Public policy for healthy living: How COVID-19 has changed the landscape

Abstract

The coronavirus disease 2019 (COVID-19) pandemic had a transformational impact on public policy as governments played a leading role, working alongside and coordinating with business/industry, healthcare, public health, education, transportation, researchers, non-governmental organizations, philanthropy, and media/communications. This paper summarizes the impact of the pandemic on different areas of public policy affecting healthy living and cardiovascular health including prevention (i.e., nutrition, physical activity, air quality, tobacco use), risk factors for chronic disease (hypertension, diabetes, obesity, substance abuse), access to health care, care delivery and payment reform, telehealth and digital health, research, and employment policy. The paper underscores where public policy is evolving and where there are needs for future evidence base to inform policy development, and the intersections between the public and private sectors across the policy continuum. There is a continued need for global multi-sector coordination to optimize population health.

Introduction

Governments across the world played a leading role in responding to the coronavirus disease 2019 (COVID-19) pandemic, working alongside business/industry, healthcare, education, the media, biomedical research, transportation and other key sectors to attenuate the risk to global health. Even though there were significant shortcomings in government responses, the scope of governments' role was massive including coordinating a public health response that included surveillance and data modernization, testing, contact tracing, containment policies, prevention, messaging to the public and local, state/regional, national, and global coordination. Governments also partially funded important biomedical research for vaccine development and other treatment strategies, provided financial relief to industries impacted by closures and reduced travel, managed border crossings and travel restrictions, and helped address supply chain shortages across numerous sectors, all with necessary consideration for national security, safety, economic ramifications and population health and well-being.

A review of the effectiveness of government responses has begun,¹ hopefully leading to critical changes and enhancements in public health infrastructure and workforce, dissemination of scientific findings and surveillance data in a more coordinated and rapid way, translating evidence into actionable and understandable policy, becoming more effective at public health communications, and prioritizing the private-public partnerships that are essential for future global pandemic challenges. The United Nations' 2030 Agenda for Sustainable Development with its 17 Sustainable Development Goals provides a foundation for global coordination around a shared blueprint to improve population health and well-being.² This paper will review areas of public policy related to healthy living and cardiovascular (CV) health, including nutrition security, air quality, physical activity, tobacco and nicotine use, substance abuse, mental health, obesity, hypertension, diabetes, access to health insurance, telehealth and digital health; areas where the pandemic has had a current and future impact. Table 1 summarizes these public policy levers, levels of government response, and impacted industries for future improvements in pandemic planning and action.

Table 1.

Public policy levers affected by the pandemic and industry/Private sector involvement.

