Category Archives: Clinical Depression

When This War Is Over, Many of Us Will Leave Medicine and the Stresses of Healthcare Workers on All Fronts

One ER physician recounts the stress of constant intubations and PPE shortages

Michele Harper reviews the stress of our frontline healthcare workers and here is a case.

I couldn’t see. My face shield was blurred by a streaky haze. I tilted my neck back and forth in an effort to peer beyond it, beneath it, through it, whatever might work. Was it condensation? I started to raise my hands to my face to wipe it away before I remembered and yanked them back down: I cannot touch my face, can’t ever touch my face — neither inside this room nor outside it.

As I stood at the head of the patient’s bed in ER Room 3, her nurse, Kate, secured a mask over the patient’s face to deliver additional oxygen. I checked to ensure the oxygen was cranked up to the maximum flow rate while we waited for the respiratory therapist. Even with that increased oxygen, the patient was saturating 85% at best, and her blood pressure was dropping.

Ninety minutes earlier, the patient — a woman of 68 years with significant impairment from a stroke — had been fine. The nurse at her nursing home called to inform us they were sending the patient to the ER for evaluation of “altered mental status” because she was less “perky” than usual. Her oxygen level on arrival was normal with no shortness of breath. Her blood pressure was a little low, but her blood glucose read high. Nothing a little IV fluid couldn’t fix, and initially, it did.

I had requested a rectal temperature; it read 103 degrees. The combination of her being a nursing home resident and running a fever was a red flag during these coronavirus times. I placed her on respiratory isolation and asked Kate to be extra vigilant for any decline. I ordered broad-spectrum antibiotics to kill any likely source of infection while I awaited her chest X-ray, urine, and blood tests. Her portable chest X-ray was done first and revealed what I had already anticipated: diffuse atypical infiltrates, a presumed telltale sign of Covid-19. Although our understanding of this viral infection is ever-evolving, it seems the only observation we can reliably conclude is that we have not yet identified anything pathognomonic about it.

Seventy-five minutes later, another nurse, Charlene, called, “They need you in Room 3.”

“Okay,” I replied as I entered orders on the next chest pain patient with shortness of breath.

“Dr. Harper, they need you in Room 3 now,” Charlene called again.

“Room 3? The nursing home patient? I’ll be right there. What happened?”

“Her oxygen is at 67%.”

I asked the clerk to call respiratory therapy for intubation. I then turned back to Charlene to ask her to help Kate prepare for the procedure.

Then the personal protective equipment (PPE) sequence. I grabbed gloves to remove my N95 mask from its paper bag and placed it over my face, checking it was snug over my nose and lower jaw. After removing those gloves, I donned my face shield, then walked to the cart for a new gown. Lastly, a fresh set of gloves before entering the patient’s room.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily.

Now I waited for the respiratory therapist. It was good that she needed extra time to get the ventilator and then don her PPE because I had to figure out why I couldn’t see without manually manipulating my face shield. My thoughts were pierced by the sound of panting. I checked the patient who was taking the oxygen quietly, rapidly, ineffectively at regular intervals that didn’t register a sound. Her eyes remained closed—no flip of an eyelash, no wince of her forehead, no twitch in a limb. Despite her instability, the patient was in no visible distress. No heaving breath there. The nurse to my left was concentrating on the patient’s oxygen. I heard only the crinkle of her gown as she adjusted her stance. The panting wasn’t hers. The nurse to my right prepared to administer the intubation medications. He read out my orders — the name and dose of the medication in each syringe and the order in which they were to be pushed. His voice was steady. It wasn’t him hyperventilating. The nurse just outside of the room kept documentation of the procedure on scrap paper she used to carefully transcribe each detail onto her laptop. She was too far away to be heard unless she yelled, so that audible breathing certainly wasn’t hers.

The panting was my own.

A hailstorm of thoughts ensued. Was my breath the fog on my face shield? If so, my N95 mask had a leak. Unsuspecting, had I already inhaled the virus? Would I be intubated next?

The respiratory therapist had arrived with the ventilator and put on her face shield. She was almost ready, so there was little time to pull myself together.

Breathe in, I commanded myself: One, two, three. Breathe out. I obeyed: One, two, three, four.

Was I already short of breath? Had I not noticed my symptoms when I drove to work this morning? Yesterday? Last night?

Breathe in. One two, three. Breathe out. One, two, three, four.

I was scared, and I don’t get scared. Other doctors do, but not ER doctors. We don’t scare easily. We’re a type of special forces who step in when everything else has failed. Typically, we do our job anonymously then leave when the mission is complete. Any injury to ourselves incurred in the line of duty is dealt with after we’re off the clock.

Once in a while, however, there are circumstances when the capacity to compartmentalize is overwhelmed, when the chronic stress breaks through so that the fear works on you. Now, as I stood at the patient’s bed with the video laryngoscope blade in one hand and the endotracheal tube in the other, panic pushed its way through me in involuntary. forceful. rapid. shallow. breaths.

Breathe in on one, two, three. Breathe out on one, two, three, four.

The respiratory therapist slapped on her gloves and in moments was at my side. It was time for intubation.

Breathe in on three and out on four.

At last, my breathing was smooth, measured, sound.

