COVID-19, frontline responders and mental health podcast

Transcript

COVID-19, frontline responders and mental health

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Thomas Felix Creighton (TFC): Hello! Welcome to the Emerald Podcast Series. My name is Thomas, and my guest today is Jennifer A. Horney, Professor and Founding Director of the epidemiology program and core faculty in the Disaster Research Center at the University of Delaware, USA. The Disaster Research Center was established in 1963 as the world's first center dedicated to the social scientific study of disasters, and has led the field ever since. It has a truly global reputation as the pioneer of social scientific research on disasters. Jennifer has been quoted in USNews.com, everydayhealth.com, and on the radio in Delaware as an expert on the pandemic. In total she has been quoted in the media on the impacts of COVID-19 more than 300 times.

Your book COVID-19, ‘Frontline Responders and Mental Health’, came out in January. First of all, could you please give our listeners a thumbnail sketch of what it was all about? 

Jennifer A. Horney (JAH): Yeah, so I'm a disaster epidemiologist. So, for about 20 years, I've been trying to understand better the health impacts of disasters. And when we talk about disasters, we include public health emergencies, like outbreaks and pandemics. And we've known for a long time that people involved in the response to these types of emergencies are actually impacted physically and mentally by just the act of being a participant in the response. And we know something about the characteristics of the people and the activities that are most detrimental to people's physical and mental health. But what we didn't know a lot about was what the impact of a response like a global pandemic that lasted for several years would be. So, that's what we're really interested in finding out in this research.

TFC: Oh, gosh, 20 years! So, you've seen you've been looking at, I imagine SARS… I imagine the Foot and Mouth outbreak, those instantly sprang to mind... 

JAH: Yes, SARS, we actually had one case on my university campus, and I was just finishing my master's degree, and starting to work in this field. That was one of the very few cases in the US. And I think that, at least globally, a lot of the lessons learned from SARS helped many countries be more effective than the US in their response. So, when we look at some of the Southeast Asian countries like Taiwan, or Korea, and they really learned those lessons from SARS, much more than we did, because they were so much more impacted by it. 

TFC: Indeed, at the time of 2020, I was working in China, and traveling in Japan, and so on. So I saw the effects of that, and then moved on to America. So how do you think it really impacted them in terms of the frontline workers? 

JAH: So, what we've seen, at least in the research data is that there's this tremendous mental health impact initially, that is tied up with the uncertainty and the fear around becoming sick yourself as a caregiver or a medical care provider, and also in accidentally transmitting something to your family or your friends. And so, as we learn more about diseases and transmission dynamics, those anxieties tend to be reduced. And so, with something novel like COVID, it just took us longer to figure out some of those things. And there was a lot of uncertainty. And there were a lot of changes in the guidance. So even as we started to understand what we should be doing, we weren't always able to access the kind of personal protective equipment or other resources to do those things. And so, I think those anxieties and fears carried on for much longer in this pandemic than perhaps prior public health emergencies. And, again, just because of the scope and scale, those fears and anxieties touched many more elements of the population beyond those typical frontline care providers. 

TFC: Did you find that they're able to fall back on previous experience with how to deal with the mental health challenges? 

JAH: So, that's actually a really good question. And one of the most novel elements of this? Because the answer is really no. Because of the public health control measures that we put in place to respond to the pandemic, we eliminated a lot of what we knew were effective interventions. So, one of our chapters deals with emergency medical services. So, we've studied them a lot in terms of it's a very stressful job. And so, we know that the risks of mental health impacts increase. But we also know that the ways that people are able to deal with that is by having social support from their colleagues and sharing workout spaces and sharing meals, and doing other types of social activities to sort of blow off steam from a very stressful job. And guess what, we took all those things away. And so people were being asked to do a lot more. And they were also losing access to what we knew were effective interventions and keeping them healthy. And well, what alternative support mechanisms were open to them? Well, many. So there were some for sure. A lot of them were also online. So access to employee assistance and other types of physical and mental care providers via telehealth or without copay or cost to employees. Many groups of managers made extra efforts to try to remove in addition to cost barriers to remove stigma, from people seeking mental health support. So particularly in some fields, it may have been viewed as something of a weakness or something of, you know, that would be seen as something that you might be passed over for a promotion, because you just couldn't, you know, handle the stress or whatever. And so, I think at the same time that we were trying to make things more available, there were efforts to try and reduce the stigma associated in participating in what was being offered. 

TFC: Do you think that was effective?