Issue	Examples of Public Policy Levers	Level of Government Response	Industries Affected by the Issue or Are Part of Creating Solutions
Prevention & treatment
Physical activity promotion	Public Health Guidance on Access to and Use of Gyms, Fitness Facilities, Recreational Spaces, (Indoor and Outdoor), Parks, Sports Programs	Federal, State, Local	Fitness Clubs, Health, Active Living, Recreation Industry, Parks Fitness Apparel/Equipment Manufacturers, Home-Based Fitness, Technology Industry, Digital Health, Curriculum Development/Support, School Equipment, Health Care, Public Health, Sports Industry/Youth Sports Programming, Sports Governing Bodies
	Comprehensive School Physical Activity Programs in Schools	State, Local
	Physical Activity Assessment, Prescription and Referral	Federal, State
Active transportation infrastructure	Complete Streets Policies Safe Routes to Schools	Federal, State, Local	Transportation, Community Planning, Engineering, Design, Manufacturing, Construction
	Community Design/Connectivity	Federal, State, Local
Nutrition security	Increased appropriations for and access to government nutrition assistance programs	Federal, State, Local	Agriculture, Local Farming, Food Manufacturers, Restaurants, Transportation, Food Retailers
	Maintaining food supply chains	Federal, State
	Food safety	Federal
	Retail food environment policies (living wage, menu labeling, public access to away from home eating during pandemics)	Federal, State, Local
Air quality	Air Quality Standards	Federal, State	Transportation, Energy, Renewable Energy - Solar, Wind, Hydro, Transportation, Vehicle manufacturing, Architecture, Design, Engineering, Agriculture, Forestry
	Reducing Wildfires	Federal, State
	Subsidizing and Incentivizing Renewable Energy Sources	Federal, State, Local
	Regulation to Reduce Leading Sources of Air Pollution	Federal, State, Local
	Integrating Health into Building Design and Community Architecture	State, Local
	Implementing Sustainable Agricultural Practices	Federal, State, Local
Tobacco use	Excise Taxes	Federal, State	Tobacco, Pharmaceutical, Health Care, Public Health
	Comprehensive Clean Indoor Air Laws	Federal, State, Local
	Retail Restrictions	State, Local
	Federal (FDA)/National regulation of Tobacco Products and Marketing/Advertising	Federal
	Access to Comprehensive Cessation Services	Federal, State
	Raising the Sales Age	Federal, State
	Nicotine Standards	Federal
	Removing Flavorings/Flavor Ingredients	Federal, State, Local
	Funding for Comprehensive Prevention and Cessation Programs	State
Substance abuse	Telehealth Treatment	Federal, State, Local	Pharmaceutical, Health Care, Public Health, Social Services
	Access to Culturally Appropriate, Evidence-Based, Affordable Health Care	Federal, State
Obesity	Access to Culturally Appropriate, Evidence-Based Affordable Health Care	Federal, State	Health Care, Pharmaceutical, Social Services, Public Health, Transportation, Education, Recreation, Health and Fitness Professionals, Dietitians, Engineering
	Comprehensive Coverage for Evidence Based Obesity Treatment and Preventive Services	Federal, State
	Appropriations for Provider Training and Patient Education	Federal, State
	Quality and Performance Measures	Federal, State
Hypertension	Coverage for Hypertension treatment and Control (Self-measured blood pressure devices, patient education on using digital health technology, provider interpretation of patient reported data)	Federal, State	Devices, Pharmaceutical, Health Care, Public Health, Food Manufacturing, Agriculture, Food Retail, Parks/Recreation, Education
	Coverage for Preventive Services	Federal, State
	Quality and Performance Measures	Federal, State
	Reducing Sodium in the Food Supply	Federal
	Increasing Access to Healthy, Affordable Foods (see above)	Federal, State, Local
	Increasing Access to Physical Activity including Comprehensive School Physical Activity Programs (see above)	Federal, State, Local
Diabetes	Access to Affordable Drugs	Federal, State	Devices, Health Care, Pharmaceutical, Technology, Digital Health, Public Health, Food Manufacturing and Distribution, Food Retail, Sports, Fitness, Active Recreation, Education
	Regulation of Devices for Evidence-based Treatment	Federal
	Access to Preventive Services	Federal, State
	Quality and Performance Measures	Federal, State
	Increasing Access to Healthy, Affordable Foods and Diet Counseling (see above)	Federal, State, Local
	Increasing Access to Physical Activity including Physical Activity Assessment, Prescription and Referral, Comprehensive School Physical Activity Programs (see above)	Federal, State, Local
Health system transformation
Access to health insurance	Medicaid expansion	Federal, State	All
	Expanded Medicaid postpartum coverage Enhanced subsidies for marketplace plans	Federal, State
Care delivery & payment reform	Broad alignment with the CMMI strategy refresh across all third-party payers will go a long way toward addressing many of the deficiencies in our current delivery and payment “system”	Federal, State	All
Telehealth	Access to Evidence-Based Telehealth Treatment Services	Federal, State	Technology, Digital, Health Care, Public Health
Digital health	Access to Evidence Based Treatment and Remote Patient Monitoring Services	Federal, State	Technology, Digital, Health Care, Health Care, Public Health, Education
	Regulation on Devices	Federal
Workplace policies	Living Wage	Federal, State	All
	Paid Family and Medical Leave	Federal, State
	Hybrid Work Policies	Federal, State, Local
Research	Determination of research priorities and initiatives to improve public health.	Federal, State, Local	Academic institutions and established research centers. Research councils and funders. Key government agencies.