I looked through my mask again. It wasn’t condensation. It was streaks from the sanitizing wipes because we had to reuse our equipment.

I adjusted my eyes to the clear spaces. Finally, I could see. My N95 mask fit. I could breathe.

The room was relatively quiet, what I like to call “ER calm.” All was still, save for the bagging of respiratory therapy, save for the swoosh of oxygen jetting from its port aerosolizing everything.

I requested that the intubation medications be administered then checked for a response. After visualizing the vocal cords easily with the video laryngoscope, I slid in the endotracheal tube, and respiratory connected it to the vent. The patient’s oxygen increased to 100% on the monitor.

Those of us who survive will return each day to battle. But when this war is over, this is why many of us will leave.

Doffing my gown and gloves, I put on new gloves to remove and sanitize my face shield. I couldn’t imagine there was a way to effectively clean the foam band across the forehead. I hoped to remove the streaks. I also hoped the impossible: to remove the virus, because it was the same shield I had to use repeatedly during my shift. I took off the N95. We’re now told that we can reuse it, too, numerous times before getting a new one due to the PPE shortages, so I put the contaminated mask back in the bag until I would need to do it again for the next patient.

This is how we get infected. This is how we die.

Those of us who survive will return each day to battle because we do not walk away from war until it’s done. But when this war is over, this is why many of us will leave.

I walked to the back of the ER to use the restroom in the seven minutes before the patient was ready for CT and saw my ER director standing in the lounge. I waved hello.

“How did it go?” she asked, her eyes gentle, her smile sympathetic.

“It went,” I replied.

“How did you feel in the PPE? Did you feel protected?”

I paused to regulate my answer. Her intentions were good. She was an ER doctor who did her best to walk the fine line between the docs on the front lines and the administrators who notified me that “doctors don’t get paid sick leave” and “thank you for your service,” which were graciously sent out in two separate emails. Just another reminder that we health care providers are regarded as more disposable than our PPE. But this wasn’t her fault, so I felt responsible, in that moment, for her feelings too.

I pulled in my tone. “No. That equipment doesn’t protect us. There’s no way that we’re not all covered in Covid, but we’re following the ‘guidelines.’”

She nodded and frowned.

“Honestly,” I continued, “and I hate to say this, but my feeling is that the majority of people will have contracted this virus. Most people will get through it, and others won’t. Many will die. I don’t want any of us to die, but many health care providers will. The thing is, it’s impossible to know which camp we’re in until it happens.”

She nodded again.

We smiled at each other, and I continued to the bathroom. I washed my hands, turning them over each other, lathering the soap along each finger, under each nail. As I dried my hands, I looked up at the mirror, noting that my breath was now imperceptible when my phone rang.

A FaceTime request from my nine-year-old nephew, Eli.

My policy used to be to not answer the phone at work unless it was critical. But this is a different era. Eli is sheltering-in-place at a military base in California while his mother, my sister, is away for deployment.

I swiped the phone to answer. “Hi, Eli!”

“Hello, Aunt,” he announced more softly than usual. His eyelids hovered low, and his eyes weren’t their typical bright.

“How are you, Eli?” I inquired, masking my concern.

“I’m good.” He smiled with sleepy eyes. “I just woke up.” He yawned; his bushy eyebrows raised high. Years ago, he said his eyebrows were the indisputable evidence that Frida Kahlo was his great, great grandmother so he had to meet her forthwith. Upon being told that she had already passed away, he cried for the woman he had decided was his long-lost ancestor. Now, as he yawned again, his thick eyelashes shut tight. His head drifted back and his mouth reeled open expelling the strongest exhale of the bravest lion cub.

Smiling to myself, I sighed easily.

He breathed.

I breathed.

Today we are OK.

Anxiety on the Frontlines of COVID-19 

It’s not just healthcare workers’ physical health but also their mental health that’s suffering

Richard van Zyl-Smit, M.D./PhD described to a friend this week the current feeling of being in the hospital with COVID-19, as like sitting under a 1,000V high-tension electricity cable: there is a constant humming above your head, which is unnerving and just does not go away.

Two years ago, he published a book called They Don’t Award Nobel Prizes to Dead People about my experience as an academic clinician with a stress-induced anxiety disorder. The context is very different now, but the lessons I learned in that time might be of help to those of you feeling this intangible “humming” — a sense of anxiety that is neither defined nor visible even with no COVID patient contact — and for those of you who are caring daily for COVID-19 patients.

The first and most important aspect of this time is to recognize that anxiety is real. This is not something you might have experienced before. For those of us who have previously or currently suffer from anxiety, it is easily recognizable for what it is, but you may never have experienced it quite like this. You are not losing your mind or losing control, you are experiencing a loss of control of your environment. In many ways, the daily changing updates, the ever-changing schedules and call rosters are unsettling at best and can be completely unnerving as we can’t be certain from one day to the next. There is not a lot you can do about it, except to acknowledge it and talk about it.

The second aspect relates directly to that gnawing “hum.”

I learned previously the benefit of and strongly believe in “downtime.” Getting away from the humming, which is not so easy anymore as we don’t have rugby or soccer scores to get excited or depressed about, we don’t have news about politics or current affairs — except COVID, COVID, COVID. I used to play Candy Crush to get my mind off work and to get away from the “hum,” but recognized that did not accomplish much — it just kept my mind going, and the anxiety was still there. I now try to be creative, to garden, draw, write, crochet (see below), paint, anything that I can do that takes the focus off my work.

