Secondary Effects of COVID-19
Contributors
Araceli Camargo, MSc Neuroscience (Kings College London)
Elahi Hossain, PhD Candidate in Neuroscience at University College London
Sarah Aliko, PhD Candidate in Neuroscience at University College London
Daniel Akinola-Odusola, MSc Neuroimaging (Kings College London)
March 2021
INTRODUCTION
This report is to help frame Covid-19 as an experience rather than the current binary framing of “sick or not sick”. The reason this is necessary is to identify the different solutions, resources, strategies required for an equitable recovery, so no one is left behind.
By experience we mean, all of the various factors that have contributed to the pandemic; lockdown, financial insecurity, social isolation, financial insecurity, disturbed family dynamics, family loss, and the experience of the disease itself. All of these factors can contribute to the secondary effects, such as mental and physical health disorders.
Delving into the experience of Covid will also highlight where there is need for further data collection to understand the experience had by different communities. In turn this data can be used to create an equitable recovery strategy and provide the right health support.
Although currently the focus on the COVID-19 pandemic has been mainly on the virus and patients affected, governments around the world should start planning for the long recovery process ahead. This does not simply mean a strong plan for the rollout of vaccines, but also understanding and preparing for the secondary effects of the pandemic in future years. In this report, we will discuss potential secondary effects of COVID-19, from a health, social and economic perspective, and what needs to be done to tackle these future challenges.
We define secondary effects of the pandemic as both the health side-effects of COVID-19 and those not directly related to the virus, but that still resulted from the pandemic and government policies enforced to curb the spread of the virus.
This document is intended for people in public health, built environment professionals, and citizens looking to advance their education on health. Given the complexity of the challenges we will face as we recover from the experience of Covid, it will need a multidisciplinary approach. This means the collaboration, awareness and contribution of various industries and skillsets.
OUR METHODS
We gathered the most current studies on the pandemic, however as it is a new and developing event, we also looked at historic data relevant to experiences of trauma and effects of previous pandemics. There are parts of the report where we have used reasonable conjecture to establish future risk. The datasets and studies are both from the United States and United Kingdom. Finally, as this is still a developing phenomenon, we also link to current reporting, especially relevant in detailing and understanding the lived experience of Covid-19.
INEQUITY
Despite being quite a new phenomenon, the scientific community has now widely acknowledged that social discriminations have caused Covid-19 to be experienced inequitably, specifically amongst the intersection of those who are Black, Asian, women, LGBTQ+, disabled, neurodiverse, and experiencing poverty. The wide range of discriminants have led to policies which force certain communities to live in areas with high levels of air, noise, and light pollution, which have acute and lasting consequences on health. It is these factors in conjunction with psychosocial stress of inequity and poverty that created a susceptibility to Covid-19.
We must acknowledge other factors such as who are the people that were most exposed to the virus due to their work or living conditions, who were the people that felt socially isolated from support or adequate healthcare, and who were the people who were more vulnerable to secondary consequences such as steeper poverty, homelessness, food insecurity, social isolation, abuse, neglect, or energy poverty. Finally, we also have to consider who were the communities that faced multiple phenomena at once, risking a more complex and difficult experience of Covid-19. For example, right before the pandemic started, Wales experienced severe flooding, leaving many people without adequate shelter, furthermore, many already were facing economic insecurity. As a result, some communities in Wales faced an economic, climate, and health crisis simultaneously. Their experience of the pandemic will therefore be vastly different to a person who only experienced the pandemic with a stable salary, working from home, and access to various resources. Whilst we all faced the same storm, we did so with vastly different tools.
Each of these different scenarios will require a different recovery response, resources, and strategies. We cannot treat them the same, doing so will create further inequities.
The Demographics
Disclaimer on health risk: not determinism / avoidable
It is important to note that when highlighting the health risk, it is not interpreted as deterministic or an inevitably. If we create an equitable recovery, we can avoid some of these secondary effects. In other words, there is no need to accept these risk factors as our fate, we must work hard to avoid further health inequities.
BAME Communities
The COVID-19 pandemic has disproportionately affected BAME communities, according to reports by ONS and scientific studies, with Black men ~4 times as likely as White men to die of COVID-19 (Chris White And, 2020). We recently proposed a reason for the significant impact of the virus on minority groups, explaining that continuous exposure to structural racism (i.e. subjecting ethnic minority communities to high levels of deprivation, pollution and classism) has made BAME communities more susceptible to disease, by lowering their immune defences due to a heightened level of chronic stress (Camargo et al., 2021).