Impact of COVID-19 on chronic disease and associated risk factors

The long-term health effects related to the COVID-19 pandemic are still being documented and will be assessed into the future. The public health sector was faced with numerous challenges, from acutely protecting those with chronic disease from COVID-19 while ensuring appropriate care and management of pre-existing disease.^{3 , 4} Looking toward the future, public health has the challenge of understanding the pandemic's impact on existing and new-onset chronic disease, including those with post-COVID syndrome (i.e., Long COVID).^{3 , 5} Research over the range of cardiometabolic outcomes after exposure to natural and human-made disasters demonstrate evidence of increased cardiometabolic risk.⁶ However, the systematic review by De Rubeis et al.,⁶ noted that many of the studies of previous disasters did not comprehensively adjust for factors related to social determinants of health (SDOH). A higher risk of severe illness or death from COVID-19 was recognized for those with pre-existing conditions like asthma, CV disease, hypertension, obesity, and diabetes, among others. SDOH are strongly linked to these conditions. The interconnectedness of important social and health determinants such as access to care, transportation, nutrition security, housing, and employment on viral infection and mortality rates during the pandemic was apparent and will continue to be elucidated.⁷

Physical activity (PA) promotion and active living infrastructure

During the pandemic, there was a significant decrease in PA, with particular disparities across certain geographies, ages, and different races/ethnicities, primarily related to a switch to remote working and stay-at-home orders, and closure of exercise facilities, parks and schools.8, 9, 10, 11 These efforts were taken to contain the pandemic but at a detrimental cost to both cardiometabolic and mental health by making it more difficult for individuals to maintain or improve PA levels.12, 13, 14

This is particularly true for those populations that are physically and financially vulnerable, which can cause cycles of negative consequences.¹² Considering the difficulties in promoting the benefits of individuals meeting PA guidelines pre-pandemic, it is more important than ever that the pandemic response balances the public health imperative with safe access to spaces, facilities, transportation and programming for PA.¹⁵ Active transportation (i.e., biking, walking, or rolling in the open air) may allow for safer ways of travel during a pandemic versus enclosed vehicles or public transportation. Prioritizing built environment strategies that combine interventions to improve systems for biking, walking and rolling (e.g., street connectivity, sidewalk and trail development, bicycle infrastructure) with one or more land use and environmental design interventions (e.g., mixed land use, access to parks and other recreational facilities) is a critical step for equitable PA promotion.¹⁶ Assuring children have access to Comprehensive School Physical Activity Programs in schools for physical education, recess, classroom activity breaks, sports and intramural programs and Safe Routes to and from School are important policy and system change priorities for kids' mental and physical well-being.¹⁷ Additionally, continued efforts should be supported to standardize the assessment, prescription, and referral of physical activity by health care providers and connect patients to community resources, recreational spaces, and health and fitness professionals to be physically active.¹⁸

Nutrition security

The COVID-19 pandemic significantly impacted the food landscape and increased the number of people at risk of food and nutrition insecurity. Food insecurity is defined as a household-level economic and social condition of limited or uncertain access to adequate food¹⁹ while nutrition security refers to an individual or household condition of having equitable and stable availability, access, affordability, and utilization of foods and beverages that promote well-being, prevent disease, and if needed, treat disease.²⁰ Although the overall prevalence of food insecurity in the United States (U.S.) remained stable between 2019 and 2020 at 10.5%, higher rates were found among Black households (21%), Hispanic households (17%), and households living at or below the federal poverty line (35%).²¹ Food and nutrition insecurity is associated with increased rates of chronic diseases^{22 , 23} and higher healthcare costs.^{22 , 24}

The COVID-19 pandemic and enforced restrictions had a direct economic impact which forced the U.S. and global economies into a crisis resulting in: 1) increased unemployment, forcing more people to request food assistance; 2) disrupted supply chains leading to empty grocery stores and supermarket shelves; and 3) prompted consumers to stockpile more processed, shelf-stable groceries in their homes. Additionally, the COVID-19 pandemic led to school closures across the world causing tens of millions of children to home school which had a disparate effect on those who are dependent on the National School Breakfast and Lunch Programs to go hungry.^{25 , 26}

In response to the devastating impact of the pandemic, all levels of government responded swiftly to prevent food and nutrition security from worsening. The expansion of several nutrition assistance programs such as healthy school meals for all, the creation of Pandemic Electronic Benefits Transfer, investments in the Supplemental Nutrition Assistance Program and increasing the Supplemental Nutrition Assistance Program for Women, Infants and Children Cash Value Voucher were key examples of addressing food and nutrition insecurity during the volatile economic times. The pandemic exposed the need to strengthen existing food policies and programs to maintain supply chains, vital nutrition assistance programs, a healthy retail environment, and food safety while evaluating the need to develop new food policies and programs to promote food and nutrition security.

