Targeted Population Health Interventions Will Boost COVID-19 Outcomes

The interaction of COVID-19 and existing chronic diseases – including diabetes, obesity, and hypertension – are associated with poorer outcomes from the virus, indicating that health systems should target population health interventions to these high-risk patients, according to researchers from the Columbia Mailman School of Public Health.

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In an opinion piece published in the British Medical Journal, the team noted that while population health strategies primarily target the elderly, underlying chronic conditions in younger people are all strongly associated with a higher risk of severe illness, hospitalization, and death from COVID-19.

The association between obesity and poor outcomes from the virus is particularly concerning. Researchers said that in the US and Mexico, more than one-third of people 15 years and older are obese. South Africa, Chile, Brazil, Colombia, and Hungary report rates of more than 20 percent.

“The global response has been to treat COVID-19 as a vertical disease rather than addressing the full ecosystem of the COVID-19 response or its interaction with the NCD pandemic or poverty,” said Nina Schwalbe, an adjunct professor in the Heilbrunn Department of Population and Family Health at Columbia Mailman School.

“This is particularly urgent given that poverty is now both a driver of COVID-mortality and an outcome of the response. Rather than relying on a vertical approach, it is time to switch gears -- assess risks, target prevention, and engage community in the response and to build synergies across care platforms.”

Interventions like social distancing and quarantine have resulted in health service disruptions and an overall worsening of health outcomes, the team stated.

“For the poor, in particular, these measures further exacerbated food insecurity and reduced access to social services.  Instead of applying blunt tools such as lockdowns to the entire population, we must urgently target those at risk,” said Juan Pablo Gutierrez, professor at the Center for Policy, Population Health and Research at the National Automous Unviersity of Mexico School of Medicine.

The impacts of these interventions will likely be felt by vulnerable communities for some time, researchers added.

“With nearly half a billion people projected to fall into extreme poverty due to the COVID-response, loss of income, high out-of-pocket costs for healthcare, food insecurity, increased unemployment levels, and lower educational attainment will all have a direct effect on morbidity and mortality worldwide,” noted Schwalbe, who is also visiting fellow at the United Nations University - International Institute for Global Health. 

To better address the association between COVID-19 mortality and underlying chronic conditions, the researchers noted that health systems will need to use data and employ improved data sharing practices to focus interventions on communities that are most at-risk.

“While the signals are clear that non-communicable diseases are a risk factor for covid-19, the granular data from the more than 400,000 deaths worldwide are not freely available to global health researchers to analyze the role of competing risk factors, disease history, medicine interactions, or other potential socioeconomic or demographic associations,” researchers said.

“Where available, it is either for purchase or researchers must sign restrictive data sharing agreements.”

Additionally, the group said that the healthcare industry should move from a vertical approach to build synergies across care platforms, particularly between underlying chronic conditions and infectious diseases.

“Rather than applying blunt tools such as lockdowns to the entire population, we must target those at risk, with more localized interventions,” researchers said.

Finally, the industry should aim to provide socioeconomically vulnerable populations with the means to reduce the pandemic response effects on poverty. The authors noted that a similar intervention is already underway in Pakistan, where the government has provided over 80 million people with emergency cash transfers.

Thus far, interventions around the world have focused only on COVID-19 and have targeted entire populations instead of those most vulnerable. This has resulted in a misallocation of resources, the team stated. Going forward, health system leaders should seek to drill down interventions to high-risk groups of patients.

“In the global response to COVID to date, we have witnessed mass fear and confusion as well as a tremendous misallocation of resources as a result of targeting the entire population rather than those most at risk,” said Schwalbe. 

“However, as COVID-19 continues to spread and there is talk of a second wave, it is not too late to apply the tools of precision, evidence-based public health to address the underlying drivers of morbidity and mortality – and this means focusing prevention efforts on people suffering from NCDs.”