Exercise is great too — but now restricted to indoors! I don’t look at the hundreds of WhatsApp group messages unless I am at work; the latest medical publication of how I should treat my ventilated COVID-19 patient on my next week on call is not important when I am at home.

I am convinced that switching off the social media, medical media, and media media when you are not working is vital for your mental health. For some, it might mean no social media, for others less, but getting out from under the electricity cable when you can, is an important way to ensure your own sustainability over the next few months.

The last aspect relates to relationships: physical distance is key — but find, and seek out the people who can support you; keep talking to each other, be kind to each other and to yourself, and talk about the anxiety, fears, worries, or stress. Professional services are available to those feeling very out of control, but simply talking with someone is a fantastic way to get the humming out of your head.

As much as we need to care for our COVID-19 patients and protect ourselves with PPE, we also need to look after ourselves and protect our mental health. It is not a sign of weakness but requires courage and bravery to ask for help.

“Asking for help is not giving up, it is refusing to give up.” — Charlie Mackesy

We are all in this together — we need to be kind to each other and to ourselves.

India coronavirus doctors: Notes on hope, fear and longing Reporter Vikas Pandey shows us how the Corona virus is affecting doctors in India. Dr Milind Baldi was on duty in a Covid-19 ward when a 46-year-old man was wheeled in  with severe breathing difficulty.

The man was scared for his life and kept repeating one question: “Will I survive?”

The question was followed by a plea: “Please save me, I don’t want to die.” Dr Baldi assured the man that he was going to do “everything possible to save him”.

These were the last words spoken between the two men. The patient was put on a ventilator, and died two days later. The doctor, who works in a hospital in the central Indian city of Indore, vividly remembers the 30 “terrifying minutes” after the patient was brought to his hospital.

“He kept holding my hands. His eyes were full of fear and pain. I will never forget his face.”

His death deeply affected Dr Baldi. “It ate away my soul from inside and left a lacuna in my heart.” Seeing patients die in critical care wards is not uncommon for doctors like him. But, he says, nothing can compare to the psychological stress of working in a Covid-19 ward.

Most coronavirus patients are kept in isolation, which means, if they become critically ill, doctors and nurses are the only people they see in their final hours.

“No doctor ever wants to be in this scenario,” says Dr A Fathahudeen, who heads the critical care department at Ernakulam Medical College in southern India.

Doctors say they usually share the emotional burden of treating someone with that person’s family. But Covid-19 doesn’t allow that. Dr Fathahudeen says he will never forget “the blankness in the eyes” of a Covid-19 patient who died in his hospital.

“He wasn’t able to talk. But his eyes reflected the pain and the fear he was experiencing.” Dr Fathahudeen felt helpless because the patient was going to die alone. But there was a tiny sliver of hope: the man’s wife was being treated for coronavirus in the same hospital.

So, Dr Fathahudeen brought her to the ward. She stood still and kept looking at him and said her goodbye. She never thought her 40-year marriage would end so abruptly.

The experienced doctor says the incident left him “emotionally consumed”. But, he adds, there was “some satisfaction that he didn’t die without seeing his wife”. “But that won’t always happen. The harsh truth is that some patients will die without saying goodbye to their loved ones.”

The emotional toll is made much worse as many doctors are themselves in a form of isolation – most are staying away from their families to protect them. As a result, Dr Mir Shahnawaz, who works at the Government Chest Hospital in Srinagar, says it’s “not just the disease we are fighting with”.

“Imagine not knowing when you will see your family next, add that to the constant fear that you may get infected and you will begin to understand what we are going through.”

Adding to the stress, is the fact that they also have to constantly deal with the emotional outbursts of patients. “They are very scared and we have to keep them calm – be their friend and doctor at the same time.”

And doctors also have to make phone calls to the families of patients, and deal with their fears too. The whole process, Dr Shahnawaz says, is emotionally draining.

“It hits you when you go back to your room in the night. Then there is the fear of the unknown – we don’t know how bad the situation will get.”

Doctors are used to saving lives, he adds, and “we will continue to do that no matter what”. “But the truth is that we are also human beings and we are also scared.” He says that the first coronavirus death in his hospital made his colleagues break down: it was when they realized that Covid-19 doesn’t afford the family a final glimpse of their loved one.

“Family members want to remember the final moments of a patient – a faint smile, a few last words, anything really to hold on to. But they can’t even give a proper burial to the dead.”

Dr Fathahudeen says such psychological pressure needs to be addressed and each hospital needs to have a psychiatrist – both for doctors and patients. “This is something I have done in my hospital. It’s important because otherwise the emotional scars will be too deep to heal. We are staring at cases of PTSD among frontline workers.”

Doorstep doctors

It is not just those working in Covid-19 wards who are on the front line, but also the doctors, community health workers and officials who are involved in contact tracing and screening suspected patients by going door-to-door in virus hotspots.