JAH: Probably, to a certain extent, I think that the main barrier was that counselors, psychologists, and psychiatrists, were also burned out. And so, there were fewer of them to access at a time when demand was skyrocketing. And so even once people decided, yes, you know, I think I will seek out the services that are available to me, sometimes it really wasn't. And so, when we look at the, you know, tremendous stressors that were placed on people from a variety of fields, not just the sort of typical frontline responders that we think about, there's that supply and demand side as well that we have to consider. 

TFC: I'm curious about the support groups. Again, my own experience at the time was as a manager in a company in China, and we had teams in Wuhan. They stayed there throughout the lockdowns, and so I set up support groups, book groups, and so on. Obviously, that wasn't originally part of my job description. It wasn't part of anyone in the world’s job description, I imagine. But I was one who put that in place with zero preparation and zero previous training. How unusual was that? As I say, I had no training to do this, but I just had to do it. 

JAH: I think it probably was, unfortunately, a case-by-case basis. There certainly weren't any policy guidelines being issued by any, you know, regulatory authority saying, you know, ‘please be sure that your employees are having access to this’. And that's why we saw tremendous levels of burnout, anxiety, depression, even suicidal ideation, among our public health workforce here in the US and in clinical and other groups as well. And so, we saw that actually subside again, in the clinical populations as it became clear what the transmission risks were. But I think we didn't see it subside as much in the public health workforce. For example, because they were just getting hit again and again with responsibilities for vaccination campaigns and setting up contact tracing efforts. And, you know, then facing a backlash when the vaccination campaigns, you know, perhaps were not as well received as they would like. And so, I think public health continually faced those stressors, even once we understood more about COVID and transmission and how to stay safe. Our state and local health departments here in the US, were still running massive testing operations, trying to crunch surveillance data running massive vaccine campaigns, running contact tracing. Those things are all much more invisible to people. So, people were not going out on their balconies and banging their pots and pans to thank public health for hanging in two years later, but they are still, still doing those things.

TFC: Now, can I say it all gets into the headlines less, but the effects still remain? 

JAH: Absolutely. So, we have a saying in public health that when it works well, it's invisible. So, no one counts all the people that didn't get measles because their kid got vaccinated at a public health clinic. And that's one of the things that public health leaders were actually talking about before the pandemic; how they needed to be better educated about the political aspects of their job, that they needed to acknowledge that their job had a political aspect, and that they needed training to understand how to operate better in those spaces. Because we had issues before COVID, we have, you know, still a public health emergency in the opioid epidemic here in the US and, you know, many other public health issues that, you know, rise to the level of policy and advocacy and that sort of thing. And so now post-pandemic, the leaders that are left are realizing that that, you know, was a very important focus area, identified pre-pandemic, but that needs to be picked up with very strong backing now. 

TFC: Do you feel that that is happening? 

JAH: Probably not. Much of the world has moved on from the pandemic to new things, although epidemiologists are still concerned with improving our understanding of population level, morbidity and mortality associated with COVID. And in understanding the vast disparities that COVID really laid bare for us here in the US, and globally, and so more and more research is coming out not just on disparities in the impacts, both physical and mental, on certain groups, racial and ethnic minority groups of, you know, getting COVID Or getting severe COVID. Now, we have to look at disparities and long COVID and post COVID syndrome. We've seen that in this country, African Americans and black patients who are diagnosed with COVID are half as likely, well, a little more than a third is likely to get a prescription for Paxlovid, the effective antiviral treatment than white patients are. So why is that? I mean, there are still lots of things that we need to work more on. 

TFC: So you're feeling that it's exposing underlying trends, trends that were there, but we might not have looked at before. 

JAH: Yeah, I think that since really September 11, 2001, we've tried to build this public health preparedness infrastructure in the United States. And after the H1N1 pandemic in 2009 turned out to be, you know, not as big as perhaps maybe we were expecting, we got a little lazy, and we lost a lot of funding and people just, you know, kept going. But we weren't really making any progress towards these larger goals that we had set for really changing the public health system to make it more effective. 

TFC: Would you say it's fair to say that we were complacent? 

JAH: Yes, very fair to say that we were complacent, and I often give this an example and it never gets picked up in the media. So maybe a podcast you have more time, but you know, we had Avian Influenza in Asia in the early 2000s… 2005. But it wasn't transmissible person to person. It was a very severe disease with a high mortality rate, but not transmissible person to person, then we had H1N1 in 2009. It was the opposite. It was easily transmissible, but, not very severe. So, it didn't make people very sick. So, we hit the jackpot here, you know, we got something that was very transmissible and potentially very severe. And so, I think that we had become complacent to the idea that the systems that we had, even though we had basically left them derelict for the last decade would somehow rise up and meet any challenge. Another challenge wouldn't be, you know, so big. 