Air quality

Air pollution is associated with an increased risk for heart disease, stroke, chronic obstructive lung disease and lung cancer,²⁷ conditions which have been identified as significantly raising the risk of severe illness or death from COVID-19. According to the World Health Organization (WHO), air pollution caused approximately 4.2 million premature deaths worldwide in 2016.²⁸ Despite efforts to improve air quality, air pollution continues to be a significant issue globally.

In the early days of the pandemic, governments across the world enacted strict isolation and lockdown protocols to slow the spread of COVID-19. These protocols forced more people to stay indoors and led to a reduced number of cars and air travel positively impacting air quality.²⁹ The research suggests that the pandemic lockdowns led to a significant short-term improvement in air quality, particularly in urban cities.³⁰ A study investigating the impact of the lockdown on air quality in New York City found that the concentration level of fine particulate matter that are ≤25 μm (PM_2.5) decreased from 10.3 to 4.0 μg/m³ during phase one (I.e. March 22–May 15, 2020) of lockdown.³¹

As the world continues to recover from the COVID-19 pandemic, there is a need to continue to enact and support policies that will address air pollution and a healthier planet. These include subsidizing and incentivizing the use of renewable energy sources, enacting and enforcing robust air quality standards, developing and implementing regulations to reduce leading sources of air pollution, reducing wildfires, implementing healthier approaches to building design and community architecture, and implementing sustainable agricultural practices.

Tobacco use

A recent systematic review found that the impact of the pandemic on tobacco and nicotine use is unclear and complicated.³² In the U.S. for example, federal and state legislation was enacted just before COVID-19, increasing the sales age for purchasing tobacco to 21 and some flavored tobacco product restrictions. The interplay between legislation, regulation and the onset of the pandemic complicates our understanding of pandemic-related tobacco and nicotine use. In most reports, smoking and nicotine consumption decreased, which appeared to be closely related to lockdowns and restrictions on social behaviors.³² However, in some areas across the world, including the U.S., smoking and nicotine use increased and may have been driven by boredom, stress, anxiety and more disposable income during the pandemic with reduced travel and away-from-home eating.^{32 , 33} Youth use varied during the pandemic and may reflect how surveillance systems were conducted and that they were at home versus in school with different levels of supervision.³⁴

Fundamentally, the pandemic underscored the importance of addressing tobacco use and nicotine addiction for COVID-19 hospitalization and mortality outcomes, reinforcing the need for evidence-based policy and systems changes to end tobacco use, one of the leading causes of preventable death across the world. These policies include access to comprehensive cessation services, screening for tobacco use at all clinical visits, implementation of tobacco excise taxes, comprehensive smoke-free air laws, ending the sale of tobacco in pharmacies and at retail outlets around schools and youth-serving institutions, funding for comprehensive tobacco prevention programs, eliminating the marketing and advertising of these products to youth, robust regulation of all tobacco products including removing all flavored products from the marketplace.

Substance abuse

Reports suggest that at least 36 million people across the world experience substance abuse disorders.³⁵ During the COVID-19 pandemic the number of individuals with substance abuse disorders increased by at least one million,³⁵ while access to substance abuse resources declined significantly.³⁶ Pandemic responses such as social distancing and shelter in place have caused many treatment options to be limited or discontinued entirely. As a result, the need to find new ways to support individuals with substance abuse disorders became evident.³⁷ A report from the United Nations highlighted ways that the medical community continued drug treatment and prevention during the pandemic including remote consultations; service hotlines; mail services for needles, syringes and naloxone; and mobile outreach programs.³⁵ Medical professionals were forced to rapidly change their method of treatment delivery and telehealth was used significantly to reach patients safely.