Dr Varsha Saxena, who works in the badly affected northern city of Jaipur, says she walks into grave danger knowingly every day. Her job is to screen people for possible symptoms. “There is no other option. It’s the fight of our lifetime, but one can’t ignore the risks,” she says. “But it poses great risk because we don’t know who among the ones, we are screening is actually positive,” she adds.

She says doctors like her don’t always get proper medical-grade personal protective equipment. “The fear of getting infected is always there and we have to live with it. It does play on our mind and we have to fight hard to keep such negative thoughts away.”

But her biggest fear, she says, is getting infected and not showing any symptoms. “Then the risk is that we may end up infecting others. That is why field doctors also need PPE,” she adds. And the stress, sometimes, also comes home.

“It’s so draining. My husband is also a doctor, most nights we don’t even have energy to cook and our dinner involves just bread.”

Aqueel Khan, a bureaucrat and a colleague of Dr Saxena, acknowledges that psychological stress is a reality for all frontline workers, including officers like him who are embedded with medical teams. The fear really comes home for these workers when somebody close to them dies.

“I lost my uncle and a friend recently. It shook me, I can’t stop thinking about them. You can’t stop thinking that it can easily happen to you,” he says.

Mr. Khan is also staying away from his family: this year is the first time he will miss his daughter’s birthday. “My heart says to go home and see her from far, but the mind tells me otherwise. This constant struggle is very stressful.

“But we can’t turn our backs on the job. We just have to just keep at it, hoping that we come out alive on the other side of this fight.” ‘The risk is always there’

There is no respite for doctors and nurses even when they are not directly involved in the fight against coronavirus. People with other ailments are continuing to come to hospitals. And there has also been a surge in the number of people who are turning up at hospitals with coronavirus-like symptoms.

Dr Mohsin Bin Mushtaq, who works at the GMC Hospital in Indian-administered Kashmir, says coronavirus has “fundamentally changed our lives”. “We are seeing patients every day for other ailments. But the risk is always there that some of them could be infected,” he said.

And it worries him even more when he reads about doctors getting infected despite wearing PPE and dying. A number of doctors have died in India and dozens have tested positive. There is nothing we can do about it, he says, adding that “we just have to be mentally strong and do our jobs”.

Dr Mehnaz Bhat and Dr Sartaz Bhat also work in the same hospital, and they say that the “fear among patients is too much”. Dr Sartaz says people with a slight cold end up thinking they have coronavirus, and rush to the hospital. “So apart from treating them, we also have to deal with their fear,” Dr Sartaz adds.

He recently diagnosed Covid-19 symptoms in a patient and advised him to go for testing. But his family refused and took him away. The patient was brought back to the hospital after Dr Sartaz called the police. He says he had never imagined doing something like this in his medical career. “This is the new normal.”

The way patients are examined has also changed for some doctors. “We really have to try and limit close interactions with patients,” Dr Mehnaz Bhat says. “But it’s not what we have been trained for. So much has changed so quickly, it’s stressful,” she says.

And several attacks on doctors and nurses across the country have made them even more worried. She says it’s difficult to understand why anybody would attack doctors. “We are saving lives, risking our lives every day. We need love, not fear.” she adds.

And even worse:

E.R. doc on COVID-19 ‘front lines’ died by suicide                             To show how serious the stress is seen in this report by Cory Siemaszko reported that a New York City emergency room doctor who was on the “front lines” of the fight against the coronavirus has died by suicide, police said Monday. Dr. Lorna Breen, 49, who worked at New York-Presbyterian Allen Hospital, was in Virginia when she died on Sunday, said Tyler Hawn, a spokesman for the Charlottesville Police Department.

“The victim was taken to U.V.A. Hospital for treatment, but later succumbed to self-inflicted injuries,” Hawn said.

It was her father, Dr. Phillip Breen, who revealed the first details about his daughter’s tragic death. “She tried to do her job, and it killed her,” he told The New York Times. “She was truly in the trenches of the front line.”

He said his daughter seemed very detached of late and that she had described some of the horrors she had witnessed at the hospital while battling the virus. “Make sure she’s praised as a hero, because she was,” Phillip Breen said. “She’s a casualty just as much as anybody else who has died.”

The hospital confirmed Lorna Breen’s death in a statement released by chief spokesperson Lucky Tran, but gave few other details. “Words cannot convey the sense of loss we feel today,” the statement said. “Dr. Breen is a hero who brought the highest ideals of medicine to the challenging front lines of the emergency department. Our focus today is to provide support to her family, friends, and colleagues as they cope with this news during what is already an extraordinarily difficult time.”

NewYork-Presbyterian Allen Hospital has 200 beds, is in northern Manhattan and is one of the seven hospitals that make up NewYork-Presbyterian Hospital.

Infectious Disease Expert Makes Chilling Prediction for States Reopening Amid Pandemic                                                                 Reporter Lee Moran noted that infectious disease expert Michael Osterholm warned that the states starting to reopen amid the coronavirus pandemic “will pay a big price later on.”

Osterholm, the director of the Center for Infectious Disease Research and Policy at the University of Minnesota, told CNN’s Jake Tapper on Thursday that states like Georgia, Colorado and others that are easing social distancing restrictions were “putting gasoline on fire.”

