The SARS pandemic tore through Hong Kong like a summer thunderstorm. It arrived abruptly, hit hard, and then was gone. Just three months separated the first infection, in March 2003, from the last, in June.
But the suffering did not end when the case count hit zero. Over the next four years, scientists at the Chinese University of Hong Kong discovered something worrisome. More than 40 percent of SARS survivors had an active psychiatric illness, most commonly PTSD or depression. Some felt frequent psychosomatic pain. Others were obsessive-compulsive. The findings, the researchers said, were “alarming.”
The novel coronavirus’s devastating hopscotch across the United States has long surpassed the three-month mark, and by all indications, it will not end anytime soon. If SARS is any lesson, the secondary health effects will long outlast the pandemic itself.
Already, a third of Americans are feeling severe anxiety, according to Census Bureau data, and nearly a quarter show signs of depression. A recent poll by the Kaiser Family Foundation found that the pandemic had negatively affected the mental health of 56 percent of adults. In April, texts to a federal emergency mental-health line were up 1,000 percent from the year before. The situation is particularly dire for certain vulnerable groups—health-care workers, COVID-19 patients with severe cases, people who have lost loved ones—who face a significant risk of post-traumatic stress disorder. In overburdened intensive-care units, delirious patients are seeing chilling hallucinations. At least two overwhelmed emergency medical workers have taken their own life.
To some extent, this was to be expected. Depression, anxiety, PTSD, substance abuse, child abuse, and domestic violence almost always surge after natural disasters. And the coronavirus is every bit as much a disaster as any wildfire or flood. But it is also something unlike any wildfire or flood. “The sorts of mental-health challenges associated with COVID-19 are not necessarily the same as, say, generic stress management or the interventions from wildfires,” says Steven Taylor, a psychiatrist at the University of British Columbia and the author of The Psychology of Pandemics (published, fortuitously, in October 2019). “It’s very different in important ways.”
Most people are resilient after disasters, and only a small percentage develop chronic conditions. But in a nation of 328 million, small percentages become large numbers when translated into absolute terms. And in a nation where, even under ordinary circumstances, fewer than half of the millions of adults with a mental illness receive treatment, those large numbers are a serious problem. A wave of psychological stress unique in its nature and proportions is bearing down on an already-ramshackle American mental-health-care system, and at the moment, Taylor told me, “I don’t think we’re very well prepared at all.”
Most disasters affect cities or states, occasionally regions. Even after a catastrophic hurricane, for example, normalcy resumes a few hundred miles away. Not so in a pandemic, says Joe Ruzek, a longtime PTSD researcher at Stanford University and Palo Alto University: “In essence, there are no safe zones any more.”
As a result, Ruzek told me, certain key tenets of disaster response no longer hold up. People cannot congregate at a central location to get help. Psychological first-aid workers cannot seek out strangers on street corners. To be sure, telemedicine has its advantages—it eliminates the logistical and financial burdens of transportation, and some people simply find it more comfortable—but it complicates outreach and can pose problems for older people, who have borne the brunt of the coronavirus.
A pandemic, unlike an earthquake or a fire, is invisible, and that makes it all the more anxiety-inducing. “You can’t see it, you can’t taste it, you just don’t know,” says Charles Benight, a psychology professor at the University of Colorado at Colorado Springs who specializes in post-disaster recovery. “You look outside, and it seems fine.”
From spatial uncertainty comes temporal uncertainty. If we can’t know where we are safe, then we can’t know when we are safe. When a wildfire ends, the flames subside and the smoke clears. “You have an event, and then you have the rebuild process that’s really demarcated,” Benight told me. “It’s not like a hurricane goes on for a year.” But pandemics do not respect neat boundaries: They come in waves, ebbing and flowing, blurring crisis into recovery. One month, New York flares up and Arizona is calm. The next, the opposite.
That ambiguity could make it harder for people to be resilient. “It’s sort of like running down a field to score a goal, and every 10 yards they move the goal,” Benight said. “You don’t know what you’re targeting.” In this sense, Ruzek said, someone struggling with the psychological effects of the pandemic is less like a fire survivor than a domestic-violence victim still living with her abuser, or a traumatized soldier still deployed overseas. Mental-health professionals can’t reassure them that the danger has passed, because the danger has not passed. One can understand why, in a May survey by researchers at the University of Chicago, 42 percent of respondents reported feeling hopeless at least one day in the past week.
A good deal of this uncertainty was inevitable. Pandemics, after all, are confusing. But coordinated, cool-headed, honest messaging from government officials and public-health experts would have gone a long way toward allaying undue anxiety. The World Health Organization, for all the good it has done to contain the virus, has repeatedly bungled the communications side of the crisis. Last month, a WHO official claimed that asymptomatic spread of the virus is “very rare”—only to clarify the next day, after a barrage of criticism from outside public-health experts, that “we don’t actually have that answer yet.” In February, officials from the Centers for Disease Control and Prevention told Americans to prepare for “disruption to everyday life that may be severe,” then, just days later, said, “The American public needs to go on with their normal lives,” then went mostly dark for the next three months. Health experts are not without blame either: Their early advice about masks was “a case study in how not to communicate with the public,” wrote Zeynep Tufekci, an information-science professor at the University of North Carolina and an Atlantic contributing writer.