Moreover, BAME people are more likely to work in the healthcare sector or as essential workers, therefore being more exposed to the virus.
BAME families are more likely to have lost a relative, the impact on mental health for ethnic minorities is also significantly larger (35% in BAME against 23% in White) (Why Have Black and South Asian People Been Hit Hardest by COVID-19?, 2020).
LGBTQ+ Communities
High baseline levels of unemployment in the trans community has pushed many to sex work, which in turn has exposed them even further to Covid-19. This is specifically in relevance to Black Transwomen. (source)
There are also high baseline levels of housing insecurity due to family disownment, housing discrimination, and insecure employment. This combined with an increased financial insecurity has created further exposure risk. (source)
Trans People face disproportionate levels of discrimination across the board, making it very difficult to access a wide range of necessary resources to keep them safe during the pandemic; housing, healthcare, mental care, necessary medicines, and nourishing food. (source) (source)
Within LGBTQ+ communities there are intersectionalities, each having respective nuanced inequities due to discriminatory systems creating socioeconomic disparities. In turn these disparities are at the root of mental and physical inequities. The experience of the pandemic has both helped exasperate these inequities and put these communities at higher risk of contracting the virus. (source)
40% of all LGBTQ persons in the US work in the service-industry jobs (compared with 22% of non-LGBTQ). Meaning that their unemployment rate during the pandemic has been high which often affects access to healthcare, creating a significant health risk.
Trans people face disproportionate rates of baseline health problems, which made them more susceptible to Covid-19. These include PTSD, diabetes, and asthma. (source)
Women
Women have been vastly affected by the pandemic through various pathways; domestic violence, loss of income, and exposure due to their jobs. (source) (source) (source) (source)
Black women in the US were more likely to have their job impacted by the pandemic, which has made them particularly vulnerable to job loss, food insecurity, and home insecurity. (source)
Black women disproportionately experience depression and anxiety, which with the experience of Covid, could make them even more vulnerable to future health crises. (source)
In the UK, Black, Asian women have faced disproportionate violence, especially those seeking refugee status. In the UK violence from a partner is one of the leading causes of women’s homelessness. Many Black, Asian, and other marginalised women have faced the pandemic with severe housing insecurity, increasing the risk of exposure as well as leaving the body highly susceptible to the effects of Covid-19 due to acute stress. (source)
Indigenous Peoples
Indigenous Americans are dying from Covid-19 at twice the rate of their White counterparts. (source)
Indigenous Americans are more likely to live without running water affecting one of the prime prevention strategies for a pandemic, good hygiene. (source)
These communities are also going through the trauma of losing several of their elders, which could leave many communities without primordial cultural resources.
Many Indigenous Americans are also more susceptible to Covid-19 due high rates of diabetes, asthma, and cardiovascular disease brought on by biological inequity (Camargo et al., 2021).
Elderly People
8 out 10 deaths reported in the United States have been for those over 65 years of age, this makes them the most vulnerable population for Covid-19. Intersectionality is also needed in terms of poor elderly and those who also from other marginalised groups such as LGBTQ+ or Black or Indigenous. (source)
Deaths in Elders in Native American communities are leaving a cultural void, threatening the future of traditions, language and culture. The hardship of losing elders in Native American communities could leave a mental health crisis amongst this group. (source)
A GP in London describes a mental health crisis in the elderly due to the pandemic; feelings of fear, pain, anxiety, and loneliness are rising within this population. In the UK those over 65 with comorbidities have been at the greatest risk for Covid-19. (Route, 2021).