TFC: A lot of people made the comparison to the illness known as The Spanish Flu. Is that the best go-to that we have? Was that the most appropriate place to look? 

JAH: it's sort of the only comparison that we have. And something to this extent, obviously, the resources that we had to respond at that time were much less. But to me, the more interesting comparison in that is that we talk about this second epidemiologic transition. So, the first transition is from people dying of infectious diseases to people dying of chronic diseases, right, because we have antibiotics, and we have all these things. But the second one is really this kind of globalization piece. So, if I can be in any part of the world, exposed to any vector or disease, and less than 24 hours, I can be in any other part of the world, you know, potentially carrying that vector or disease that really puts us in a different place. So, I think that's where the comparison falls short, is just the rapid way that people and therefore diseases can move globally. 

TFC: Now, somebody suggested to me that by the time of a virus is fully identified in one country, it's already spread to others. Would that be fair to say on what you're saying here? 

JAH: Yes. And that's why things like singling out South Africa when the Omicron variant was discovered there are really unfair, because first we want to encourage countries to be transparent with data and not blame them or punish them. And also that's why, in large part, things like travel restrictions are seen as ineffective in limiting the spread of disease. Because even if we could set them up in such a way that they were not porous in any way, it's too late. By the time we know, it's too late. Of course, by that time, we're already dealing with it. Well, there are really good examples of practices…  

TFC: You mentioned, it could be very, very variable. 

JAH: There wasn't a standard that was necessarily the training already can ask whether specific instances have really good support or frontline workers. I'm not sure there were particularly examples of good support, I think that the opportunity for people to follow science was really important. In another study that we did. We heard a lot from public health leaders about the trust from their supervisors, as well as their elected officials in their jurisdiction. And so, feeling that you were standing on a stage with someone who was saying something that didn't agree with your data, was one of the big things that really led to people wanting to either resign from their job or being fired from it. And so I think that leads leaders and elected officials who trusted the science and understood that the science would change over time, but that didn't mean that it was necessarily wrong and then right, presented the best environment for their public health staff to operate in. Certainly very, very challenging. 

TFC: And you mentioned earlier about long COVID And how this is affecting especially frontline workers today. 

JAH: Yeah, I think long COVID is the big question. So, our data is not that good. Long COVID is hard to define. It's a ‘constellation of symptoms’ is what CDC calls it. So, certain groups will certainly be under-diagnosed with long COVID. There are a lot of issues to think about in terms of discrimination in terms of employment in terms of access to treatment and care, that are really hard to answer because we don't fully understand even the definition of what a case may be, right. And there is a very large segment of people who had COVID, who have COVID symptoms for a period of time that's greater than one month or even greater than six months. And so, thinking about where we draw those lines, and how we set those definitions will mean a very different population will be impacted going forward. And some of those who are being severely affected or those who would normally be in a position to help others. And now they're in a position where others are having to help them and that change of role can be quite challenging to think about the frontline experiences of people who might not have previously been considered frontline. Initially, I wanted to focus on public health workers because they tend to not be known. The responsibilities during an emergency of the public health worker are not well known. But as part of developing the book, we really learned about how so many different groups that had never been considered frontline before, really were a part of the response to COVID. So for example, we have a chapter about university professors in the book. And we know from research that the shift to online school, and the additional home-based responsibility, maybe you’re teaching your students online, and homeschooling your kids had an impact on university faculty, particularly women, who tended to have those dual roles. So, I think there's never been a public health response where we've thought, Oh, yes, university faculty are really frontline responders. But we haven't had something that impacted our education system before to the extent that COVID did, and with the response that COVID had. 

TFC: And you mentioned different types of what we might consider first responder who's a first responder and who isn't. 

JAH: In the US, when the initial lockdowns were happening, people who worked at homeless shelters were considered essential and provided with passes so that they could drive to work. But, people who worked in domestic violence shelters were not. While they've always seen themselves as emergency responders, they were not viewed as ‘essential’. And so, thinking about these different groups of people, who were suddenly put in the situation of being frontline and essential, who we never really think about, right? And the disparities that those groups of people suffered during particularly the initial wave of the pandemic did take us time to get into the realm of what we should be doing. 