“I think right now, this is one of the things we’ve learned, if we’re going to learn to live with this, then you just don’t walk in the face of it and spit in its eye, because it will hit you,” said Osterholm. “And I think that that’s a really important issue right now,” he continued. “When we have transmission increasing, when our hospitals are not able to take care of it and we don’t have enough testing to even know what’s going on, then that’s not the time to loosen up.”

Osterholm suggested it was “the worst example of how to start this discussion” about the “loosening” of society. “I wouldn’t do it,” he added. “I fear that these states will have to pay a big price later on because of what they’re doing.”

COVID-19: National Psychiatrist-Run Hotline Offers Docs Emotional PPE                                                                                              Emily Sohn reported that Mona Masood, DO, a Philadelphia-area psychiatrist and moderator of a Facebook forum called the COVID-19 Physicians Group, reviewed post after post about her colleagues’ fears, anxieties, and the crushing pressure to act like a hero, inspiration struck. Would it be possible, she wondered, to create a resource through which psychiatrists would be available to provide frontline physicians with some emotional personal protective equipment (PPE)?

She floated the idea in the Facebook forum, which has more than 30,000 members. The response was immediate. “All these psychiatrists just started contacting me, saying, ‘Please let me be a part of this. I want to volunteer,’ ” she told Medscape Medical News.

On March 30, Masood launched the Physician Support Line, a free mental health hotline exclusively for doctors. Within the first 3 weeks, the hotline logged more than 3000 minutes of call time. Some physicians have called repeatedly, and early feedback suggests the resource is meeting a vast need.

“Most of the cases have a lot of emotion from both sides. There are a lot of tears, a lot of relief,” said Masood.

“If Not Me, Then Who?”

Physicians have been facing mental health challenges long before the pandemic, and doctors have long struggled with stigma in seeking psychological help, says Katherine Gold, MD, a family medicine physician at the University of Michigan, Ann Arbor, who studies physician well-being, suicide, and mental health.

As a whole, physicians tend to be perfectionists and have high expectations of themselves. That combination can set them up for mental distress, Gold notes. Studies that have focused mainly on medical students and residents show that nearly 30% have experienced depression. Physicians are also at significant risk of dying by suicide.

Compounding the issue is the fact that physicians are also often reluctant to seek help, and institutional stigma is one persistent reason, Gold says. Many states require annual license renewal applications in which physicians are asked questions about mental health. Doctors fear they’ll lose their licenses if they seek psychological help, so they don’t pursue it.

A study conducted by Gold and colleagues that analyzed data from 2003 to 2008 showed that compared to the general public, physicians who died by suicide were less likely to have consulted mental health experts, less likely to have been diagnosed with mental health problems, and less likely to have antidepressants in their system at the time of death.

The COVID-19 pandemic may exacerbate these trends, suggests a recent study from China in which investigators surveyed 1257 healthcare workers in January and February.

Results revealed that a significant proportion of respondents had symptoms of depression, anxiety, insomnia, and distress. This was especially true among women, nurses, those in Wuhan, and frontline healthcare workers who were directly engaged in diagnosing, treating, or caring for patients with suspected or confirmed cases of COVID-19.

As Masood watched similar concerns accumulate on the COVID-19 Physicians Group Facebook forum, she decided to take action. She says her mentality was, “If not me, then who?”

Assisted by a team of experts, she created the hotline without any funding but with pro bono contributions of legal and ethical work, and she received a heavy discount from a company called Telzio, which developed the hotline app.

The hotline is open daily from 8:00 AM to midnight Eastern Time, and calls are free. Services are available only to physicians, in part because as a group, doctors tend to harbor guilt about asking for help that someone else might need more, Masood says.

When other types of healthcare workers call in, volunteers redirect them to hotlines set up for first responders and other healthcare providers.

So far, more than 600 psychiatrists have volunteered. They sign up for hour-long shifts, which they fit in between their own patients. Two or three psychiatrists are available each hour. Calls come directly through the app to their phones. There is no time limit on calls. If calls run long, psychiatrists either stay on past their shifts or pass the call to another volunteer.

Since its launch, the number of calls has steadily increased, Masood says. Callers include ICU doctors, anesthesiologists, surgeons, emergency department doctors, and some physicians in private practice who, Masood says, often express guilt for not being on the front lines.

Some physicians call in every week at a certain time as part of their self-care routine. Others call late at night after their families are in bed. If indicated, psychiatrists refer callers for follow-up care to a website that has compiled a list of psychiatrists across the United States who offer telehealth services.

There are no rules about what physicians can discuss when they call the hotline, and popular topics have evolved over time, says Masood. In the first week after the hotline’s launch, many callers were anxious about what the future held, and they saw other hospitals becoming overwhelmed. They worried about how they could prepare themselves and protect their families.

By the second week, when more doctors were in the thick of the pandemic and were working long hours, sometimes alone or covering shifts for infected colleagues, there were concerns about coworkers. Some were grieving the loss of patients and family members. The lack of personal protective equipment (PPE), says Masood, has been a common topic of conversation from the beginning.

Given the many unknowns about the virus, physicians have also grappled with the uncertainty around safety protocols for patients and for themselves.

On a deeper level, physicians have expressed a desire to run away, to stop going to work, or to quit medicine altogether. These escape fantasies are a normal part of the fight-or-flight response to stress, Masood says.

