The first confirmed case of the coronavirus disease 2019 (COVID-19) was reported in December 2019, and the contagion has since spread across international borders, leading to a widespread global pandemic that will likely define our modern times.

As of May 1, 2020, more than 5.2 million cases had been confirmed worldwide with more than 337,000 deaths due to the sequelae of the disease.1 On January 30, 2020, the World Health Organization declared COVID19 a public health emergency, because of the reproduction number and communicability of the disease.1,2

The United States alone accounts for more than 1.59 million total cases and more than 96,000 deaths.1,3

Questions regarding the impact that COVID-19 will have on our economy, education system, mental and physical health, and overall well-being are fervently being explored worldwide.4-6

As health care providers, this pandemic provides an opportunity to rise and stand at the front line to care for patients while we adjust to a new sense of normalcy and rebuild our society.

Sustaining the Economic Blow
In addition to the deleterious effects of the infection, COVID-19 has disturbed every facet of our daily living.

In April 2020, the number of unemployed individuals rose to a staggering 18.1 million from 1.4 million before the pandemic took hold, according to the US Bureau of Labor Statistics.7 Additionally, the closing of educational institutions has left many US families in desperate need of childcare and some without a means to feed children who depend on school lunches for nutrition.8 The US Department of Agriculture National School Lunch Program, School Breakfast Program, and Child and Adult Care Food Program assist more than 35 million children in receiving adequate nutrition, and without access to school systems, more than two-thirds of US children’s nutritional needs may be compromised.8

School closures will also add to rising economic decline and unemployment rates.

In 2009, the Brookings Institution estimated that the cost of school closures for 1 week would lead to $142 lost per student and projected that a nationwide closure of just 4 weeks could cost 1% of the gross domestic product.9 The full economic impact of COVID-19 has not yet been seen. However, as much of the nation and world remain in quarantine, economic instability is predicted to rise.

Health Care Institutions at Risk
Historically, times of economic depression, natural disaster, and world wars have left the US health care system relatively unscathed in regard to economic stability.10 COVID-19 presents a new challenge. On 1 hand, hospitals in heavily affected states such as New York are facing shortages in all directions, from manpower to personal protective equipment.11 Although acute care institutions are bracing for heavy impact, ambulatory care practices are at risk of closing their doors because of the decline of billable hours and patient visits.12 Subsequently, a decrease in work hours, furloughs, and loss of jobs for many health care workers may ensue. Michigan provides an example, with health care businesses accounting for the second largest source of unemployment insurance claims at the end of March.10

Although the US Federal Government’s Coronavirus Aid, Relief, and Economic Security Act, passed on March 27, 2020, is providing more than $2 trillion in aid to US families and loans for small businesses, as well as $100 billion in aid to hospitals, resources are quickly being depleted. A sustained closure is predicted to decrease health care resources, availability of care to vulnerable populations, and further attrition of the health care workforce.10,13

Effect on Vulnerable Populations
The national decline in economic expenditure and increase in the US unemployment rate have also disproportionally affected the vulnerable and weak and have led to a loss of adequate health care coverage for many.10 Patients displaced from the health care system, because of an inability to afford care and poor insurance coverage may be inequitably affected by this pandemic, while the country remains at a standstill.14

The Centers for Disease Control and Prevention said that individuals with chronic health conditions, such as asthma, diabetes, and heart, liver, and kidney disorders, as well as the immunocompromised and adults 65 years and older are at an especially high risk of suffering poor outcomes if infected with COVID-19.15 A reduction in chronic disease management because of an inability to afford health care costs poses an additional risk of succumbing to the negative outcomes of the virus for individuals in this population.

Psychological Impact
Social distancing poses yet another challenge that is unprecedented in modern times. The increasing uncertainty surrounding the reopening of society and a shift to “normalcy” may have an impact far greater than the pandemic alone.16 The question of how individuals and communities at large will respond to mandatory social distancing and sheltering-in-place orders is a question yet unanswered.

In many ways, society is better prepared for a socially distant world by comparison to historical periods of quarantine, such as during the 1918 Spanish Flu.17 A readily accessible online consumer market and widespread access to virtual social platforms has temporarily softened the blow of isolation for many.17 However, even with the availability of a “virtual reality,” the psychological impact of quarantining should not be minimized.

Historical evidence has demonstrated that levels of anxiety, depression, posttraumatic stress disorder, and substance use disorder all rise following natural disasters, wars, and other traumatic world events.5,18 Literature regarding the aftermath of pandemics is scarce. However, even the short period following the 2009 SARS epidemic saw a rise in anxiety and depression for both patients and providers.5 Additionally, stay-at-home orders may be accompanied by increased rates of child abuse and domestic violence.5 Furthermore, reduced access to mental health providers and support groups during social isolation may make it more difficult for at-risk populations to seek appropriate care. Health care providers must take extra caution to stay attuned to their patients’ emotional well-being to prevent chronic mental health issues that may affect our society for generations to come.18

Pharmacists’ Role
Pharmacists’ role in the COVID-19 pandemic is paramount. Community pharmacists are working on the front line as some of the few health care providers who remain accessible in an increasingly virtual world.19 Given the risk that uncontrolled chronic diseases can play in leading to poor COVID-19 outcomes, pharmacists must ensure that medication accessibility and adherence is maintained during these uncertain times. Additionally, a need for widespread national testing remains, and local pharmacies provide a safe and trusted location for individuals to get tested for the virus. With the US Department of Health and Human Services authorizing licensed pharmacists to order and administer COVID-19 tests, pharmacists are able to help ensure the safety of communities and serve as essential providers during this pandemic.20 Additionally, counseling on appropriate medication use and encouraging stringent management of chronic conditions will be increasingly necessary during this time. Pharmacists should take this opportunity to engage with health professional colleagues to ensure that patients are not lost to follow-up and are able to receive medications in a timely manner.19

Conclusion
The COVID-19 pandemic has undoubtedly shaken our society and world in ways we cannot yet understand. From a sudden economic recession to worldwide isolation, the effects of this disease will likely define our era. Historical references of social quarantine provide us with valuable lessons regarding the short- and long-term effects of social distancing and closure of our brick-and-mortar institutions. Amid social isolation, pharmacists offer refuge to the sick and vulnerable by serving as frontline providers and remaining accessible during these uncertain times. As the COVID-19 pandemic continues to unfold, health care providers can respond to those in need by donning our white coats and advocating for patients to help maintain the health and well-being of our society.
 
