COVID-19: The Invisible Impact of an Invisible Threat

Contributor: Z. Colette Edwards, WG’84, MD’85
To learn more about Colette, click here.

 

image001.jpg“One day you will tell your story of how you overcame what you went through, and it will be someone else’s survival guide.”   

~ Lene Andersen

At the time this article is being published, the number of confirmed COVID-19 cases across the globe is greater than 16 million people, and the number of deaths is well over 650,000. Over the past several months, the U.S. has typically represented 1/3 of the world’s cases and 1/3 of its deaths.

COVID-19 will impact everyone sooner or later, in ways that are simply inconvenient for some and completely life-changing for many others. No one will go unscathed.

COVID-19 has taken a toll on physical health and has taken lives. Those are the visible signs of its presence. But what about its many invisible impacts?

The novel coronavirus spreads quickly, unseen by the human eye and not physically perceived in 40 – 60% of individuals who are infected. Those very facts serve as the starting point of the cascading ripple effect that may be manifest in the insidious way it can enter our lives. How do you combat a threat you can’t see and may not feel?

Endangering Our Emotional Health and Well-Being
COVID-19 has had a devastating impact on emotional health and well-being, and, in some cases, has exacerbated the conditions of those suffering from mental health disorders. Recent reports and knowledge gained following outbreaks like Ebola tell us:

  • 1 in 5 children in Wuhan show signs of depression and anxiety.
  • A JAMA article in which listening sessions were held with groups of physicians, nurses, advanced practice clinicians, residents, and fellows revealed 8 areas which consistently triggered anxiety in these healthcare professionals:
    1. access to appropriate PPE (personal protective equipment)
    2. exposure to COVID-19 at work and taking the infection home to their family
    3. suboptimal access to testing if they develop COVID-19 symptoms and concomitant fear of propagating infection at work
    4. uncertainty regarding whether or not their organization will support/care for their personal and family needs if they develop infection
    5. access to childcare during increased work hours and school closures
    6. support for other personal and family needs as work hours and demands increase (food, hydration, lodging, transportation)
    7. being able to provide competent medical care if deployed to a new area (for example, non-intensive care unit healthcare workers having to function in the intensive care unit)
    8. lack of access to up-to-date information and communication
  • image003.jpgCompassion fatigue, also known as vicarious or secondary trauma, is on the rise. The emotional distress or apathy resulting from the constant demands of caring for others and witnessing pain, suffering, and trauma is a natural response which represents the high price many pay emotionally by virtue of doing their jobs.
  • Moral injury has entered the lexicon of medical professionals perhaps more intensely than ever before. Moral injury is a term first coined in 2009 by Brett Litz at Boston University and described as the profound psychological distress that comes from “morally injurious events, such as perpetrating, failing to prevent, or bearing witness to acts that transgress (one’s own) deeply held moral beliefs and expectations.” 
  • Past meta-analyses have shown that up to 24% of patients discharged from a hospital stay that included time in the ICU developed PTSD. PTSD has been noted in 96% (!) of those hospitalized with COVID-19 infections in Wuhan, China. 
  • Healthcare workers are at risk for the development of acute stress disorder, a condition which converts to a diagnosis of PTSD if symptoms last longer than a month.
  • For those with addictions, relapse is a very real possibility. 
  • More than 50 million Americans are now unemployed, many of whom who are medically uninsured or underinsured, do not qualify for unemployment benefits, are now food insecure, and have no financial reserves. And it is too early to know how many of those jobs will not return at all. They are subject to the mental health impacts identified by the study of past recessions – feelings of uselessness and hopelessness and increased rates of suicide. During the 2007 - 2009 recession, there was a 1% increase in suicide for every 1% increase in unemployment in the United States.
  • The Crisis Text Line is a free, around-the-clock resource for frontline workers struggling with anxiety, stress, fear, and isolation during the COVID-19 pandemic. It has noted that 78% of frontline workers report intense anxiety, and mentions of sexual assault and emotional abuse are 25% higher in settings of quarantine. And outreach from Asian Americans has doubled, with texters reporting issues with bullying, harassment, and depression.


image005.jpgExacerbating Pre-Existing Challenges
Sales of alcoholic beverages have surged as people self-medicate to relieve feelings of anxiety and fear. A spike in suicides is anticipated, and physicians already had a higher rate of suicide than the general population before the arrival of COVID-19. 

Social distancing and stay-at-home measures have proven to be key to prevention and mitigation of exposure risk and spread of COVID-19. Just when one could argue we need each other more than ever, social isolation has literally become a survival technique. 

The impact of social isolation and loneliness, particularly in older adults, was well documented long before the onset of the pandemic. According to the American Psychological Association and an analysis by Julianne Holt-Lunstad, PhD, a professor of psychology and neuroscience at Brigham Young University, the health risks of social isolation and loneliness are (1) as high as smoking 15 cigarettes a day or having alcohol use disorder and (2) twice as harmful to physical and mental health as obesity.