Doctors often feel they can’t share their fears, even with family members, in part because of societal pressures to act like heroes on the front lines of what has been framed as a war, she adds.

Heroes aren’t supposed to complain or show vulnerability, Masood says, and this can make it hard for physicians to get the support they need. Through the hotline, psychiatrists give doctors permission to feel what they are feeling, and that can help motivate them to go back to work.

“They don’t want to look like cowards, because that’s the opposite of a hero,” she said. “Saying it to another doctor feels much better because we get it, and we normalize that for them. It’s normal to feel that way.”

Each week, Masood conducts debriefing sessions with volunteers, who talk about conversations filled with raw emotion. When conversations wind down, most physicians express gratitude.

They tell volunteers that just knowing the hotline is there provides them with an emotional safety net. Masood says many physicians tell volunteers, “I know that if anything’s going wrong, I can just call and somebody will be there.” Volunteers, too, say they are benefiting from being involved.

“We are all really having this desperate need to be there for one another right now. We truly feel like no one gets it as much as we get one another,” said Masood.

Long-term Fallout

The need for psychiatric care is unlikely to end after the pandemic retreats, and Masood’s plan is to keep the hotline running as long as it’s needed. Like the rest of the world, physicians are in survival mode, but she expects a wave of grief to hit when the immediate danger ends. Some might blame themselves for patient deaths or question what they could have done differently. The long-term impact of trauma is definitely a concern, Gold says. Physicians in the ER and ICU are seeing many patients who decline quickly and die alone, and they witness young, previously healthy people succumb to the virus.

They’re seeing these kinds of cases over and over, and they’re often doing it in an environment where they don’t feel safe or supported while people in many places stage protests against the measures they feel are helping protect them.

Like veterans returning from war, they will need to reflect on what they’ve experienced after the adrenaline is gone and there is time to think.

“Even when things calm down, it will be great to have resources like this still functioning that can help folks think back through what they’ve been through and how to process that,” Gold said. “Things are going to remind them of experiences they had during COVID, and they can’t predict that right now. There will be a need for the support to go on.”

Masood is optimistic that the pandemic will bring the issue of physicians’ mental health out of the shadows.

“We have a really deep feeling of hope that that there’s going to be a lot more empathy for one another after this,” she said. “There’s going to be a willingness to not take mental health for granted. Doctors are people, too.”

We understand about those on the frontline of this pandemic. But do you all realize that many physicians and nurses are being furloughed during this pandemic due to elimination of elective surgery, many of which are necessary such as transplants and cancer treatments and surgery as well as limitation of their practice during this pandemic.

How do physicians pay their malpractice insurance and pay their staff and overhead and their huge education loans?

I fear that we may see a mass quitting/retirement of many nurses and physicians in our country and maybe world wide or many suffering from PTSD (Post Traumatic Stress Syndrome).

What then happens to our healthcare system? Will this pandemic force Congress to finally get serious regarding improving our healthcare system for All?

What It’s Like to Watch Your Business Fail? The New Labor Movement and Comicon!

I discussed previously regarding the stress and anxiety of self-isolation, state-wide lockdowns and quarantine, but what about the effect on business owners? Chris Thompson noted that his wife’s job has always been to keep people relaxed. The stress of keeping that dream alive is agonizing. Chris Thompson noted that the widespread crumbling of American small businesses in the year 2020 will ultimately be a second- or third-order concern, at best, as millions of people are infected by the novel coronavirus and some horrifying percentage succumb to Covid-19. It’s worth observing, though, that just as the ultimate tally of lives lost will be bloated by a slapdash governmental response that left many folks to balance for themselves the danger of multiple existential threats, so too will the eventual failure of hundreds of thousands of small businesses reflect the confusion, incompetence, and indifference of the people whose job it is to manage this crisis.

My wife has owned and operated a boutique day spa in the Virginia suburbs of Washington D.C. for going on 15 years now. A dozen practitioners tend to rosters of dedicated clients; a small handful of support and administrative staffers keep things organized. Because it’s a very small operation, my wife is both the main administrator and also a practitioner who sees clients. It’s a demanding job, and it eats up much more of her time than a full-time job in someone else’s spa would, but she’s very good at it and is fulfilled by the opportunity to execute her own vision of how a spa should operate.

Turns out when a novel virus leaps oceans and uses close human contact to navigate its way to the most vulnerable, businesses that make their money via direct physical contact between workers and customers are put in a uniquely difficult situation. The spa industry is loaded down with standards designed to limit the transmission of diseases between parties, but zero transmission is not possible, and this isn’t the common cold. Somewhere around 200 people come into the spa each week, and all 200 are in direct physical contact with a staff person; half or more are there to have another person’s hands and fingers directly applied to their face for an hour or longer, in services where steam is applied and hangs in the air. There is no such thing as social distancing inside a spa. Even with every safety measure applied as fastidiously as possible, two perfectly healthy seeming clients sharing a waiting room can trade illnesses in the time it takes to fill out a single-page intake form.

The spa industry is loaded down with standards designed to limit the transmission of diseases between parties, but zero transmission is not possible, and this isn’t the common cold.

