Psychosocial and Economic Impact of COVID-19—A Nation Under Siege

SARS-CoV-2 has radically transformed our society not only because of widespread infections among people all over the globe but also due to its profound social and economic impact. Together, these two factors exacerbated the levels of stress experienced not only by individuals who were infected by SARS-CoV-2 but also those whose lives were irrevocably changed by the direct and indirect effects of the pandemic. This chapter examines some of the specific psychological, economic, environmental, and psychosocial effects of the pandemic, as well as the way in which individuals’ stress responses can adversely affect their mental health and wellbeing. While SARS-CoV-2 is a viral disease with a specific pathology that has already been discussed, the COVID-19 pandemic has proven to be a psychosocial disease with truly devastating social, economic, and psychological consequences.

Understanding COVID-19 as a Psychosocial Disease

There is a popular belief in some circles that human nature is defined almost entirely by experience. In the most basic terms, those who advocate this view believe that the human mind is largely a blank slate (or tabula rasa)
when an individual is in infancy and over time it is filled in by experience. Of a similar vein, there is a belief that humans are almost endlessly adaptable and that we are capable of thriving in an almost infinite number of social conditions so long as the physical environment into which we have been placed is not too hostile. In other words, so long as we have the most basic needs for survival (water, food, air, etc), we will be able to endure and possibly even thrive.

Endure? Yes. Thrive? Hardly.

As psychoanalyst Erich Fromm wrote over 60 years ago, “The statement that man can live under almost any condition is only half true; it must be supplemented by the other statement, that if he lives under conditions which are contrary to his nature and to the basic requirements for human growth and sanity, he cannot help reacting.”¹ As humans, we have our physical, social, and psychological limits, and they are all interconnected. We are not infinitely malleable. We can adapt and endure a great deal, but, eventually, we reach a breaking point. As a result, there are conditions to which we cannot adapt.

For hundreds of thousands of years, we have persevered and thrived in tribes and in clans. Survival was only possible if we worked together to overcome environmental dangers and to ward off attacks from other animals (and other humans). In time, this process of collaboration gave way to language and highly sophisticated cultures and further ingrained the need for social interaction into our psychological DNA. Human beings are social animals, and this requires us to interact with other humans. Consequently, when we are placed in isolation, we deteriorate psychologically and physically and these two have a reciprocal effect—meaning psychological deterioration accelerates physical deterioration and vice versa (more on that below). After all, if we were not social creatures, solitary confinement would not be considered a form of torture.

One of the core elements of human nature is the need for physical interactions with other humans—and not just over the phone or through Zoom. The sense of smell and touch is an essential part of being human. The pandemic and social distancing robbed us of being able to be physically close to others and took away these essential elements of our existence. We need to feel other people’s presence, to share space with them, and to touch and even smell them. Virtual meetings may have been an acceptable solution in the short-term and may allow us to fulfill certain professional duties, but it became apparent relatively quickly that these ersatz interactions are flat and alienating ordeals that cannot substitute authentic social interactions. They simply do not satisfy our need for social engagement, and many of us have learned during the pandemic that this
lack of real human interaction can lead to a deterioration of mental health, even if we may not develop a diagnosable mental illness.

Social interaction and social engagement provide us with two vital sources of comfort. On the one hand, it gives us a sense of belonging, that we are part of a group, and makes us feel accepted and validated. On the other, it makes us feel safe and gives us a sense of security, which is another basic requirement for human beings to thrive. This is not to say that we need to be coddled or babied or meticulously kept out of harm’s way. We absolutely do need to be challenged in order to learn and to grow. However, when these challenges are constant and one feels as though they need to remain hypervigilant and fear for their life, it takes a toll on one’s mental health. This was the reality for many essential workers during the first phase of the pandemic who had no security blanket, no protection via natural immunity or vaccination, and oftentimes limited supplies. They were forced to confront the persistent threat of infection and the possibility that they might even spread the virus to others, including their loved ones at a time when very little was known about the acute or long-term effects of the virus.

