COVID-19 and the economic shutdown. What should clinicians expect next?

COVID 19 and the economic shut down. What should clinicians expect next?

The COVID 19 pandemic has led to dramatic government responses to diminish the spread of the virus and the mortality associated with it. In order to prevent our healthcare system from being overwhelmed, jurisdictions have instituted significant social distancing measures, where for the first time in modern history, well people essentially quarantined. These interventions have been associated with widespread unemployment, financial difficulty and social isolation. In the United States, up to 40 million people have filed for unemployment benefits. (1) In Canada, millions of people and have been affected economically. A recent estimate by the United Nations indicates that under the most extreme scenario, there may be a 20% income contraction, and the number of people living in poverty could increase by up to 580 million persons. (2) In addition to this historic economic downturn, individuals are being exposed to social isolation as never before. Virtually all public gatherings in society have been prohibited and the salutary effects of community and connectedness have been eliminated. It is important for the health care community to consider the negative effects of unemployment and social isolation, particularly on the economically vulnerable, as we consider our patients and public health policy. Ontario’s York Region has seen a 22 per cent rise in domestic violence incidents and calls to Vancouver’s Battered Women’s Support Services have tripled in the last three weeks. (3)
While any attempt to minimize the number of deaths associated with COVID 19 is laudable, one needs to be cognizant of the consequences of those actions. The medical literature indicates that unemployment, adverse socio-economic conditions and social isolation increase the risk for depression, anxiety, suicide, alcohol use, other illicit substance use, intimate partner violence, as well as all cause mortality. Through most of the public health calculus, it appears that the potential deaths caused by COVID 19 were the primary factors influencing government policy. This paper will provide a brief review the substantial health risks associated with the shut down of the global economy and unprecedented well person quarantine. Clinicians and public health authorities need to consider the risks as well as the purported benefits of any policy initiatives, especially when they are cause such dramatic changes to the fabric of our society.
The governmental response to the pandemic of the COVID 19 has led to a staggering increase in unemployment claims. In the United States, the highest spike in applications for unemployment insurance ever recorded occurred in April of 2020. (1) Up to 50% of small businesses have been closed as a consequence of government action. Some public health officials are advocating that they should be in place for 18 months. There is a wide body of medical literature which indicates that economic and social upheaval is likely to cause substantial morbidity and mortality.
Unemployment and adverse economic circumstances contribute to suicidal ideation and suicide. (4, 5, 6, 7) Naher et al, indicated that the incidence of suicide increases 1.2%, for every 1% increase in unemployment. (4) The effect is worse in one-person households, where a 1% increase in unemployment leads to 1.65% increase in suicide. In Canada, given the annual suicide incidence of 7000 persons, a 10% increase in unemployment could lead to over 1100 more suicide deaths. The association between suicide and unemployment may be higher among women. (5) Unemployment is a significant factor predicting suicide death, with an odds ratio of 5. (7) During the Greek recession from 2009-2015, the suicide rate increased 33%. (8) One third of suicides could be directly attributed to unemployment, one third to other consequences of the recession, the others of unknown origin If this factor was applied to Canadian annual incidence, an anticipated 2300 more suicide deaths would occur.
People in precarious employment status have higher odds of suicidal ideation than those with more stable employment. (9, 10) Social inequality and unemployment as social determinants of suicide may even be stronger in adolescence. (11) Economic uncertainty alone can lead to an increase in the risk of suicide, with uncertainty acting as a trigger to the death. (12) Social isolation is also a significant risk factor for suicide. (13) Suicidality is strongly linked to a patient’s perception of social isolation, family dysfunction, and being marginalized at work. Social isolation is a major risk factor for suicide among nursing home residents. Sadly, social distancing efforts may protect the nursing home residents from getting a respiratory virus but may increase the risk of suicide (14).
Unemployment status is strongly associated with problematic use of substances. Psychological distress triggered by unemployment and income reductions can increase drinking problems. (15) Macro-economic crises are associated with multiple adverse alcohol outcomes and some authors recommend special alcohol screening and intervention efforts in these times. (16) The unemployed are more likely to engage in risky alcohol consumption including hazardous, binge and heavy drinking. People who are unemployed are also more likely to be smokers and use illicit and prescription drugs and to have alcohol use disorders. (17) Unemployment also increases the risk of relapse after alcohol and drug addiction treatment. During the 2008 economic downturn in the United States there were higher rates of tobacco and illicit drug use, heavy alcohol use, and drug or alcohol abuse/dependence amongst the unemployed. (18) The detrimental impact on substance use seems to be worse for young adults who spent their childhood and adolescence in lower socioeconomic households. Individuals under the age of 25 who experience short and long-term unemployment were at increased risk of later alcohol-related morbidity. (19)
Adverse economic circumstances contribute to domestic violence. Unemployment rate has a direct impact on child maltreatment with an unemployment rate increase of 1% associated with a child maltreatment increase of 7%. (20) Unemployment has been strongly correlated with intimate partner violence, including psychological, physical and sexual violence. (21) Wives were more likely to be abused when their husbands were unemployed. (22) This in turn led to higher levels of anxiety, insomnia, greater social dysfunction, and more symptoms of depression in the abused wives. The cascade of negative effects of unemployment are evident in that intimate partner violence can contribute to suicide. 26% of all suicides in one study were identified as having known intimate partner violence.
Some studies indicate that adverse economic circumstances and unemployment contribute to all-cause mortality. Junna documented that unemployment was associated with mortality from psychiatric and self-harm related conditions. (23) They also concluded that substance use outcomes, fatal accidents and violence were associated with unemployment. Those exposed to both unemployment and hostility were at a markedly high risk of premature mortality. (24) Chu demonstrated that late career unemployment was associated with increased all-cause mortality and functional disability. Older adults were encouraged to maintain normal employment during the later stage of their career before retirement to maintain good health. (25)
Governments around the world have embarked upon an unprecedented practice of enforcing social isolation and the quarantining of well people. While our society is well versed in dealing with the medical management of viral illness, the unprecedented economic measures will probably have adverse effects. The literature indicates that unemployment and social isolation will increase the burden of depression, substance use, domestic violence, all-cause mortality and suicide. Clinicians should have a high index of suspicion for these negative consequences and consider their role as advocates for the poor and economically marginalized who are the most likely to suffer from these societal experiments.

1. COVID 19 to slash global economic output by 8.5 trillion over next two years May 2020
2. US job losses pass 40,000,000 as coronavirus crisis sees claims rise 2.1 million in one week www.theguardian 28 May 2020
3. Calls to Vancouver domestic violence crisis line spike 300% amid COVID-19 pandemic April 7 2020
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