The right thing to do, then, is to suspend operations at least until widespread testing has begun, if not until the spread of the virus is fully understood and the brunt of the pandemic has been absorbed. While no one knows who the hell has the virus and while hospitals are having their asses kicked by the surge of infections, operating a serene little coronavirus distribution center in a densely populated area would be a very shitty thing to do for the public good.

But closing the business, even for just a few weeks, presents some immediate challenges. Practitioners depend upon commissions from services in order to pay their bills. A cut of service income is set aside to pay administrative staff. Shuttering the business for a couple of months means coming up with tens of thousands of dollars to help keep these people afloat, or setting them adrift to fend for themselves. And there are other expenses applying considerable pressure to that primary concern: Lease payments are due on expensive machinery; professional insurance cannot be allowed to lapse; the landlord is expecting another rent payment, and another, and then another.

The Trump administration directed the Small Business Administration on March 12 to offer a special reduced interest rate on get-me-over “recovery” loans to businesses affected by the pandemic, money that at least in theory could provide a source of cash with which to pay staffers to stay home. But there’s a rub—or several. For absolutely no good reason, the disaster rate is contingent on a given state’s emergency posture. So, for example, if your business is in, say, Kansas, where prominent politicians have said coronavirus is not a threat because there is not a large Chinese population, you would not qualify for the disaster rate without a statewide disaster declaration. If you want to do the right thing for your staff and community and temporarily suspend the operations of your small business ahead of this declaration, any loans you seek to increase your cash on hand will not be protected from predatory rates.

As it happens, Virginia declared a state of emergency on March 12, which meant the “recovery loans” should’ve been available within hours of the executive directive to the SBA. But here we encounter the second and third rubs. First, it turns out no one at the SBA had been given much direction about what exact governmental declaration qualified businesses in a given state for the special rate, and so no one at the SBA and none of the SBA-linked banks could say for sure whether a Virginia small business qualified. Second, and most horrifying of all, the recovery loans were not available for businesses “with credit available elsewhere.” If the SBA determined that a business had opportunities to borrow money without its protections, it was happy to dropkick that business out into the wilderness.

It’s worth noting how backward and screwy it is that a once-in-a-lifetime pandemic would force otherwise perfectly successful small businesses to take on crippling debt and pay interest to lenders, in order to provide disaster pay to workers who, like their employers, did absolutely nothing wrong. If there’s going to be a thing called a Small Business Administration — hell, if there’s going to be a thing called a federal government — it ought to have better tools at its disposal than a Rolodex of carrion-circling lenders and a negotiated interest rate. In fact, it does! It’s just that the real help is being shifted to billion-dollar companies with tycoon CEOs, while small businesses are being fed to the sharks.

The next-best option for my wife’s efforts at keeping her staff on their feet involved emptying savings accounts used for reserving money for taxes and liabilities (think gift certificates, which accrue impressively but which are not payment for services rendered, cannot expire, and are refundable). A day spa, even a reasonably successful one, is a low-margin business: A savings account reserved for liabilities holds roughly $10,000; another savings account reserving estimated tax money holds another $4,500; one single payroll for half a month’s regular work runs $23,000 to $32,000. Emptying those accounts would mean dealing a grievous self-wound for very fleeting, dubious benefits. It would cover somewhere around half of a paycheck per staff person but would make it far more likely that the business would fold before the end of the current crisis, depriving these people of a job to which they would otherwise happily return.

So, this is all pointing at layoffs — a strategic termination so that her people could collect unemployment and the company could still be around to gather them back up again in a few months. But first, my wife had to see if she could lower her non-payroll expenses to as close to zero as possible if she was to have any chance of avoiding the devastating defeat of cutting loose a good and loyal and dedicated staff of excellent people, many of whom have families to support. This meant seeking forbearance from lenders, banks, and the landlord.

The only thing that seems to matter to anyone with any power is whether money continues to flow upward. It only ever flows upward; the only thing that trickles down is pressure.

The first two calls were to lenders, and they were not encouraging. The first lender said my wife could go through the usual payment deferral process, but that her interest rate would increase and penalties would accrue, and there would be an eventual balloon payment at the end of her loan period. The second lender had disconnected their telephone and was unreachable for four days. Both lenders ultimately settled on limited forbearance through April — payments could be missed, but hundreds of dollars in penalties would accrue per payment missed, and the sum of missed payments, plus penalties, would be added to payments beginning in May. Her interest rate would jump, per the original agreement, to reflect missed payments.

The word from the landlord was even more troubling. My wife pays $4,500 in monthly rent to a developer that manages an impressive spread of commercial real estate. Their representative announced in a bemused tone that they had not even considered whether they would need to offer any sort of relief or forbearance to their tenants. After having the situation explained to them, their best offer was one month of forbearance in exchange for extending the lease period by a full year, and they indicated they’d be offering this deal to their tenants on a case-by-case basis. Two days later, they sent a form email to their tenants announcing that the deal would, in fact, be two months of forbearance in exchange for two years added to existing leases.