The human race did not evolve to be placed under this kind of solitary and persistent stress—be it due to social isolation or due to months-long fear of a pathogen without respite. We evolved specifically to avoid these kinds of issues by forming strong social networks and working together, thereby giving us the opportunity of repose. The pandemic led to the disintegration of our social fabric, which under normal circumstances provides us with a sense of tranquility and inner calm. As a result of quarantine, being cut off from our social supports which function as emotional and psychological sustenance, as well as a barrage of psychosocial stressors amidst a backdrop of extreme political polarization, violent rhetoric, mass protests, and a cavalcade of terrifying economic and geopolitical news, it seemed as though the social order that we had come to recognize as the bedrock of our day-to-day existence began to crack and crumble.

This environment has been noxious and conducive only to cultivating psychological distress, which is why many people without preexisting conditions or genetic predispositions or a history of mental illness have reported struggles with their mental health. Throughout the pandemic, nearly everyone has exhibited some of the symptoms of affective, anxiety, or substance abuse disorders. Having these conditions does not mean that one is mentally ill, an addict, or in any way weak. Rather, it suggests that one could not thrive in conditions that are contrary to the needs of humans. If anything, it is a proof of their humanity, a reminder to practice humility, and a reason that each one of us should wear our empathy on our sleeve.

What is reassuring is that the vast majority of those who were forced into long periods of social isolation or perpetual fear during the pandemic will ultimately recover. As I have said elsewhere, humans are exceptionally resilient.

Despite this, many people will not be so lucky, and it is therefore important to understand why we need to examine COVID-19 not merely through the lens of a disease that produces specific physical symptoms but also as a social phenomenon that produced not only direct psychosocial effects but also indirect effects that exacerbated many of the preexisting health problems that are common throughout the United States. Without a doubt, the greatest tragedy during this pandemic has been the deaths of millions of people around the globe, including hundreds of thousands of Americans. However, despite that horrendous number of deaths, one cannot minimize the everlasting physical and psychological scars among the sick who survived but had to be hospitalized and continue to struggle with the onslaught of lingering symptoms associated with long COVID. In addition to those who became sick, there are millions who will experience some degree of secondary and tertiary tragedies that could play out for years to come. An unfathomable number of people across the United States and the world were inundated by stress—struggling with their living situations, employment status, or the fact that they or their loved ones could become sick—and the fear and stress of contracting COVID-19 or lack of economic or social supports have been the root cause of depleting their psychological reserve and resilience.

Additionally, the biological and psychosocial aspects of COVID-19 have been intertwined such that the pathology of COVID-19 and numerous social aspects of the pandemic led to pernicious effects on an individual’s health and in particular mental health. As described in Chapter 3: Pathology—What We Knew and What We Know, even mild cases of COVID-19 can lead to an errant immune response and systemic inflammation. Furthermore, as explored in Chapter 4: Neuropsychiatric Symptoms and Postacute Sequelae of SARS-CoV-2—The Long Haulers, systemic inflammation can lead to neuroinflammation which may contribute to or exacerbate symptoms of anxiety and depression. Needless to say, when social stressors are added to this mix, it further amplifies these symptoms and may worsen one’s mental health.

Hard evidence is now starting to emerge about the colossal impact of the COVID-19 pandemic on individuals’ mental health, and we are finding that those who were the most vulnerable before the pandemic and were already struggling with multiple stressors—particularly those tied to socioeconomic difficulties (food insecurity, housing instability, precarity of transportation, interpersonal violence, etc)—appear to have suffered the most.² As was observed multiple times in the early stages of
the pandemic, most of these problems were not new; they were merely exacerbated by COVID-19.

Considering the abovementioned facts, a psychosocial approach to these issues should not be in any way controversial. Social stressors seem to have played a direct and significant role in the pathology of COVID-19 and have also impacted the mental health of millions of people who were never infected by the novel coronavirus. To fully understand and describe every social component that potentially contributed to COVID-related anxiety or depression would require a vast chronicle of the COVID Era, which is something that is beyond the scope of this book. However, there are crucial social components to the story of COVID-19 that need to be touched upon before moving on to discuss the larger issue of stress and some of the specific manifestations of that stress.