There may be opportunity to continue to expand the use of telehealth treatment where appropriate through videoconferencing, text, or web-based interventions. Studies have shown that providing access to virtual group treatment may assist in meeting the psychosocial needs of patients.³⁸

Obesity

Almost 70% of Americans and almost 53% of Europeans are considered overweight or have obesity.^{39 , 40} Obesity is a central risk factor for developing chronic diseases and is a major risk factor for severe illness and mortality from COVID-19. Research suggests that those living with obesity are more likely to be hospitalized or die from COVID-19 than those who do not have obesity.⁴¹ A report from the Centers for Disease Control and Prevention (CDC) found that obesity is associated with higher hospitalization rates in acute or intensive care for COVID-19.⁴² A survey by the American Psychology Association found that 61% of American adults experienced undesired weight changes since the pandemic started, with 42% reporting they gained more weight than they intended.⁴³ The challenges that stem from obesity emphasize a need for more upstream policies and programs to prevent obesity, including access to healthy, affordable foods and beverages, availability of PA programming and access to active living infrastructure. There is also the need for policies that support more effective treatment and management of excess weight in health care delivery, including access to health insurance, appropriations for provider and patient education, implementation of appropriate quality and performance measures, and comprehensive benefits coverage for evidence-based obesity treatment.

Hypertension

Exacerbation of chronic disease, including hypertension, surged during the COVID-19 pandemic, amplified by health disparities across racial/ethnic and socioeconomic populations who were already at disproportionate risk for contracting the COVID-19 virus. A recent study of almost 500,000 adult Americans found that there was a statistically significant increase of 1.00–2.50 mmHg and 0.14–0.53 mmHg in systolic and diastolic blood pressure, respectively, every month during the pandemic (April 2020 – December 2020).⁴⁴ This same trend was not seen when the researchers analyzed blood pressure measurements prior to the pandemic (January 2018 – March 2020).⁴⁴ With such a large study sample, these results have global implications as they clearly show that pandemic-related restrictions, lifestyle changes, and stressors around employment and income, which were all felt globally, negatively impacted blood pressure.

Policy issues highlighted during the pandemic related to hypertension control included implementation of coverage determinations for self-measured blood pressure monitoring for diagnosis and treatment, initiating coverage for the devices by private and public payers, drug affordability, patient education, use of quality and performance measures for clinical diagnosis and treatment of pre-hypertension, and hypertension, as well as upstream preventive and adjunctive efforts including PA promotion, access to healthy, affordable foods, and regulation to promote sodium reduction across the food supply.

Diabetes

While the incidence of newly diagnosed diabetes among adults has been in decline over the last decade,⁴⁵ deaths due to diabetes in the U.S. increased by 17% in 2020, marking the first year >100,000 Americans died from diabetes, and contributing to an overall decrease in U.S. life expectancy.⁴⁶ While these numbers do not include deaths directly attributable to COVID-19, in 2020, data from the CDC revealed that nearly 40% of the people who died of COVID-19 in the U.S. had diabetes. Globally, diabetes prevalence continues to rise with considerable impact on long-term health outcomes.⁴⁷ Historic neglect of the social and environmental conditions that contribute to the proliferation of diabetes is a likely contributor to this landscape, leaving many of these individuals disproportionately vulnerable to the impact of the pandemic.⁴⁸ It is estimated that more than one in three Americans will develop diabetes within their lifetime if current trends continue, posing significant medical and economic consequences at the individual and population levels. To that end, advancements in the prevention and treatment of diabetes are integral to achieving health equity and improving population health during the COVID-19 pandemic and beyond. Key policy levers to address increasing prevalence include addressing the cost of insulin and other pharmacologics, assuring affordable access to health care for diagnosis and management and moving further upstream to support preventive measures such as physical activity and access to healthy affordable foods.

Health system transformation – Access barriers, care delivery & payment reform

In addition to exposing the considerable deficiencies in public health infrastructure, the pandemic revealed startling health inequities experienced by historically marginalized populations, the tenuous financial position of numerous providers dependent on the quantity of services to remain financially viable, and the precariousness of employer-sponsored health insurance in times of economic distress.⁴⁹

Within the first three months of the COVID-19 pandemic, millions of workers lost their jobs or left the labor force, resulting in an estimated 5.4 million Americans losing health insurance coverage.⁵⁰ People without insurance by and large are less likely to pursue necessary medical care, fill their prescriptions, or even take advantage of preventive care services, potentially contributing to an increased incidence of preventable diseases and deaths. Also concerning is the disproportionate number of adults with chronic health conditions who reported forgoing or delaying care during the pandemic compared to those without a chronic disease.⁵¹ This situation was even more dire for communities of color, tribal nations, and rural and low-income communities, who are disproportionately burdened by chronic disease, were disproportionately affected by COVID-19 and suffered higher rates of death.