TFC: A politician in the UK was once asked, if you had done something differently, what would you wish? And he replied ‘the things I did well, I wish I’d done sooner’. What things, could I ask, would you wish we had done sooner to support frontline workers? 

JAH: So, I think really just started with defining who and what was a frontline worker, and so there are some department of labor guidelines that sort of say, oh, this is an essential field that has to be done in person, and this is not. But that changed. Obviously, we figured out how to do things we thought we had to do in person, we figured out how to do those things remote. But some things. There's just no way of doing them remotely. And so, there were some interesting, what we would call natural experiments. So, there were states that shut down certain aspects of their economy, for example, maybe construction for a period of time and states that did not. And so, we could go back and look at those data and see whether that was effective. But I think that some of the bigger, more obvious policy issues are around sick leave and access to care. Part of the reason why so many people were willing to get tested is that it was free and easily available, right? You could drive your car through. And that's not typically the way that our healthcare system works. I think really, as a disaster researcher, the frustrating thing is that it's very easy to return to the status quo. It's harder to say, ‘okay, let's critically examine what we did well, and what we did not do well’... and change. Because some things are great, virtually, and some things are not. And there were other things that we did, in the response, to cope with the threat, that we're really good ideas, and we should keep doing. But, without really critically going back and looking at those things. I think it it's frustrating to see us falling back into that. And it's easier in a natural disaster, because it's easier to say, you know, it's not okay to go back to the way you were, you need to do better, you can't have an earthquake and then go build sub-par housing that will collapse again. In a pandemic, it's a little bit harder to define what that status quo looked like. But certainly, we can think we shouldn't go back to a time that people came to work sick, because they didn't have any sick time, absolutely can ask what positive things would you like us to carry on forwards. So, I think that we found out that we could increase access and reduce stigma to mental health care. That I think is a major step forward, because we saw increasing trends, especially among certain population groups, like young women, before the pandemic, and those were intensified by the pandemic. But I think this is a really crucial time, because here in the US, our emergency declaration is going to expire in May. And for many people that will mark the end of the pandemic. But in a sense, that is just marking the end of exceptions to the way that we do certain things that we're able to do differently, because it's a quote unquote, “emergency”. So, I hope that the end of the emergency does not mislead us to think that there isn't more work to do, because there is a lot more work to do, especially around equity and thinking about global equity, as well as thinking about equity within the US.

TFC: Fantastic. Thank you very much. Writing a book is a tremendous undertaking, but is there anything that you wanted to put in the book would love to have put in the book we just simply didn't have room for simply weren't able to work in? 

JAH: I know a few things, we wanted to include more on women, because there was a lot of research to show that they were the ones who left the workforce, to take care of children or be a caregiver to other family members that needed it. We joke to say that all the people who researched women were so busy researching women that they couldn't write a chapter in this book. And there were other groups I had worked with some groups that worked on prison, mental and physical health. And they were really trying to take the pandemic as a learning opportunity to understand the ways in which spaces that are unhealthy for rehabilitation physically and mentally, without a pandemic could be changed because of the pandemic to be better in general. So that was another group that I wish we had been able to hear from more directly because they were so deeply impacted by the pandemic. I'm hearing ideas for future books, and I hope very much that you write them.

TFC: I'm always curious, you know you if there's anything you've personally been involved in, and then you see it in a movie or in a TV show, it's often quite wrong. Policemen I know who watch police dramas, military people watch military dramas, have been frustrated at their portrayal in films. Are there any shows or films that you particularly like as a portrayal of other frontline workers or anything in that topic that you've studied? 

JAH: So there was a movie called contagion. That was actually one of the movies that epidemiologists really enjoy because it was a sort of more realistic amalgam of different outbreaks that have happened. And so, we really do worry about those mixing of bats and pigs and people and those kinds of things. So, I am not a science fiction fan at all, but every epidemiologist that I know, either read or watched Station 11, during the pandemic. Every year when I teach outbreak investigation to my graduate students, I'm stressed at the beginning of the semester, and I think, oh, will we be able to find enough examples? So, each week I like to focus on an outbreak that's happening in real time and every year, there are always plenty to choose from so we have more than we can handle in real life.

TFC: Thank you for listening to today's episode. For more information about our guests. For a transcript of today's episode, please see our show notes on our website. I would like to thank Katy Mathers Daniel Ridge for their help in today's episode. And Alex Jungius from This Is Distorted.

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