A combination of racism and ageism in the US has left elderly Black individuals at high risk of death for Covid-19. They are also at high risk for housing insecurities and social isolation, making the experience of the pandemic very harsh and traumatic. (source)
Children
Children will be by far the demographic that suffers the most long term consequences. The pathways of vulnerabilities and risk are as follows;
Disturbed family dynamics: This can include separation from caregivers due to quarantine practices, family discord, financial insecurities, acute poverty, abuse, neglect, and the death of parents or other family members due to the pandemic. The children most affected will be those who belong to the classifications of BAME and BIPOC. Future studies on childhood development will have to include how the pandemic affected child development and its consequences for adulthood. Studies will also need to be broken down to include Indigenous, Black, Asian, and LGBTQ children as well as how these demographics intersect with poverty, racism, homophobia, and transphobia. (source) (source) (source)
Social isolation: The brain and nervous system are under acute development, which requires various forms of socialisation, which is at the moment being hindered due to the virus. This will require future studies as to how social isolation affects their cognitive development and adult attachment. (source)
Educational Gap: Children from poor Indigenous, Black, and Asian populations are at a higher risk of falling behind due a combination of factors; digital resources, stress from family dynamics, lack of personal space to concentrate, and food insecurity. This is not to say that they are guaranteed to fail or they will not catch up once the pandemic is over. This is to acknowledge that access to education has not been equal. (source) (source)
Multi-system inflammatory syndrome in children (MIS-C) is a disorder that is affecting children who have contracted Covid-19. It “can lead to life-threatening problems with the heart and other organs in the body. In this condition, different body parts, such as the heart, lungs, kidneys, brain, skin, eyes, or gastrointestinal organs, can become inflamed.” (source)
Disabled People
Due to the high numbers of hospitalised COVID-19 cases, medical and social care for other illnesses or for disabilities have been halted, cancelled or reduced with hospitals not able to cope with demands. The ONS has estimated that over 45% of people with a disability receiving treatment/care before the pandemic have had the treatment either cancelled or reduced. (source)
The lockdowns have increased social isolation, feeling of loneliness and have worsened mental health and wellbeing for disabled (41%) more than for non-disabled (20%) individuals. (source)
With limited access to healthcare, with over burdened food delivery services and lack of social interaction, the quality of life of people with a disability has significantly gone down. (source)
6 out 10 people who have died from Covid-19 have been disabled. (source)
Neurodivergent People
Neurodivergent communities are classed as a high-risk group for contracting the virus, with severe outcomes.
Social distancing measures and school closures have increased the risk of comorbidities such as anxiety, depression, learning disabilities in children and severe loneliness (Eshraghi et al., 2020).
Hospital Workers
Hospital (cleaners, nurses, doctors, etc) staff have been at the fore-front of the response to the pandemic, being continuously exposed to infected patients and having to sustain longer and more intensive hours of work.
During the first wave of the pandemic in the UK, the government failed to procure appropriate and sufficient PPE resources, which resulted in higher COVID-19 infections among healthcare workers, as well as increased levels of anxiety (Vindrola-Padros et al., 2020).
In different countries around the world, the same patterns of mental health erosion amongst healthcare workers has been reported, with increased levels of anxiety, depression, PTSD (Khanal et al., 2020; Rossi et al., 2020; Vizheh et al., 2020; Zhang et al., 2020).
Insomnia due to increased shift work has been shown to increase susceptibility to COVID-19 by lowering the immune defence (Silva et al., 2020), therefore causing a constant loop of poor mental health and viral infection in medical staff.
FUTURE INEQUITY PATHWAYS
This section goes into more detail about the secondary effects of COVID-19 and its pathways to further inequities.
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From the different demographics it is clear that if we do not offer an equitable recovery, we are going to have a widespread mental health crisis. This is one of the main secondary effects of the pandemic.
As the main focus of the pandemic has been curbing the spread of the virus, very little attention has been devoted to the psychosocial effects of governmental policies, such as lockdowns and social distancing measures. Partly due to the inability to collect data during lockdowns, the mental health effects the pandemic is causing have been under-researched and not addressed by governments (Rajkumar, 2020).
Lockdowns have enforced social distancing, causing some to live in complete isolation. Importantly, lack of social contacts reduces quality of life and wellbeing overall, by removing support groups and opportunities for social resilience (Goswami, 2012; Newman & Zainal, 2020; Saeri et al., 2018).
During the first wave, it was estimated that 16-28% of people in the UK experienced depression or anxiety as a direct result of the pandemic, causing reduced quality of sleep (Rajkumar, 2020). A study conducted at the start of the second wave compared longitudinal data from a cohort of UK participants pre-pandemic and during the first/second wave. Results indicated that the prevalence of mental health disorders rose in the overall population by ~8.4% during the pandemic, with 18-34 year olds and women among the groups most affected (Pierce et al., 2020). In the UK, the Office for National Statistics collected survey data from higher education students, indicating that 63% of students expressed that their mental health deteriorated as a result of the pandemic (Hamilton, 2021).
