In the many months since the sweeping winds of the virus that called upon the public health system to mobilize society to immunize, mask and socially distance, our approach to preventive care also been a medical casualty. Fortunately, many people were able to shift from doctors’ waiting rooms to their computer screens to tune in and Zoom in to their physicians to address more pressing health needs. But, the operative word is pressing and not preventive.
Telehealth services remain distant dreams to others. The digital divide further expands the wedge between the haves and have-nots, people with broadband, and others in rural America. Survival — whether to schedule a vaccine or doctor’s appointment — rests on being tech-literate. Good intent alone cannot resolve access-to-care problems.
The words of Howard University’s President, Dr. Wayne A.I. Frederick, who is also a professor of surgery at Howard University School of Medicine, reached the New York Times in an opinion piece and should find its way into the hands of every health-sector leader and elected official:
Expanding primary and preventive care efforts is urgent and long overdue. We should train more health care professionals who have regular contact with patients to conduct primary care services. Imagine going to the dentist or the pharmacy and getting a mammogram or a diabetes screening, in addition to having your teeth cleaned or picking up a prescription. With more trained professionals looking out for patients, we can prevent emerging problems from becoming emergencies.
Access to Care is Survival
Convenience of care is essential to people’s well-being. We read each day of too many seniors and rural Americans struggling to access this nation’s health system. We see the wise moves of public health officials to ensure the continuation of telehealth services and recognize that hybrid care is a step toward integrating in-person with on-screen medical professional relationships. Convenience supports access to care. Access to care is survival.
One of the nation’s more pressing public health threats is now gathering momentum when our front-line medical defense force — primary care — is in retreat. Slowly driven underground by the coding maze, mysterious reimbursement hurdles, physician burnout, and consumer desire for on-demand appointments, primary care is morphing before our eyes into a pharmacy-store service add-on. That change may be the straw that breaks the camel’s back when it comes to the growing threat of prediabetes and other non-communicable illnesses that progress step-by-step from sickness to death.
Consider the work needed to apply what we have learned during these many months of confronting COVID. It’s evident that people with non-communicable diseases (NCDs) such as cancer, diabetes, heart conditions, obesity and respiratory illnesses — amplified by COVID-19 – are at heightened risk for morbidity and mortality. While we look to tackle inflation and address supply chain challenges, we must revisit and reinvigorate our public health prevention and primary medicine network to engage and intervene around NCDs.
The Prediabetes Epidemic is the Perfect Public Health Storm
The scale of the problem is immense. Approximately 84 million adults — more than 1 in 3 Americans — have prediabetes. According to the Centers for Disease Control (CDC), 90% of people with prediabetes do not know they have it — nor that, left unchecked, it leads to Type 2 diabetes.
Though its symptoms are subtle, prediabetes is not benign. Like elevated blood pressure and high cholesterol, the unseen becomes the deadly.
Further complicating our ability to address this growing threat may be how we define the term “prediabetes.” For most people, prediabetes means, “Whew! I don’t have diabetes.” But prediabetes requires the toughest treatment — a real pledge on the part of the patient to change their behavior. Without a consistent commitment to healthy diet and exercise patterns, they will join an ever-growing community of people with Type 2 diabetes. If a routine medical test raised a red flag that something was precancerous, we would jump into action; a diagnosis of prediabetes can be treated no less seriously.
The Last Part of the Problem is Primary Care Access
Medical school debt — the need to see more patients in a day to make ends meet — has shifted physicians toward higher-paying medical specialties. Physician assistants and nurse practitioners have filled the gaps in front-line patient-care roles. Plus, the Amazon-era “I want it now” consumer mindset is transforming expectations for primary care. The ability to walk into a CVS MinuteClinic, Walgreen DR Walk-In, or Walmart Care Clinic for primary care is a win for patient access. But will ongoing, comprehensive medical needs — a plan for self-care instead of sick care — be tackled?
Today, fewer and fewer people have a long-term family physician who tracks their needs and feels responsible for their longevity. At the same time, the single-practitioner office — like pharma companies and hospitals — is now being “rolled-up” into larger practice groups and private practices are vanishing. At this pace, the discipline will become practically extinct. Yet, without the primary diagnostic oversight provided by a trusted health care provider, we are missing an important strand in the medical safety net between urgent and specialty care — between prevention and illness — between prediabetes and diabetes.
A Perfect Storm
It is a perfect storm. Poorer diet, higher sugar intake, and increasingly sedentary lifestyle are leading to prediabetes, which isn’t straightforward to diagnose and is often not taken seriously by patients. The most important player in defense against the condition — the primary care physician — is beginning to phase out.
Considering how the care market and medical ecosystem are shifting, we have our work cut out for us in getting ahead of this epidemic. We must take on more responsibilities ourselves as patients, armed with the knowledge that one-in-three has prediabetes. We must continue to foster good relationships with healthcare professionals, increasingly with specialists, to fill the role that primary care doctors are leaving vacant. Plus, communication between physician and patient around prediabetes must dial-up, with physicians combining tough love with access to behavioral insights to better understand how to motivate their patients. Both must find a conversational bridge that connects how a stitch in time saves eyesight, peripheral nerves, kidney function, and quality of life.
People with Health Needs are Calling Out Urgently
Dr. Fredrick, as an educator, public health advocate and physician maps out a commonsense and compassionate approach to preventing needless suffering and death — engage! His words must be read again and again by everyone allied to the cause of preventing illness:
The health care industry should also invest more in-patient outreach, communication, and education. Patients should not be required to fully understand their health risks and navigate complicated systems to receive the care they need. Nor should they have to travel far for it. We must create more convenient opportunities for patients to receive health care, especially for those who can’t take time off work or afford transportation. We should expand telemedicine efforts, which are still inaccessible for many minority communities that lack consistent access to the internet. We should also bring mobile health care services into low-income communities, just as we have set up coronavirus testing and vaccination sites across our cities.
A learned medical advisor — whether an in-person physician advocate or one powered by smart technology — who knows our name and knows what’s happening with us over time. It is the best defense we have against prediabetes and other chronic conditions. Even in the changing medical landscape (still struggling to overcome COVID-19 and the unresolved challenges of racism that result in illness), there must always be a place for that relationship. Otherwise, the ticking time bomb of 84 million prediabetic Americans will morph into the next overwhelming public health crisis.