Economic and Social Effects of COVID-19

What follows is by no means an exhaustive list of the economic and social effects of COVID-19. These are, rather, the tips of the iceberg that either caused increased stresses or were the results of stresses on individuals who were suddenly deprived of their familiar support networks and often incapable of moving freely, working, socializing, or taking part in activities that had given their life meaning.

COVID-19 either set off or contributed to multiple domino effects that all seemed to collide in a spectacular fashion in early 2020. The result was widespread chaos, collapses in supply chains and local economies, shortages of staples, and unprecedented layoffs in virtually every sector of the economy from which we are still recovering. Within the United States, an estimated 22 million jobs disappeared in the 4 weeks after a national emergency was declared on March 13, 2020. A record 6.9 million people filed for unemployment the week ending March 28, 2020, alone.³ One cannot underestimate the colossal impact of this economic loss that halted the lives of millions and caused mayhem, confusion, anxiety about the future, and in many cases, a deep sense of fear and depression.

Domestic Abuse

By April 2020, 95% of the U.S. population lived in an area where people were under instructions to remain at home, which meant that most individuals who lost their job were not going to be able to find a new one quickly.⁴ This, combined with the widespread job losses and other stressors described above, appears to have forced many individuals into
living situations that would have been untenable in less dire circumstances. Despite the abominable domestic situation, many of these individuals, who were often women with children, opted to remain in place, and endure the abuse, as they understood that leaving their homes could mean living on the streets, potential exposure to the virus, as well as the many dangers associated with homelessness. In fact, domestic abuse was even characterized in Time Magazine as “a pandemic within the COVID-19 pandemic.”⁵

Studies that have analyzed the types of injuries reported in emergency room visits since the beginning of the pandemic have found evidence to suggest that incidence of intimate partner violence and child abuse increased as more victims were forced to choose between the abuse and the street.⁶ A systematic review and meta-analysis of officially reported domestic violence in multiple countries showed similar results.⁷

Unfortunately, an accurate picture of just how pervasive domestic abuse has been during the pandemic has not emerged at this time. Preliminary studies and anecdotal stories indicate that rates of incidence have increased and that this will be an enduring source of trauma for countless individuals who may go on to develop either trauma- and stressor-related disorders or dissociative disorders. The latter may be particularly common among victims of child abuse who faced serious maltreatment by a relative or friend of the family who was given shelter during the pandemic.⁸

Depopulation of Urban Centers

The past 30 years has seen a growing number of young professionals and “creative” office workers from around the world move to a handful of what urban studies theorist Richard Florida termed “superstar cities” in his 2017 work, The New Urban Crisis.⁹ This has led to increased gentrification of neighborhoods in cities that were originally home to lower middle-class and working-class communities, while a simultaneous dearth of affordable housing projects has made it increasingly difficult for the affected communities to remain in their home cities. Simply put, these working class and lower middle-class individuals who work in sectors of the economy like retail, hospitality, manufacturing, construction, and education are being pushed out, and professionals, who typically work in offices, are moving in.

When the pandemic began, many professionals were told that they would be allowed to work remotely for the foreseeable future and, consequently, many fled their homes in urban areas. Those who had cottages or houses in the country took up residence there. Others began a mad scramble to purchase homes in suburban and exurban areas.¹⁰ Some even moved into so-called “Zoom towns” in more rural areas.¹¹
Meanwhile, many younger people moved back home with their parents. As of September 2020, for the first time since the Great Depression, a majority of young adults between the ages of 18 and 29 years were living with at least one of their parents.¹² While young professionals in this situation were able to work remotely, nonprofessionals often struggled to find work and exert their financial independence.