In the U.S. alone, 6 in 10 people suffer from a chronic condition, and 4 in 10 suffer from two or more chronic diseases. Individuals with underlying chronic diseases are generally at higher risk for a condition like depression. And conversely, those with depression are at greater risk of developing a chronic condition. Just think about the perfect storm brewing as a result of COVID-19, when those with chronic conditions have been shown to be at higher risk of severe complications and death if they become infected.

Communities of color often suffer a greater burden of chronic disease and live knowing they are at much greater risk of severe complications and death should they become infected with the novel coronavirus. The disparities in health, wealth, and social justice have left many in an even more vulnerable position than existed pre-COVID. 

And the greater representation of people of color in low-paying jobs deemed essential and in densely populated locales means the risk of exposure to COVID-19 is high each and every workday. Often not provided with the type of PPE needed to protect and maintain safety and knowing 40-60% of those infected are asymptomatic, many of these frontline workers face well-founded fear and anxiety that can lead to long-term psychic trauma.

 

“Where there is anger, there is always pain underneath.”~ Eckhart Tolle

 

And, finally, reports of the daily brutality against black (especially male) and brown people and recent events like the murders of George Floyd, Breonna Taylor (herself an EMT), David McAtee, Elijah McClain, Rayshard Brooks and Ahmaud Arbery have triggered turmoil and a wide range of emotions – fear, horror, disbelief, grief, heartbreak, anger, resentment, rage, an ignited sense of purpose and a reactivated commitment to action. For some, eyes have been opened, and for others over whelming physical and emotional exhaustion has set in. 

This pandemic of yet another sort – man’s inhumanity to man - adds yet one more stressor that traumatizes its victims, their families, and society as a whole. And given the protests of millions across the globe, the impact extends far beyond U.S. borders. 

image007.jpgGrief and Mourning
The novel coronavirus has made grief and mourning experienced simultaneously by millions across the globe a commonplace fact of life. From the loss of daily routines and rituals to furloughs and unemployment which lead to the loss of financial and food security, from the loss of physical health and well-being to the loss of a business, from the loss of childhood innocence to the loss of physical connection with friends, grief runs deep and wide. 

And the death of a family member, friend, or colleague has been made even more tragic by the inability to be by their side and knowing they died alone, perhaps scared and suffering to the very end. And for those whose loved ones had dementia and may have felt abandoned, the heartbreak is wrenching. 

The anguish and grief then extends to the loss of the closure and comfort that might have come from the rituals of loss – whether a wake, funeral, burial, and repast, sitting shiva with family and friends, or an in-person memorial service, to name a few. Our lives have been robbed in a very visceral way. An increase in the rate of complicated grief can be anticipated. And sorrow may become a constant companion.

image009.jpgWhat’s Coming?
At least for now, no one can tell us how long we will be living with COVID-19. And some scientists say, even with the eventual development of a vaccine, the novel coronavirus may be an inescapable recurring visitor, like the flu……. only more contagious and more lethal. 

Dr. Anthony Fauci, Director of the NIH’s National Institute of Allergy and Infectious Diseases and previously a key clinical member of the White House Coronavirus Task Force, has predicted a high likelihood of COVID-19 surging again in the fall. Recent surges that surpass the heights of coronavirus cases in April mean we may still be in the midst of gaining control of the first wave before an expected second wave hits. 

There is significant concern in the medical community about what will unfold with the upcoming flu season starting at the same time the number of individuals infected with COVID-19 is expected to swell again. According to the CDC, last year’s flu vaccine was 45% effective, and the 2019-2020 flu season resulted in an estimated 32 million cases of influenza-like illnesses, 310,000 hospitalizations, and 18,000 deaths. To further complicate an already overwhelmingly complex picture, there is now word of an emerging flu virus, G4, found in pigs in China that has the potential to become a pandemic. It bears a resemblance to H1N1, and current seasonal flu vaccines aren’t likely to provide any protection.

That means no respite for healthcare workers and caregivers, ongoing uncertainty, and perhaps even greater volatility in the guidelines we are to follow to protect ourselves and each other.

What lies ahead is unclear. Although a national plan for a 3-stage reopening of the economy has been released, the current reality is an ongoing insufficient supply of PPE for healthcare workers, a rate of testing that is often frighteningly lower than what scientists tell us we need to gain control of the virus, and a patchwork of pandemic responses, with some states that never shut down and others still under stay-at-home orders with requirements to wear masks in public. 

And recent data analysis performed after all 50 states have reopened to varying degrees (most not meeting White House/CDC criteria) indicates a rolling wave of spikes of COVID-19 infections, hospitalizations, and deaths 2 – 3 weeks after “reentry” begins.

image011.jpgTake a Journey of Knowledge and Preparation
Being vigilant and taking action means less stress and a greater sense of control. Recognizing that it is OK to not be OK in a world that has been turned upside down can be liberating. That acknowledgment can help summon the courage to feel your feelings and seek help when you need it. Educating yourself and knowing that your path to emotional well-being may be circuitous and rocky at times will empower you. 

Taking a journey of knowledge and preparation can serve as a stepping stone to the resilience that can make living your life easier, even in the face of a pandemic trifecta – COVID-19, emotional distress/mental health disorders, and man’s inhumanity to man.

 

Contact Colette at:
colette@accessinsightmd.com