The American Rescue Plan Act of 2021 passed by the U.S. Congress in response to the pandemic included several provisions to improve access to quality care and bring health coverage within reach for those most at-risk during the pandemic including financial relief for rural providers; public health workforce support; funding for vaccines and testing; incentives for state Medicaid expansion; a pathway to extend postpartum Medicaid coverage to a full year; and importantly, an increase in and expansion of eligibility for premium subsidies for people enrolled in the Affordable Care Act (ACA) Marketplace plans. Additional legislation tied to the declaration of COVID-19 as a Public Health Emergency has contributed to significant enrollment growth in Medicaid, with total Medicaid/CHIP enrollment increasing by nearly 25% between February 2020 and January 2022.⁵² While the Inflation Reduction Act of 2022 supported access to affordable health coverage by extending the enhanced Marketplace subsidies at least through 2025, the looming unwinding of the COVID-19 Public Health Emergency and subsequent expiration of many of the flexibilities temporarily enacted to respond to the pandemic presents a new series of access challenges including inevitable coverage losses as a result of Medicaid eligibility redeterminations and navigating potentially the largest shift in health insurance since the passage of the ACA.⁵³ This necessitates targeted effort and investments to minimize disruptions in access to and quality of care and coverage.

Additional changes are needed to address the significant shortcomings of health care delivery and payment, especially in the U.S. The absence of concordance between different types of health insurance and coverage contributes to fragmentation and access issues that particularly affect more vulnerable populations and further contributes to inequities. The lack of focus generally on ensuring equitable treatment and access to services across all populations also has exacerbated the health inequities. A flawed payment system that rewards volume over quality and undervalues prevention and health maintenance services resulted in significant financial difficulty for many providers and, in particular, for primary care and other safety net providers.⁵⁴ In October 2021, the Centers for Medicare and Medicaid Innovation Center (CMMI) released a strategy refresh⁵⁵ to guide the next phase of care delivery and payment models. CMMI's vision is to influence the creation of a health system that achieves equitable outcomes through high quality, affordable, person-centered care. Broad alignment with the CMMI strategy refresh will go a long way toward addressing many of the deficiencies in the current delivery and payment “system” that existed before but became even more evident during the pandemic.

Integration of telehealth in health care delivery

One of the more obvious changes COVID-19 brought to the healthcare landscape was its impact on virtual modalities of care delivery. Telehealth, once considered a “high tech” novelty to many, became, nearly overnight, the new standard for protecting patients, providers, and society at large, in a world challenged by multiple strains of a highly transmissible disease. Long-held policy and payment barriers were quickly, if only temporarily, lifted to accommodate access to services. Healthcare providers who once could not see the value in virtual care came quickly to the realization that it was now the only path forward. In the United Kingdom (U.K.), the role of virtual wards was crucial and is likely to become part of standard of care practice.⁵⁶ Yet that path is still filled with uncertainty. A worldwide pandemic has tested the long-held promise of digital health technologies to deliver high quality support to the masses across all subspecialties of care. The effects of such a seismic shift are yet to be fully understood, but some of the early findings are at once promising and concerning.