The effects of this mass exodus were immediate. The urban centers that had attracted people for generations looked deserted overnight. Within just a few weeks, the cacophony of some of the most illustrious global cities fell to a murmur. The volume of foot traffic that had justified stratospheric rents in central business districts areas plummeted as more office workers were told to do their jobs remotely and stay-at-home orders were issued. Millions of construction, manufacturing, hospitality, and retail workers subsequently lost their jobs, meaning they were not only unemployed but also forced to remain at home and were unable to look for a job. While many retail and hospitality workers continue to face significant headwinds finding comparable jobs that pay more than minimum wage, the cornucopia of bars, restaurants, and retail stores in major business districts simply cannot return to normal business without the spending power of a professional class who have moved to suburban areas and no longer need to venture downtown areas.

Should the virus become endemic, which does seem highly probable, this will likely have long-lasting impacts on urban centers, as people amend their lifestyle to account for the increased risks posed by the virus. At this point in time, it is far too early to tell what these impacts will look like.

Substance Use

With the sudden economic downturn and millions of individuals becoming unemployed, the natural outcome was boredom, familial friction, increased domestic violence, and increased substance use, particularly alcohol. Studies have found that no amount of alcohol use is healthy, but the negative health effects of limited and occasional alcohol use are relatively minor so long as the individual drinking is not pregnant, has no significant medical comorbidities, is not taking certain medications, or is not planning to operate heavy machinery or drive a car. If done in excess, alcohol can lead to a host of health problems that affect the liver, heart, GI tract, and brain. Overuse of alcohol can also wreak havoc on one’s familial, social, and work lives.

Anecdotal evidence suggests that people started drinking more to cope with the stresses of the pandemic and surveys have found that consumption of alcohol increased manyfold when compared to prepandemic levels. At
least, one survey conducted by the American Psychological Association found that 23% of adults reported drinking more.¹³ Meanwhile, retail alcohol sales have skyrocketed as people have consumed more alcohol at home, but this begs the question: Are people drinking more at home, or are they consuming more alcohol than they once did?

What this question sidesteps is the cultural importance of alcohol in many societies, including the United States. As Kate Julian observed in a very well-written article published in The Atlantic’s July/August 2021 issue, humans have consumed alcohol socially for millennia and getting inebriated with one’s friends and family has social benefits because it strengthens social bonds.¹⁴ Alcohol becomes problematic when drinking begins to occur without friends and family or in excessive amounts, which is precisely what happened during the COVID-19 pandemic.

Meanwhile, individuals with histories of substance use disorders were confronted with disruptions in treatment access and social programs designed to assist the most in need. Networks like Alcoholics Anonymous and Narcotics Anonymous are built around the sharing of personal stories and participating in group work. The pandemic made these kinds of in-person meetings impossible, while also causing the temporary suspension of outreach programs and the closure of facilities to help homeless and mentally ill patients, many of whom, unfortunately, have comorbid substance use disorders. As we have learned to adapt to live with the virus, many of these programs have since come back online.

However, these interruptions in service, in conjunction with the more universal stresses associated with the pandemic, almost certainly fueled a wave of relapses, especially in the first months of the pandemic.¹⁵ Instances of opioid overdoses also spiked in the early months of the pandemic and have not fully returned to pre-COVID levels. Data suggest that the opioid crisis, which was already costing as many as 60,000 lives per year, kept burning unnoticed through 2020 like a mine fire.¹⁶ Approximately 93,000 overdose deaths were reported nationwide in 2020.¹⁷ The exact number of accidental overdoses compared to suicide by poisoning is unclear.¹⁸

Collective Panic

Yet another unfortunately salient example of how the psychological, social, and economic triad can converge is when collective panic takes place. As mentioned earlier in the case of the stampede and how panic buying during perceived gas shortages creates a positive feedback loop, the pandemic initially caused panic buying in grocery stores (especially with toilet paper) and was one of the defining cultural moments of early 2020. It was shocking to see throughout the United States, the land of abundance, empty shelves in stores everywhere one looked.

