A man is brought into Elmhurst Hospital in the Queens neighborhood, which has one of the highest infection rates of coronavirus in the nation, on April 03, 2020, in New York City. “There's going to be a tremendous number of people who die from COVID-19 who never get infected with SARS-CoV-2," said James Phillips, an emergency physician at George Washington University. (Spencer Platt/Getty Images)

On Sunday afternoon, Sarah Williams lost her cousin amid the coronavirus pandemic. Hardly into his 30s, he was never infected with the virus, said Williams, whose name has been changed to protect the family’s privacy. But a severe pain crisis, the hallmark of sickle cell disease, drove her cousin to an emergency room in Chicago utterly overwhelmed with COVID-19 patients, where he died waiting for care that could have saved his life. To his family, separating the loss from a pandemic that has swept the nation with grief is impossible — one missing tally in Illinois’ death toll Monday. Top health officials predict a U.S. COVID-19 death toll in the order of 100,000 to 240,000. But another, invisible death toll is slowly building on its back — people succumbing not to the virus, but circumstances created or exacerbated by the crumbling of the health system. “There’s going to be a tremendous number of people who die from COVID-19 who never get infected with SARS-CoV-2,” said James Phillips, an emergency physician at George Washington University. The country has a remarkable amount of resources, “but there is a limit, and when we reach that limit, you’re gonna see a lot of people not getting routine care.” The rationing of care — once unthinkable in the United States — now seems unavoidable, and at a moment of reckoning for the health system, providers are having difficult conversations about resource allocation, palliative care and end-of-life care that’s been historically undervalued. It’s important, Phillips added, that health systems collect exhaustive data on mortality rates across patient populations to inform future decisions on tailoring care.

Though the virus itself has no regard for race or socioeconomic status, early data finds black people are becoming infected and dying at higher rates, and downstream effects will certainly not fall evenly across all groups. Postponed procedures and canceled clinic visits are not expected to resume anytime soon, and telehealth is not equally accessible across the board. And although that will pay dividends insofar as reducing the spread of the coronavirus, physicians share a major concern with advocates for underserved communities: indirect damage caused by the crisis will persist long after the country declares victory over COVID-19, and disproportionately affect people who already have disparate access to care. The failure to associate those consequences with the pandemic may blunt efforts to understand not only the magnitude of tragedy, but the need for major reforms to the health system and social safety net. Sveta Mohanan, a family medicine physician at Atrium Health in Charlotte, N.C., said her greatest concern for her patients is not just the virus but the compounding effect of existing comorbidities and social and environmental inequities. With respect to rationing, not just for COVID-19 patients, but across all diseases, her fear is for patients who struggle to get care even when resources are plentiful. Physicians, advocates and experts noted that for the rich and healthy, COVID-19 itself poses the greatest threat of the moment — but it’s a risk at least partially mitigated by practicing social distancing measures. For everyone else, and especially for marginalized groups, those very measures may obstruct care for chronic illnesses and medical needs which, left unaddressed, could be fatal. Anna Nagurney, a professor at the University of Massachusetts Amherst, noted that the ongoing blood shortage could devastate patients with sickle cell anemia, chronic disease and other cancers — many of which disproportionately affect black people — dependent on blood donations. People in extreme pain, many of whom are waiting on postponed elective procedures, are struggling to get pain medication. If those patients are excluded from the COVID-19 response, “there’s going to be another disaster after this health care disaster.” Amy Hinojosa, president of MANA, A National Latina Organization, said Latino patients already struggle to get appointments rescheduled. Studies have found implicit racial bias leads clinicians to underestimate nonwhite patients’ pain, leaving them vulnerable to more severe consequences down the road.