Luma Munjy, PharmD, is an assistant professor of pharmacy practice at the Chapman University School of Pharmacy in Irvine, California.


REFERENCES
  1. Coronavirus disease (COVID-19) pandemic. World Health Organization. Updated May 23, 2020. Accessed May 24, 2020. https:// www.who.int/emergencies/diseases/novel-coronavirus-2019
  2. Ho CS, Chee CY, Ho RC. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Ann Acad Med Singapore. 2020;49(3):155-160.
  3. Coronavirus disease 2019 (COVID-19). Centers for Disease Control and Prevention. Updated May 23, 2020. Accessed May 24, 2020. https://www. cdc.gov/coronavirus/2019-ncov/cases-updates/cases-in-us.html
  4. Nicola M, Alsafi Z, Sohrabi C, et al. The socio-economic implications of the coronavirus and COVID-19 pandemic: a review. Int J Surg. 2020;78:185-193. doi:10.1016/j.ijsu.2020.04.018
  5. Galea S, Merchant RM, Lurie N. The mental health consequences of COVID-19 and physical distancing: the need for prevention and early intervention. JAMA Int Med. 2020. doi: 10.1001/jamainternmed.2020.1562
  6. Anderson RM, Heesterbeek H, Klinkenberg D, Hollingsworth TD. How will country-based mitigation measures influence the course of the COVID-19 epidemic? Lancet. 2020;395(10228):931-934. doi: 10.1016/ S0140-6736(20)30567-5
  7. Employment situation summary. US Bureau of Labor Statistics. Updated May 11, 2020. Accessed May 24, 2020. https://www.bls.gov/ news.release/empsit.nr0.htm
  8. Dunn CG, Kenney E, Fleishchhacker SE, Bleich SN. Feeding low-income children during the Covid-19 pandemic. N Engl J Med. 2020;382(18):e40. doi: 10.1056/NEJMp2005638
  9. Lempel H, Epstein JM, Hammond RA. Economic cost and health care workforce effects of school closures in the U.S. PLoS Curr. 2009;1:RRN1051. doi: 10.1371/currents.rrn1051
  10. Cutler D. How will Covid-19 affect the health care economy? JAMA Network. April 9, 2020. Accessed April 24, 2020. https://www.jamanetwork.com/channels/health-forum/fullarticle/2764547
  11. Ranney ML, Griffeth V, Jha AK. Critical supply shortages - the need for ventilators and personal protective equipment during the COVID-19 pandemic. N Engl J Med. 2020;382(18):e41. doi: 10.1056/NEJMp2006141
  12. Bebinger M. Furloughs, retirement cuts and less pay hit Mass. doctors and nurses as COVID-19 spreads. WBUR. March 28, 2020. Accessed April 24, 2020. https://www.wbur.org/commonhealth/2020/03/27/doctors-nurses-mass-coronavirus-infections-pay-benefits
  13. The CARES act works for all Americans. US Department of the Treasury. Accessed April 24, 2020. https://www.home.treasury.gov/policy-issues/cares
  14. Woolhandler S, Himmelstein DU. Intersecting U.S. epidemics: Covid19 and lack of health insurance [published online ahead of print April 7, 2020]. Ann Intern Med. 2020 Apr 7; M20-1491. doi: 10.7326/M20-1491
  15. People who are at higher risk for severe illness. Centers for Disease Control and Prevention. Updated May 14, 2020. Accessed May 24, 2020. https://www.cdc.gov/coronavirus/2019-ncov/need-extra-precautions/ people-at-higher-risk.html
  16. DeLuca S, Coleman J, Papageorge N, Kalish E. The unequal cost of social distancing. Johns Hopkins University. Accessed April 28, 2020. https://www.coronavirus.jhu.edu/from-our-experts/the-unequal-costof-social-distancing
  17. Ungerer C. Portugal A. Leveraging e-commerce in the fight against COVID-19. Brookings Institution. April 27, 2020. Accessed April 28, 2020. https://www.brookings.edu/blog/future-development/2020/04/27/leveraging-e-commerce-in-the-fight-against-covid-19/
  18. Pfefferbaum B, North CS. Mental health and the Covid-19 pandemic. N Engl J Med. 2020. doi: 10.1056/NEJMp2008017
  19. Kretchy IA, Asiedu-Danso M, Kretchy JP. Medication management and adherence during the COVID-19 pandemic: perspectives and experiences from low- and middle-income countries. 2020;S1551-7411(20)30332-6. doi: 10.1016/j.sapharm.2020.04.007
  20. HHS statements on authorizing licensed pharmacists to order and administer Covid-19 tests. News release. US Department of Health and Human Services; April 8, 2020. Accessed April 20, 2020. https://www.hhs.gov/about/news/2020/04/08/hhs-statements-on-authorizing-licensed-pharmacists-to-order-and-administer-covid-19- tests.html