The White House, for its part, has repeatedly contradicted the states, the CDC, and itself. The president has used his platform to spread misinformation. In a moment when public health—which is to say, tens of thousands of lives—depends on national unity and clear messaging, the pandemic has become a new front in the partisan culture wars. Monica Schoch-Spana, a medical anthropologist at the Johns Hopkins Center for Health Security, told me that “political and social marginalization can exacerbate the psychological impacts of the pandemic.”
Schoch-Spana has previously written about the 1918 influenza pandemic. Lately, she says, people have been asking her how the coronavirus compares. She is always quick to point out a crucial difference: When the flu emerged in America at the end of a brutal winter, the nation was mobilized for war. Relative unity prevailed, and a spirit of collective self-sacrifice was in the air. At the time, the U.S. was reckoning with its enemies. Now we are reckoning with ourselves.
One thing that is certain about the current pandemic is that we are not doing enough to address its mental-health effects. Usually, says Joshua Morganstein, the chair of the American Psychiatric Association’s Committee on the Psychiatric Dimensions of Disaster, the damage a disaster does to mental health ends up costing more than the damage it does to physical health. Yet of the $2 trillion that Congress allocated for pandemic relief through the CARES Act, roughly one-50th of 1 percent—or $425 million—was earmarked for mental health. In April, more than a dozen mental-health organizations called on Congress to apportion $38.5 billion in emergency funding to protect the nation’s existing treatment infrastructure, plus an additional $10 billion for pandemic response.
Without broad, systematic studies to gauge the scope of the problem, though, it will be hard to determine with any precision either the appropriate amount of funding or where that funding is needed. Taylor told me that “governments are throwing money at this problem at the moment without really knowing how big a problem it will be.”
In addition to studies assessing the scope of the problem, which demographics most need help, and what kind of help they need, Ruzek told me researchers should assess how well intervention efforts are working. Even in ordinary times, he said, we don’t do enough of that. Such studies are especially important now because, until recently, disaster mental-health protocols for pandemics were an afterthought. By necessity, researchers are designing and implementing them all at once.
“Disaster mental-health workers have never been trained in anything about this,” Ruzek said. “They don’t know what to say.”
Even so, the basic principles will be the same. Disaster mental-health specialists often talk about the five core elements of intervention—calming, self-efficacy, connectedness, hope, and a sense of safety—and those apply now as much as ever. At an organizational level, the response will depend on extensive screening, which is to the mental-health side of the pandemic roughly what testing is to the physical-health side. In disaster situations—and especially in this one—the people in need of mental-health support vastly outnumber the people who can supply it. So disaster psychologists train armies of volunteers to provide basic support and identify people at greater risk of developing long-term problems.
“There are certain things that we can still put into place for people based on what we’ve learned about what’s helpful for PTSD and for depression and for anxiety, but we have to adjust it a bit,” says Patricia Watson, a psychologist at the National Center for PTSD. “This is a different dance than the dance that we’ve had for other types of disasters.”
Some states have moved quickly to learn the new steps. In Colorado, Benight is helping to train volunteer resilience coaches to support members of their community and, when necessary, refer them to formal crisis-counseling programs. His team has also worked with volunteers in 31 states, the United Kingdom, and Australia.
Colorado’s approach is not the sort of rigorously tested, evidence-based model to which Ruzek said disaster psychologists should aspire. Then again, “we’re sitting here with not a lot of options,” says Matthew Boden, a research scientist in the Veterans Health Administration’s mental-health and suicide-prevention unit. “Something is better than nothing.”
In any case, the full extent of the fallout will not come into focus for some time. Psychological disorders can be slow to develop, and as a result, the Textbook of Disaster Psychiatry, which Morganstein helped write, warns that demand for mental-health care may spike even as a pandemic subsides. “If history is any indicator,” Morganstein says of COVID-19, “we should expect a significant tail of mental-health effects, and those could be extraordinary.” Taylor worries that the virus will cause significant upticks in obsessive-compulsive disorder, agoraphobia, and germaphobia, not to mention possible neuropsychiatric effects, such as chronic fatigue syndrome.
The coronavirus may also change the way we think about mental health more broadly. Perhaps, Schoch-Spana says, the prevalence of pandemic-related psychological conditions will have a destigmatizing effect. Or perhaps it will further ingrain that stigma: We’re all suffering, so can’t we all just get over it? Perhaps the current crisis will prompt a rethinking of the American mental-health-care system. Or perhaps it will simply decimate it.
In 2013, reflecting on the tenth anniversary of the SARS pandemic, newspapers in Hong Kong described a city scarred by plague. When COVID-19 arrived there seven years later, they did so again. SARS had traumatized that city, but it had also prepared it. Face masks had become commonplace. People used tissues to press elevator buttons. Public spaces were sanitized and resanitized. In New York City, COVID-19 has killed more than 22,600 people; in Hong Kong, a metropolis of nearly the same size, it has killed seven. The city has learned from its scars.
America, too, will bear the scars of plague. Maybe next time, we will be the ones who have learned.