and removing our masks is a solid step toward resuming normalcy, but our inner worlds need help, too. Parents are worried about the accumulated toll of pandemic restrictions on their kids. One state found students failing at twice the rate of 2019. The mothers I see in my office feel powerless to help. They may not feel like they’ve been through trauma, but the research suggests otherwise.

Two years ago, the lifetime risk of post-traumatic stress disorder (PTSD) in the U.S. was about one in 11. A recent meta-analysis of post-pandemic PTSD after other pandemics estimated the prevalence at one in five. This may even be an underestimate. Previous studies suggest that a quarter of disaster survivors experience depression and a third experience PTSD. A generation with double the likelihood of PTSD needs us now.

More than ever, our patients need help reclaiming their health and sanity. Primary care can name, normalize, and navigate patients’ mental and physical health struggles. Funding is pouring into recovery plans. A commensurate investment in rebuilding primary care is necessary if we are to address the fallout from this pandemic and attenuate the next one — whether it’s bacterial, viral, or emotional.

Primary Care Was Broken Pre-COVID

Physician shortages, burnout, poor reimbursement, workload, and time constraints conspire to make the current healthcare situation untenable. The U.S. invests heavily in health but relatively poorly in primary care: two doctors per 1000 population compared to four or more in Norway, Denmark, Sweden, and Russia. Key health outcomes, such as maternal mortality, infant mortality, and life expectancy, in the U.S. are on par with or worse than many other developed nations. At least one study suggests deficiencies in primary care — not specialists — are to blame.

Despite comprehensive health reform, many Americans still cannot afford healthcare. A study of primary care visit trends found that even those with insurance visit a doctor less frequently when sick or injured, carry debt, and skip medical care. And during the pandemic, the number of families living in poverty increased 28% to more than 65 million.

The toxic combination of fear, confusion, grief, loss, misinformation, and mixed messaging during the pandemic has made people sick. Sensing people’s desperation for practical tools and nuanced advice, many doctors (including myself) turned to writing regular newsletters and hitting social media, cable TV, and podcasts to help provide support and guidance.

People clearly want and need help managing stress. The absence of such resources itself causes anxiety, depression, and physical illness. The demand for mental health services is clear. In a 2014 CDC study, mental health visits to psychiatrists were double that of primary care. In fact, an estimated three in four patients have a physical condition with a substantial underlying mental health component.

As a primary care doctor, I spend most of my time helping people manage stress, mood, and the resulting effects on their sleeping, eating, movement, and relationships at work and at home. It’s impossible — and no longer appropriate — to ignore the relevance of our everyday mental health to our physical health and medical outcomes.

Disaster Worsens Endemic Mental Health Issues

Diseases of despair were rampant well before COVID-19. With the added trauma of the pandemic, everyone has experienced stress and loss on some level. As a result, alcohol intake, weight, and blood pressure readings are up. Sleep, activity levels, and self-care are down. It makes sense: when fear is in the driver’s seat, our thoughts, feelings, and behaviors become dysregulated. People have had a hard time coping with uncomfortable feelings, new stressors, and the absence of normal stress-relieving activities.

Every state experienced a surge of overdose deaths. A third of Americans consistently report anxiety or depressive symptoms despite the plunging COVID-19 case rates and attendant optimism for a better summer. We made no headway on reducing suicide rates.

Depression is well correlated with an elevated risk of cardiovascular disease, diabetes, and mortality. Following the Great East Japan Earthquake and Tsunami in 2011, depression was significantly tied to all-cause mortality more than three years later. Trauma researchers know that often the greatest need emerges after an acute crisis recedes.

People know to see a medical doctor for diabetes and cardiovascular disease. But they don’t necessarily realize that their blood sugar and blood pressure are directly informed by their mood, stress, sleep, and everyday mental health.

Expand Primary Care to Repair the Damage

Most peoples’ mental image of COVID-19 is set in the ICU, but COVID-19 was actually an outpatient war. Primary care providers saw patients’ chronic conditions worsen, and in some cases exacerbate COVID-19. Well aware of hospitals’ capacity, we innovated to keep patients safe at home. We set up telemedicine platforms nearly overnight. We loaned pulse-oximeters to the high-risk, enrolled patients in trials of monoclonal antibodies, and set up home-based hypertension monitoring.

Primary care is where our patients want to go. Why create parallel lines of service and communication when primary care can — and does — provide the relationships and trust needed to convey nuanced medical information?

Recovery is a fragile time, with economic and emotional stressors continuing. Primary care doctors are ready to address the endemic physical and emotional toll of this crisis. Expanded access to primary care can help people pick up the pieces after the effects of stacked trauma. We need to bring our most vulnerable patients in for regular care, and we need more time with our current patients to help them take better care of themselves. We have seen what adequate funding can do to bring vaccines to the people. Now we need to rebuild primary care to provide the personalized, integrated medicine patients need if we hope to stay well.

Vaccines = Solution. Primary Care = Prevention.

Your car has a regular mechanic you trust and a recommended maintenance program. Don’t we owe our patients a system that does the same for their bodies and minds?

Let’s make the top commodity this: the relationship and time with a doctor — not testing and referring. We should be the hub for problem-solving, a place where mental and physical health meet and where we address root causes and not merely symptoms.

Let’s increase access by expanding telemedicine and ensuring everyone has a primary care doctor.

According to a Pew Research survey of U.S. adults earlier this year, 97% of U.S. adults own a cell phone. Let’s dial into people’s needs and put them back in touch with primary care when they sign a cell phone contract.

Let’s train medical students to understand the value of seeing the whole person. In fact, let’s make going to med school fun again, by offering training and residency experiences abroad in countries where primary care excels.

Let’s arm current primary care doctors with the resources they need. Foremost among these, we must bring behavioral health resources into the doctor’s office because it drives physical health and medical outcomes.

Physicians must be reimbursed for counseling, patient education, and preventive care, each of which develops the rapport which translates into good medical outcomes.

By being present with patients, instilling hope, and reminding them of how they have coped in the past, primary care providers can empower them to regain their agency and resume health-promoting habits.

Primary care can treat the endemic mental health issues worsened by collective trauma. Primary care can also attenuate the next pandemic by improving wellness.

We remain the most trusted source of medical information. We can redefine what it means to be healthy. It is not just about seeing a doctor once a year, renewing a prescription, or ordering a blood test. It’s about our everyday thoughts, feelings, behaviors.

We need to talk to our patients about the bidirectional relationship between physical and mental health. Our health and well-being depend on it.

Lucy McBride, MD, is a practicing internist in Washington, D.C. She is the author of a popular COVID-19 newsletter working to increase awareness of the intersection of mental and physical health.