In the pre-pandemic U.S., the early advancement of telehealth had been driven more by theoretical impact than by rigorous research and development of best practices. State-to-state variation in regulations, poor reimbursement, a patchwork of confusing privacy laws, and wide discrepancies in resources resulted in great variability across institutions and providers of telehealth practice and provision of services.⁵⁷ The pre-pandemic telehealth environment, as outlined above, was largely geared toward management of minor, acute conditions with out-of-pocket payment models that often did not require standard billing and documentation. Therefore, integration of telehealth services into standardized workflows of the electronic health record —for scheduling, intake, documentation, billing, etc.— was limited. Additional programs that provided virtual emergency room care, such as telestroke services, were not heavily utilized because patients were not presenting to emergency rooms.⁵⁸ Services had been targeted toward “consumers” with easy access to technology and the means to pay out of pocket, so adequate technology and processes needed to ensure access for underserved, rural, and disadvantaged populations were not in place. Furthermore, the patients at highest risk for COVID-19 morbidity and mortality—racial minorities, non-English-speaking populations, and the chronically-ill—often had limited access to telehealth options since services had not been designed with them in mind. Further complicating the rapid roll-out of telehealth services was the fact that due to the low pre-pandemic adoption of telehealth practice across the health care system, the majority of providers who were suddenly tasked with treating patients remotely had minimal to no training or experience with the provision of virtual care. What research had been conducted was often limited by small sample sizes of highly specific populations and service types resulting in difficulty generalizing outcomes. There is no question that the COVID-19 pandemic has provided a trove of data which is already improving understanding of how telehealth and associated technologies affect care delivery and outcomes across specialties and in primary care.

Findings from initial data show a substantial cumulative reduction in visits across all specialties over the course of the pandemic and a 20% reduction in cardiology visits.⁵⁹ One critical question is whether visit volumes will rise above the baseline level of March 2020 visits as we move beyond the pandemic and people receive care that had been deferred. A hybrid approach to telehealth implementation may offer the most adventitious path forward. Incorporating digital services across the entire span of the traditional healthcare continuum – from outpatient services and primary care to acute care and chronic disease management – is likely to increase patient-centeredness, improve quality and value, and access.

Digital health technologies

Digital Health is a term used to encompass all technologies used to deliver and monitor health remotely. It includes modalities of care such as eHealth, telehealth, remote patient monitoring, genomics, and the use of new machine learning algorithms and artificial intelligence which use vast amounts of accumulated data to advance healthcare delivery systems. Pre-pandemic, digital health transformation was modest. However, it surged during the pandemic as uses for such technologies became necessary. Since then, many countries have adopted digital-first strategies, remote monitoring, and telehealth platforms to enable healthcare provision without physical interactions. In the U.K., primary care has embraced telehealth at scale and deployed a new digital-first pathway as a route to managing the streaming of care to the appropriate place. In 2013, the Health Assembly of the WHO, adopted resolution WHA66.24 on eHealth standardization and interoperability, which urged the Member States “to consider developing … policies and legislative mechanisms linked to an overall national eHealth strategy”.⁶⁰ This helps explain why a rapid expansion of digital health technologies was seen in many other areas of the world during the COVID-19 pandemic. Unlike the U.S., whose regulatory, legal, and political systems created barriers to more wide-scale adoption of digital technologies beyond telehealth, the E.U., U.K., and many other nations across the globe were able to deploy such innovations over a short period. The reasons for such swift and wide-reaching adoption are fourfold. First, single payer systems allowed for quick payment parity to be easily enacted. Second, vetting systems for applications and solutions were already in place and needed only to be adapted to the circumstances and were therefore easily deployed at scale. Third, many countries, including the U.S., relaxed their data sharing and privacy standards during the pandemic allowing for easier use of video and audio technologies. And finally, a change in care delivery became necessary as many governments required that any care that did not require physical interaction be provided through remote consultation.⁶¹

However, digital transformation – particularly as it relates to innovations in prevention and population health management – is not only a technical and scientific process but is also organizational and cultural in nature. And further research is needed to determine short-term, intermediate, and long-term outcomes of its effect on issues related to disparities in care and access, chronic disease management, and quality and cost effectiveness.

Employment policy

As outlined in previous sections, the COVID-19 pandemic has undoubtedly posed an unquestionable challenge to public and global health and despite attempts by governments to restore social and economic activities, the pandemic has exacerbated historic health inequalities and brought new challenges to the forefront of public attention.⁶² An important consideration is how people engage and deliver their employment obligations. During the early stages of the pandemic, there was an urgent need to suppress global transmission, resulting in millions considered to work in non-essential roles (i.e., outside of healthcare, food production and transportation) worldwide being ordered by law to stay and work from home (often referred to as remote working).⁶³ Despite the endemic of COVID-19, part of the economic drive is to restore pre-pandemic activities which include re-establishing pre-pandemic employment routines, however there is a growing shift in some areas to adopt a culture to adopt hybrid models of working that are tailored to individual and business needs.