Even before the first stay-at-home order was issued, the spread of the virus spurred panicky runs to grocery stores and frantic online buying. As China was still in the midst of their tight lockdown, and since many of our supply chains are reliant on Chinese manufacturing, shortages began to be reported just as retail supply chains were being strained to the limit.¹⁹ The spike in demand combined with interruptions in production and distribution resulted in empty shelves in grocery stores, which only encouraged more frenzied hoarding behavior throughout the spring of 2020 as people stockpiled things like flour, yeast, and, of course, toilet paper.

Meanwhile, farmers who had contracts with restaurants and schools that had suddenly shuttered were unable to quickly accommodate this shift in demand.²⁰ Over the course of decades, they had developed and manufactured products that specifically met the demands of these outlets, and as a result of the pandemic, they could not suddenly alter the production, distribution, and supply chain, which put tremendous strain on their bottom line. Even local food banks were unprepared for the surge in supply and could not accommodate all the fresh produce and dairy.²¹

The end result was a cruel juxtaposition: Empty store shelves in the city and farmers overwhelmed with millions of pounds of rotting fruits and vegetables they could not sell. Outbreaks of COVID-19 at meatpacking plants also forced processors to scale back or in some cases temporarily close to avoid seeing their workforces decimated by the disease.²²

It was not just grocery items. Health care workers faced severe shortages of personal protection equipment as supply chains failed and hospitals ended up competing with one another and with the public for items like N95 masks. Supplies of many drugs, particularly analgesics, sedatives, and paralytics, also became strained.²³ These drugs are necessary for patients who need to undergo invasive mechanical ventilation, which is routinely used to treat acute respiratory distress syndrome,²⁴ one of the more common and dangerous complications associated with COVID-19.²⁵ These shortages proved to be particularly stressful for medical personnel who were on the frontlines of the fight against COVID-19 and no doubt contributed to the higher levels of posttraumatic stress disorder (PTSD) reported among the health care staff.²⁶

Crime

Reported crime appears to have dropped during the first days of the pandemic as states shut down and people remained inside. Crime rates then remained low for several weeks.²⁷ After a brief respite, however, these rates began to rise once again. In the United States, a very pronounced surge in gun violence began in the spring of 2020 and has continued well into 2021.²⁸ Precisely, what is causing it is unclear, but it is yet another social factor that
can contribute to stress, especially among individuals in large urban areas, where homicide rates have been particularly high.²⁹ As the summer of 2021 comes to a close, it appears as though the uptick in murders is slowing and that other violent crimes have fallen when compared to their 2020 levels, though it is far too early to properly place this into a larger context about trends in crime.³⁰

Stress

Stress is a ubiquitous word in modern society and a normal part of everyday life. Anyone reading this is familiar with the feeling, and we typically associate it with the feeling of being overburdened or when circumstances do not go our way. Physically, it can feel like a valve has been shut off somewhere in our bodies and that there is a pressure building up within us. This is reflected in our idioms about stress, and we complain about feeling “under pressure,” or “about to burst,” “about to snap,” or “at the breaking point.”

Somewhat more formally, stress can be defined as any type of change that causes physical, emotional, or psychological strain.

In some cases, stress can be a good thing. For example, exercise is a form of stress. It puts strain on muscles, but this strain is relatively short-lived and controlled. Similarly, fear is oftentimes a good thing. As unpleasant as it may be, it is key to our emotional lives and our very survival. In fact, one could think of our fear response as really no different than a threat response. That feeling of stress or dread or terror or aggression is precipitated by perceived threats, and they start a cascade of neurochemical signals to ready our bodies to be more capable of responding to threats.³¹ This physiological reaction is known as the acute stress response or, more famously, the fight or flight response.

The Science of the Stress Response

Central to this response are two small, almond-shaped regions on the left and the right sides of the brain known collectively as the amygdala (see Figure 5.1). In addition to playing a role in triggering the body’s stress response, the amygdala also plays a major role in fear, memory, and aggression. Like a properly functioning smoke detector, the amygdala jumps into action when stimuli that are recognized as potentially threatening are observed. The smoke detector is programmed to respond to smoke; when there is smoke, there is fire. Similarly, the amygdala only sends out distress signals when specific stimuli are observed that could potentially mean threat.

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