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Mental Health Impact of COVID-19: A Survey of 59 Countries

By Shlomo Maital   

  We are approaching almost a year of the coronavirus pandemic – and in virtually every country (except perhaps New Zealand, where fans are filling stadiums to watch the All-Blacks), it is beginning to wear people down.  Here are the results of  large-scale study of the mental health impact, based on a sample of 6,882 individuals in 59 countries. *

  • Elisabet Alzueta et al., “How the COVID-19 Pandemic has changed our lives: A study of psychological correlates across 59 countries”.  J. of Clinical Psychology 2020: 1-15.

Of the nearly 7,000 participants, 25.4 % reported moderate-to-severe depression,  while 19.5% reported anxiety symptoms. 

  What caused the depression?  A variety of factors:  Among them,

*  the country’s income level (higher income correlated with higher depression),  * exposure to COVID-19 (e.g. unconfirmed symptoms), * government lockdowns, * life changes (e.g. working from home); and * conflicts with other adults at home.  However, all these factors ‘explained’ (in a statistical sense) only about one-fifth of the variance in depression.

A major battle is underway between the “the cure (of the pandemic) is worse than the disease, let’s open at once” camp,  and the “you cannot heal the economy until you stamp out the damned virus” camp.  I think the latter are more right – better to severely lock down, like taking a very bitter medicine to cure an illness, to shorten the prolonged impact on mental health by failing to do so.

  It is surreal that American voters are basically being asked to choose between these two camps, Trump vs. Biden —  when the issue is really rooted in complex epidemiology and shrouded in massive uncertainty.   It is clear, however, that the science and the scientists overwhelmingly favor the “end the virus first, clamp down hard” policy. 

It’s So Darn Simple! Wear the Damn Mask!

By Shlomo Maital

Listen carefully. Wear the damn mask! In Asia, countries where people are used to wearing masks, and do so, have fewer cases. Wear the damn mask! Make it a federal requirement. Personal freedom? First amendment rights? Come on, blockheads – you do not have the right to infect others and endanger their lives.

But hey – don’t believe me. Would you believe Goldman Sachs? They are very careful about what they say – the service investment banks offer is mainly trust and credibility. And Goldman Sachs says, 60% (you got it – 60%) of current cases could be prevented if everybody, everywhere, would wear masks in public. If everybody agreed to wear the damn mask, it would not be so necessary to keep shutting and opening restaurants, bars, beaches, small businesses, etc. The benefits would be huge.

   So why don’t people wear them in the US? Why are cases spiking, in 30 or more states?

   Ask your President.

   Unless mask attitudes and behavior change fast, the picture for the US economy is bleak. Here is Goldman Sachs’ take on it:

   “The sharp increase in confirmed coronavirus infections in the US has raised fears that the recovery might soon stall,” Jan Hatzius, Goldman’s chief economist, said in a note. “Although a significant part of the increase reflects higher testing volumes … a broader look at the CDC criteria for reopening shows that not only new cases but also positive test rates, the share of doctor visits for covid-like symptoms, and hospital capacity utilization have deteriorated meaningfully in the last few weeks.”   GDP fell 5% in the first quarter, part of a mostly self-induced recession aimed at stopping the coronavirus spread. It was the biggest one-quarter drop since the fourth quarter of 2008, during the Great Recession. As cases decreased, states slowly began reopening amid hopes that the sharp drawdown would be short-lived. Indeed, even if Goldman’s reduced call is correct, that would mark, by a wide margin, the biggest quarterly rebound since at least 1947. The U.S. has seen 340,000 new virus cases over the past week, a rise of 13.4%. That has come with 3,447 deaths, a 2.9% increase.”

Keep it simple, Stupxxx.   Wear the damn mask!



Why Seattle Saved Lives – and New York City Did Not!

By Shlomo Maital

   In “The Pandemic Protocol”, The New Yorker, By Charles Duhigg, April 26, 2020, the question is asked: Why has Seattle largely escaped the ravages of COVID-19, while New York City has been ravaged?

   The short answer by Duhigg: A bit of luck (a flu test study whose swabs later revealed the widespread presence of COVID-19, and city leadership which listened closely to scientists (Seattle, by the way, is the world capital of epidemiologists).

   Here are the numbers. As of April 27, Seattle (King County) had 5,863 cases of COVID-19, and 408 deaths. As a % of Seattle’s population, 744,955,   that comes to: 0.8 % of the population contracted the virus, and 0.05% of the population died from it.

     For New York City, 160,000 cases have been identified, or over 2% of the population, 8.4 million; there have been 12,287 deaths, or 0.15% of the population.

   Basically, Seattle proportionally has had a third of the COVID-19 cases that New York City has. True – Seattle is less dense than NYC, and has fewer homeless and poor…

   But why? Why did Seattle largely escape? In short: Seattle did its lock down a week or 10 days before New York City did. And those few days were enough to save many many lives. But why did Seattle get this head start?

