I have written extensively and spoken about the slew of behavioural health ‘nudges’ emanating from hundreds of countries around the world that are, literally, a matter of life and death as the COVID-19 pandemic started descending upon the world.

Chief among these ‘nudges’ was the holy triad of quarantine, shelter-in-place and stayat-home. Take your pick, really. They all had the same basic intent and end goal in mind: do not go out and needlessly expose yourself or others to the virus. Unless you are a frontline worker, you should stay at home as much as possible. We must flatten the curve and keep the R0 (pronounced R naught) number, otherwise known as the reproduction number, from spiralling out of control. In the absence of a vaccine or larger population-level herd immunity, we need that R0 to be below one or, at the very least, at one if we have any chance of tamping down the spread of COVID-19.

And now, as we stare at the numbers of infected and dead scroll across our television screens on a nightly basis, we realise that there is a massive healthcare implication, outside the obvious direct impact of COVID-19, that comes with this stay-at-home nudge. People are afraid to leave their houses. And with good reason, to be sure. The disease is still ‘active’, is incredibly infectious and has a devastating effect on the most vulnerable in society, such as the elderly and immunocompromised.

But people are skipping much-needed medical appointments. Postponing previously cancelled elective procedures that have been rescheduled. Families are not vaccinating their children, as the Centers for Disease Control and Prevention (CDC) and the World Health Organization (WHO) have warned might happen. And the New York Times reports that ‘in a new study released by the Centers for Disease Control and Prevention, the vaccination rates in May for children under two years old in Michigan fell to alarming rates, including fewer than half of infants five months or younger.’ So, what the CDC and WHO said might happen, is actually happening.

As counterintuitive as it might sound, you might be risking your health by not risking your health.

The cataclysmic manifestation of the problem may lie in the effects that we see with respect to chronic disease management. The diabetic and hypertensive patients who are skipping check-ups and routine follow-up visits because  the mortality profile of this disease suggests that one of the groups that is most susceptible are those with underlying co-morbidities like metabolic syndrome and cardiovascular disease. Of course, the respiratory patients – those with chronic obstructive pulmonary disease, bronchitis and asthma – are in the same boat as the diabetics and hypertensives. The impact of this disease on the lungs is well-documented. The mental health impact of COVID-19 is clear as the pandemic weighs heavily on front-line healthcare workers. But there were millions and millions of people who had mental health conditions that required treatment and follow-up before COVID-19 hit. And then we have a whole ‘other’ group – patients with psoriasis, rheumatoid arthritis, Crohn’s disease, and also oncology patients.

And there is some evidence, albeit small, that points to the potential for a real problem in the next 12-18 months. A study published following the 2002-2004 SARS outbreak showed that chronic-care hospitalisations for diabetes dropped precipitously during the crisis but rebounded afterwards and, to no surprise, public health and health policy experts are worried that similar problems could crop up as a result of the COVID-19 pandemic.

This tsunami of chronic disease management patients who are missing regular and routine  care, the reticence to rebook previously cancelled elective surgeries and the alarming reductions in important childhood vaccinations are all exacerbated by two factors. First, we do not have a vaccine available and we probably will not for at least another 12 months when manufacturing and distribution times are factored into the equation. Second, there is widespread agreement that there will be a potentially calamitous return of this virus in the late fall and early winter in northern hemisphere countries.

All of these factors combined make those who are staying at home fearful of venturing anywhere near a healthcare facility (and, in some cases, other places too). We need to find a way, through the use of telehealth, the designation of specific hospitals as non-COVID-19 facilities, and urgent health communication strategies, to get those who are able and who are at low risk to continue with regular and routine care.

Otherwise, it seems, COVID-19 is not going to be our only problem.

You thought getting people to stay at home was hard – getting them to leave home might be harder

This article was originally published here.