These results are only estimates and preliminary studies into the real impact of the pandemic on the mental health of younger generations. However, they do already portray a worrying picture for what could become a mental health epidemic. At the time of writing no plan has currently been provided for a phased return to work, education and social activities, we predict that mental health disorders will rise further throughout the year.
When viral infections subside, researchers and governments should turn their attention at understanding the prevalence of mental health disorders post-pandemic and design plans for supporting and offering therapies to people affected. If we do not create specific healthcare programmes that properly support people who have developed mental disorders we will create further inequities.
The inequities are in two pathways:
(1) The more acute a person’s mental health challenges are, the more risk of unemployment. This could be through not having the support to take the right sick leave or simply not being mentally supported to sustain an arduous work schedule.
(2) The second pathway is the social isolation that can occur when facing a mental health challenge. Being social is a very key part of human development. Social isolation can impede the ability to seek career and personal goals. In turn this could lead to further economic inequities.
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There is clear literature that highlights how deprivation has put many communities at a disproportionate risk for Covid-19 (Camargo et al 2021). However, we also have to consider how Covid has created further deprivation amongst those already experiencing it and how the pandemic has plunged more people into deprivation.
The lockdowns have not only isolated us socially, cutting ties from families and support groups, but have also caused a significant impact on worldwide economies. For instance in the UK, GDP fell by record numbers in March, April and November 2020, with a record 18.8% fall in April at the height of the first wave (Stephens et al., 2021). So far, >800,000 people were laid off and >9 million people have been relying on the furlough scheme in the UK for financial support while their workplaces were mandated to close (HM Revenue & Customs, 2020).
Although statistics indicate a record increase in household savings overall, 54% of low-income families have borrowed more money to cover costs (Francis-Devine, 2021; Sumaya Abdi And, 2020). These results suggest that the socio-economic divide in the UK is widening further, with some families increasing their wealth and others falling into poverty. Indeed, it is estimated that 700,000 people, of which 120,000 children, were driven into poverty during the pandemic in the UK (Butler, 2020) and that 70,000 people became homeless during the same period (Jayanetti, 2021).
The increase in poverty and homelessness, or deprivation in general, are known to be precursors to severe mental health issues such as post-traumatic stress disorder (Araceli Camargo, Elahi Hossain, Sarah Aliko, Josh Artus, Guillame Dezecache, 2019; Golin et al., 2016; Parto et al., 2011). It is therefore imperative to address these economic issues in the immediate future, and in particular potential issues arising from the unequal distribution of wealth that is becoming more and more apparent during the pandemic. Governments should design a plan to offer and guarantee work and training opportunities for the unemployed and those in low-income households.
Due to how our socio-economic system is set up, if a person cannot access financial resources, it can affect health through lower access to nourishing food, lower access resources such as time for self-care, lower access to energy affecting the ability to cook non processed foods or heat or cool a home, lower access to adequate homes clear from mould, have proper insulation, proximities to green space, and adequate noise and light insulation - all of these factors influence the quality of health of a person. Therefore, if we are to have an equitable Covid-19 recovery specific financial programs to help people back on their feet will have to be created. This goes beyond “eat out to help out”. It will require rent amnesty, developed food programmes, free childcare, financial education, and grants to financially vulnerable families.
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In many countries, particularly in Europe, school closures due to the pandemic have been prolonged and conducted without the adequate infrastructure. For example, providing households with laptops, free internet access, and a guidebook of how to do remote schooling. Instead, parents, teachers and students were thrown into a new normal without any help and for those families that were under financial pressure that didn’t have a quiet dedicated learning space or the ability to access digital resources, the experience has been far worse.
Although the move to online learning has impacted over 50% of children, it has more significantly impacted students from low-income households who are more likely not to own a computer, or lack access to wifi and technologies needed to support the change. Indeed, 9% of pupils lack adequate technologies for accessing online learning resources, with children in single-parent households being most affected (Children without Internet Access during Lockdown, 2020; Williams et al., 2020). This has disproportionately impacted schools in deprived and low-income areas, meaning that the educational gap between wealthy and low-income families has further widened. The ramifications of reduced quality of education for over a year cannot be understated. Adults from low-income backgrounds already face barriers to higher education and white collar jobs, but the lack of learning hours that pupils are currently facing can only serve to further exacerbate this phenomenon. Moreover, due to closures, young people not in higher education have reduced opportunities for training and entering the workforce, thus increasing unemployment risk.