   Here is the story. Warning: It’s long, 2,300 words. The heroes? Seattle-based scientists – and a little-known King County executive named Dow Constantine. His wisdom and prompt action saved many many lives.   The story by Duhigg is rather long, but worth reading:

   “The first diagnosis of the coronavirus in the United States occurred in mid-January, in a Seattle suburb not far from the hospital where Dr. Francis Riedo, an infectious-disease specialist, works. When he heard the patient’s details—a thirty-five-year-old man had walked into an urgent-care clinic with a cough and a slight fever, and told doctors that he’d just returned from Wuhan, China—Riedo said to himself, “It’s begun.”

   “For more than a week, Riedo had been e-mailing with a group of colleagues who included Seattle’s top doctor for public health and Washington State’s senior health officer, as well as hundreds of epidemiologists from around the country; many of them, like Riedo, had trained at the Centers for Disease Control and Prevention, in Atlanta, in a program known as the Epidemic Intelligence Service. Alumni of the E.I.S. are considered America’s shock troops in combatting disease outbreaks. The program has more than three thousand graduates, and many now work in state and local governments across the country. “It’s kind of like a secret society, but for saving people,” Riedo told me. “If you have a question, or need to understand the local politics somewhere, or need a hand during an outbreak—if you reach out to the E.I.S. network, they’ll drop everything to help.”

   “Riedo is the medical director for infectious disease at EvergreenHealth, a hospital in Kirkland, just east of Seattle. Upon learning of the first domestic diagnosis, he told his staff—from emergency-room nurses to receptionists—that, from then on, everything they said was just as important as what they did. One of the E.I.S.’s core principles is that a pandemic is a communications emergency as much as a medical crisis. Members of the public entering the hospital, Riedo told his staff, must be asked if they had travelled out of the country; if someone had respiratory trouble, staff needed to collect as much information as possible about the patient’s recent interactions with other people, including where they had taken place. You never know, Riedo explained, which chance encounter will shape a catastrophe. There are so many terrifying possibilities in a pandemic; information brings relief.

     “A national shortage of diagnostic kits for the new coronavirus meant that only people who had recently visited China were eligible for testing. Even as EvergreenHealth’s beds began filling with cases of flulike symptoms—including a patient from Life Care, a nursing home two miles away—the hospital’s doctors were unable to test them for the new disease, because none of the sufferers had been to China or been in contact with anyone who had. For nearly a month, as the hospital’s patients complained of aches, fevers, and breathing problems—and exhibited symptoms associated with covid-19, such as “glassy” patches in X-rays of their lungs—none of them were evaluated for the disease. Riedo wanted to start warning people that evidence of an outbreak was growing, but he had only suspicions, not facts.

   “At the end of February, the C.D.C. began allowing the testing of patients with unexplained respiratory-tract infections or “fever and/or symptoms of acute respiratory illness.” Riedo called a friend—an E.I.S. alum at the local department of health. If he sent her swabs from two patients who had needed ventilators but had tested negative for influenza and other common respiratory diseases, would she test them for covid-19? At that point, there had been only sixteen detections of the coronavirus in the U.S., and only the one in Washington State. “I can’t remember why we picked those two patients,” Riedo told me. “I was sure they’d be negative. But we thought it would be good to start collecting data, and it was a way to make sure the testing lab was working.” The health official told him to send the samples to her lab.

   “Riedo remembered that other local researchers had been conducting a project called the Seattle Flu Study. For months, they had collected nasal swabs from volunteers, to better understand how influenza spread through the community. During the previous few weeks, the researchers, in quiet violation of C.D.C. guidance, had jury-rigged a coronavirus test in their lab and had started using it on their samples. They had just found a positive hit: a high-school student in a suburb twenty-eight miles from Seattle, with no recent history of foreign travel and no known interactions with anyone from China. The boy wasn’t seriously ill; if the researchers hadn’t done the test, the infection probably never would have been detected. The genetic sequence of the boy’s virus was unnervingly similar to that of the man with the first known case, even though the researchers couldn’t find any connections between them. The frightening implication was that the coronavirus was already so widespread that contagion was passing invisibly among community members.

   “On February 28th, around the time that Riedo learned of the covid-19 cluster at the Life Care nursing home, the news was also relayed to another E.I.S. alum, Dr. Jeff Duchin, the top public-health physician for Seattle and surrounding King County. To Duchin, the cluster suggested that there was already an area-wide outbreak. He told Dow Constantine, the King County Executive, that it was time to start considering restrictions on public gatherings and telling residents to stay home. This advice struck Constantine as possibly crazy. There were only two dozen covid-19 diagnoses in the entire nation. Life looked normal. How could people be persuaded to stop going to bars, much less to work, just because a handful of old people were sick?

“At that moment, there were no known U.S. coronavirus fatalities. Schools, restaurants, and workplaces were open. Stock markets were near all-time highs. But when Riedo stopped to calculate how many of his hospital employees had been exposed to the coronavirus he had to quit when his list surpassed two hundred people. “If we sent all of those workers home for two weeks, which is what the C.D.C. was recommending, we’d have to shut down the entire hospital,” he told me. He felt like a man who, having casually swatted at a buzzing insect, suddenly realized that he was beneath a beehive.”