Research that has explored the benefits and drawbacks of remote working has provided unequivocal evidence highlighting increased benefits of remote working that include increased productivity, employee satisfaction, positive implications for family relationships, health, and wellbeing and even positive environmental considerations via a reduction in primary pollutants.⁶⁴ Conversely, there is growing evidence that highlights challenges of remote working which is considered alongside roles, responsibilities, and additional pressures for families, where home schooling was required, resulting in increased tension with employers and reductions in productivity, job satisfaction and mental, and physical health and wellbeing.⁶⁵ In those roles where remote working was not possible there is considerable evidence, especially in the healthcare sector with growing concern of long term physical and mental issues in front line healthcare workers who have been inadvertently affected by primary (increased workload due to COVID-19) and secondary factors (issues with long term illness contributing to increased workload and resultant pressures).⁶⁶ Latest data in the U.K. highlights that over 200,000 frontline healthcare workers are currently absent from work due to issues directly related to COVID-19 which includes a significant burden of Long COVID and places a considerable challenge to service delivery at a time where the National Health Service is attempting to clear a backlog of routine procedures (>6 million) that were curtailed during the pandemic.⁶⁷ Issues and uncertainty relating to employment, health and wellbeing are important and will create sustained pressure for employers and employees alike. The challenges are confounded by novel challenges and uncertainties that plague the global economic environment, legislation, and policy to support the workforce and to ensure that population health and wellbeing are not sacrificed at the expense of economic agendas. This could see the implementation of novel incentive programs that are backed by governments and reward business and industry with implementing strategies to promote positive health lifestyle behaviors and increased health and wellbeing outcomes that are coordinated with the ambition to achieve economic growth as part of the international post-pandemic recovery. A change of this magnitude might feel like a monumental shift, but the potential benefits to population health and wellbeing and the economy are far reaching.

Supporting biomedical/Population level/Epidemiological research

What is clear as we emerge from the pandemic is a need to normalize global collaboration in the interest of population health and wellbeing. The rapid development and deployment of COVID-19 vaccines is a feat of true scientific collaboration that saw international groups working together in the pursuit of public wellbeing. What arises from this incredible achievement is a question of what can be achieved to improve outcomes in key public health research with sustained collaboration that prioritizes population health over academic progression and extrinsic recognition. It is currently estimated that 144 million people worldwide are living with complex, multi-dimensional and episodic symptom profiles that impair functional status and quality of life.⁶⁸ In the absence of mechanistic knowledge and efficacious treatment approaches, future variants and sustained transmission will result in increased incidence of Long COVID which is arguably an emerging global health crisis.⁶⁸ Recognizing the importance of global collaboration, governmental policy should be developed to encourage collaboration and establish global multi-disciplinary research approaches to tackle social, environmental, and clinical priority areas and maximize the benefit to public health.

Adopting collaborative research approaches, where the focus is placed on developing a detailed understanding of cause-and-effect and lifestyle behaviors could and should be used by key decision makers and policymakers in the development of coordinated approaches to address global health challenges. Collaboration must be enhanced between clinical sciences, public health, business, technology, economics, and the exercise sciences and sports medicine community, among others to determine mechanistic insight against the longstanding impacts of COVID-19.⁶⁹ This understanding should inform the development of global research approaches that address global health challenges in a coordinated and collaborative manner. Such unified approaches would consolidate efforts into achieving global changes in population health at the heart of the global response to rising health threats and health. Adopting such approaches would be complex and key organizations such as the United Nations, WHO and World Bank with global prominence would need to lead and deliver such initiatives.

Conclusion

The COVID-19 pandemic has left an indelible impact on global health public policy. Lessons learned will inform future public health restructuring and pandemic response, biomedical research, prevention, access to care and care delivery, and public policy that transforms and supports the settings where we learn, work, and recreate. There is a continued need for global multi-sector coordination and response by governments working in close collaboration with non-governmental organizations, philanthropy, the private sector, and media/communications to optimize population health.

Disclaimer

The views provided in this paper do not necessarily reflect the policy positions of the American Heart Association.

Disclosures

None.

Declaration of Competing Interest

None.