The problems with access to in-person education and lack of online access for some pupils, has meant that parents of low-income families were faced with the difficult choice of either reducing working hours or support their children with homeschooling (Poverty in the Pandemic: The Impact of Coronavirus on Low-Income Families and Children, 2020). Finally, schools offer unique environments for support and growth of pupils, including free school meals, appropriate heating, and learning tools that are not always available in more deprived homes. It is estimated that ~10% of children in Europe live in unhealthy homes, 5% lack access to appropriate learning materials and >6% do not receive nutritious food (Van Lancker & Parolin, 2020).
One of the biggest challenges for governments will be to create a comprehensive plan to tackle youth poverty, education and health post-pandemic. All these phenomena are tied together and cannot be addressed in a vacuum, but should be considered in combination.
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Most of shift-workers are also in the category of essential workers, who have had to continue working to keep our society safe and moving forward.
However, when shift-workers are scheduled for night shift their body is forced to stay awake during times the body would naturally be asleep, additionally they are over exposed to artificial blue light. Both factors instigate the production of melatonin outside the usual sleep/wake cycle, with time this can cause a disruption to the neuro-endocrine system (Reinberg and Ashkenazi 2008). This disruption can have an effect on the quality sleep, often leading to sleep disturbances and sleep deprivation. Severe sleep deprivation is also highly associated with the dysregulation of immune functions (Axelsson et al 2013).
It is through this sleep disruption that shif-work contributes to the risk of contracting Covid-19 (source), additionally, as the dysregulation of the immune system could also elongate their recovery time. However, the story doesn’t end here. Shift work is highly associated with zero contract hours, which are well known to cause financial insecurity amongst this demographic. In turn this insecurity can force people into crowded homes, homes with inadequate infrastructure, and homes located in areas of high environmental stressors. These factors will also contribute to further stressors that can also affect our biological functions.
In thinking about a more equitable recovery, we have to consider how we improve society as a whole. Shift Work, even without the threat of a pandemic can be quite harmful to a person’s health through its direct biological pathways and indirect lived experienced pathways. Therefore, we have to create policies that end zero contract hours and how many days a person can work a night shift. There also has to be adequate health support in the work environment; adequate breaks, access to free healthy food on the premises, and financial support for health practices such as yoga and meditation which are known to help support the immune system. Finally, we have to stop expecting for non emergency resources to be available to us around the clock as it contributes to health inequities.
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Whilst climate change seems like a far fetch factor many people were heavily affected by it. There are two ways climate change both acted as a contributing factor to Covid-19 and as a significant factor in our recovery. In the run up to the pandemic Welsh towns experienced severe flooding due to back to back storms. After the storms various stories of homeless due to the flooding were reported (source). Problems such as inadequate housing conditions such as no access of electricity, water, or heating were also reported (source). Many residents told reporters they felt abandoned and scared (source).
These communities were left facing a pandemic under acute stress, financial instability and home insecurity. Whilst there have not been any studies linking the stress and trauma of experiencing a weather based crisis and susceptibility to Covid-19, there are various studies linking trauma and dysregulation of immune function, which makes people susceptible to illness (source). Therefore, we can make an accurate inference that the trauma from the flooding would follow a similar risk structure. This inference is anecdotally supported by the current reporting on the Welsh areas which have experienced the worst per capita rates of Covid-19 in the UK, Merthyr Tydfil and Rhondda Cynon Taf. These two areas were also some of the worst affected by the floods. These areas are also some of the most deprived areas in the UK (source), therefore the combination of deprivation, trauma, housing insecurity, flooding, and Covid-19 have created a very acute health emergency in these areas. The US would see similar trends with the fires, hurricanes, and winters storms, specifically in Native American communities. A Covid recovery has to take climate change into account and target areas where various factors have coalesced to create deep health inequities.
RACISM NOT RACE DISCLAIMER
While Centric has broken down this document via race, it is important to note that it is not a person’s race that contributes to poor health outcomes, instead it is the racist systemic structures. We highlighted race because the structure of White Supremacy uses it as an identifier and reason to enact discriminatory practices that end up in structurally racist policies, zoning, and decisions. In turn, this structural racism ends up in specific consequences that lead to health risks we have highlighted.