   Constantine told me, “Jeff recognized what he was asking for was impractical. He said if we advised social distancing right away there would be zero acceptance. And so the question was: What can we say today so that people will be ready to hear what we need to say tomorrow?” In e-mails and phone calls, the men began playing a game: What was the most extreme advice they could give that people wouldn’t scoff at? Considering what would likely be happening four days from then, what would they regret not having said?

   “Even for public-health professionals, the trade-offs were painful to contemplate. At a meeting of public-health supervisors and E.I.S. officials in Seattle, an analyst became emotional when describing the likely consequences of shutting Seattle’s schools. Thousands of kids relied on schools for breakfast and lunch, or received medicine like insulin from school nurses. If schools closed, some of those students would likely go hungry; others might get sick, or even die. Everyone also knew that, if the city shut down, domestic-violence incidents would rise. And what about the medical providers who would have to stop working, because they had to stay home with young kids? “It was overwhelming,” one E.I.S. official told me. “Every single decision had a million ripples.”

   “Yet the burdens caused by closing the schools could make an enormous difference in curtailing the spread of the virus: all kinds of parents would have to stay home. In 2019, Seattle had closed schools for five days after a series of snowstorms. Afterward, the Seattle Flu Study discovered that traffic in some areas had nearly disappeared, public-transit use had tumbled, and the transmission of influenza had dropped.

   “Constantine thought that announcing school closings was a potent communication strategy for reaching even people who weren’t parents, because it forced the community to see the coronavirus crisis in a different light. “We’re accustomed to schools closing when something really serious happens,” Constantine told me. “It was a way to speed up people’s perceptions—to send a message they could understand.”

     “While the logistics of classroom closures were being worked out, Constantine contacted Brad Smith, the president of Microsoft—which is headquartered in Redmond, east of Seattle—and asked him to consider ordering employees to work from home. “Microsoft is a big deal here,” Constantine told me. “I thought if they told everyone to stay home it could shift how the state was thinking—make the pandemic real.” Microsoft, as a tech company, was poised to switch quickly to remote work, and could demonstrate to other businesses that the transition could occur smoothly. On March 4th, with only twelve known covid-19 fatalities across the nation and no diagnoses among Microsoft workers, the company told employees to stay home if they could. Smith told me, “King County has a strong reputation for excellent public-health experts, and the worst thing we could have done is substitute our judgment for the expertise of people who have devoted their lives to serving the public.” Amazon, which is also headquartered in the area, told many of its local employees to work from home as well. “That’s a hundred thousand people suddenly staying home,” one Seattle resident told me. “From commute traffic alone, you knew something big had happened.”

   “On February 29th, Constantine held a press conference. He had asked Riedo, Duchin, and Kathy Lofy—another E.I.S. alum and the state’s top health officer—to play prominent roles. Duchin spoke first, and it was as if he had prepared his remarks with the Field Epidemiology Manual in hand. “I want to just start by expressing our deep and sincere condolences to the family members and loved ones of the person who died,” he said. He explained what scientists knew and did not know about the coronavirus, and noted, “We’re in the beginning stages of our investigation, and new details and information will emerge over the next days and weeks.” He predicted that “telecommuting” was likely to become mandatory for many residents, and repeated several times an easy-to-remember sohco: “more hand washing, less face touching.” Duchin told me that his words had been chosen carefully: “You have to think about managing the public’s emotions, perceptions, trust. You have to bring them along the path with you.” Since then, Washington State politicians have largely ceded health communications to the scientists, making them unlikely celebrities. “Hey people!! Jeff Duchin is the real deal,” one fan tweeted. A newspaper hailed him as “a bespectacled, calming presence.”

   “Constantine told me that he understands why politicians “want to be front and center and take the credit.” And he noted that Seattle has many of “the same problems here you see in Congress, with the partisanship and toxicity.” But, he said, “everyone, Republicans and Democrats, came together behind one message and agreed to let the scientists take the lead.”

   “By the time Seattle’s schools were formally closed, on March 11th, students and teachers were already abandoning their classrooms. The messaging had worked: parents were voluntarily keeping their kids home. Cell-phone tracking data showed that, in the preceding week, the number of people going to work had dropped by a quarter. Within days, even before Washington’s governor, Jay Inslee, issued official work-from-home orders, almost half of Seattle’s workers were voluntarily staying away from their offices. When bars and restaurants were officially closed, on March 15th, many of them were already empty. Constantine himself had been working from home for a week. He was giving interviews all day, and always underscored to reporters that he was speaking from his bedroom, and that the noises in the background were coming from his children, who were home from school. After he heard that the county’s basketball courts were still being heavily used, he ordered them closed.”

     In Seattle, mainly the scientists spoke, not the politicians. And the politicians listened.

     Seattle should be carefully studied; our understanding has already been illuminated thanks to Duhigg’s fine reporting.  Well done, Duhigg.

     I urge everyone to read the full article in The New Yorker, online.

Blog entries written by Prof. Shlomo Maital

Shlomo Maital