What has been lacking in all this is firm direction from the federal government. It has been in their power all along to suspend collection of rent, mortgage, and debt payments, and to mandate two or three months of social distancing and a halt on all nonessential business. Hilariously, they’ve managed to suspend rent payments for airlines at airport terminals, once again directing relief at massively profitable, publicly-traded, billion-dollar businesses and ignoring everyone else. They’ve left it up to governors and mayors to determine how much traffic and business to permit; they’ve left it up to banks and landlords to determine how much relief is appropriate; they’ve left it up to business owners to figure out how to balance the threat to the public of staying open versus the threat to the business of shutting down; they’ve left it up to individuals to hammer out arrangements for keeping a roof overhead and food on the table. There are no right answers. The only thing that seems to matter to anyone with any power is whether money continues to flow upward. It only ever flows upward; the only thing that trickles down is pressure.

What is likely to finally kill my wife’s business, in a blast of dark cosmic humor, will be the administration’s favoring of the market over public health. While society was settled on indefinite self-isolation and a hiatus for all nonessential work — something the federal government never quite got around to championing but which was nonetheless taken for granted by all nonsociopaths — it was possible to make limited headway negotiating forbearance from banks and lenders and landlords, using phrases like “act of God” and “force majeure.” If and when the president arbitrarily declares the battle won after a few short weeks of half-assed social distancing — long before a framework for widespread testing has been established, to say nothing of any formal measures to quickly increase the stockpile of masks and ventilators — small businesses will be forced to ignore the urgent pleas of the scientific and medical communities and reopen for business or face down creditors and landlords without the backing of an official mandate. Small businesses will have to choose between operating as coronavirus distribution centers or sinking immediately under the weight of debt.

Here is where things stand for my wife and her business: Her rent has been deferred for one month, at the cost of another full year on her lease; her two loans have been deferred for two months each, but not without penalty. Insurance for her company and its practitioners has not been deferred. Bills will begin piling up in earnest, thousands and tens of thousands of dollars at a time, beginning [checks watch] uhh yesterday. An end to social distancing is months and possibly a year away; Virginia’s current stay-at-home order runs into June. There is no telling how soon it will be anything other than catastrophically reckless to reopen her doors and accept business, but the people upstream have drawn their line. The clock is ticking.

Most painfully, the staffers who could not survive without immediate income have agreed to have their employment terminated, so that they can collect unemployment and seek Medicaid. My wife, who is a good practitioner and a good business owner and has not done anything wrong to put her business at risk, is in an impossible, untenable position. Because she will have to start paying rent again in one month, and because she will have to start making loan payments by summertime, and because she has several very talented and qualified and hardworking staff people in the wind, there will be enormous pressure on her to turn the lights back on before the end of April. If she does, she and all the other small businesses forced into the same position will be active vectors for coronavirus, despite every possible effort. If she doesn’t, it is very likely she never will again.

America Is About to Witness the Biggest Labor Movement It’s Seen in Decades

It took 40 years and a pandemic to stir up a worker revolution that’s about to hit corporate America!

Steve LeVine remembered that in September 1945, a little-remembered frenzy erupted in the United States. Japan had surrendered, ending World War II, but American meat packers, steelworkers, telephone installers, telegraph operators, and auto assemblers had something different from partying in mind. In rolling actions, they went on strike. After years of patriotic silence on the home front, these workers, along with unhappy roughnecks, lumberjacks, railroad engineers, and elevator operators — some 6 million workers in all — shut down their industries and some entire cities. Mainly they were seeking higher pay — and they got it, averaging 18% increases.

The era of raucous labor is long past, and worker chutzpah along with it. That is, it was — until now. Desperately needed to staff the basic economy while the rest of us remain secluded from Covid-19, ordinarily little-noticed workers are wielding unusual leverage. Across the country, cashiers, truckers, nurses, burger flippers, stock replenishers, meat plant workers, and warehouse hands are suddenly seen as heroic, and they are successfully protesting. For the previous generation of labor, the goal post was the 40-hour week. New labor’s immediate aims are much more prosaic: a sensible face mask, a bottle of sanitizer, and some sick days.

The question is what happens next. Are we watching a startling but fleeting moment for newly muscular labor? Or, once the coronavirus is beaten, do companies face a future of vocal workers aiming to rebuild lost decades of wage increases and regained influence in boardrooms and the halls of power?

For now at least, some of the country’s most powerful CEOs are clearly nervous. Late last month, Apple, faced with reporters asking about a company decision to furlough hundreds of contract workers without pay, did a quick about-face. Those employees, Apple now said, would receive their hourly wages. A few weeks earlier, after Amazon warehouse workers demanded better benefits during the virus pandemic, that company also reversed course, offering paid sick days and unlimited unpaid time off.

The backdrop is a country at a standstill and uncertain over which businesses will survive the current economic shakeout, and in what form. With some notable exceptions, very few companies seem prepared to risk riling their employees, especially given broad popular support for workers at their grocery stores, nurses at their hospitals, and drivers who are keeping supply arteries open.

The past four decades have been perhaps labor’s weakest since the Industrial Age.

But if companies are responding to those who are protesting, they might also think ahead and preempt festering trouble down the road. “I like to believe people will say, ‘We treat these people as disposable, but they are pretty indispensable. Maybe we should do what we can to recognize their contribution,’” says David Autor, a labor economist at MIT and co-director of the school’s Work of the Future Task Force.

Until the 1980s, layoffs were barely a thing, writes Louis Uchitelle in The Disposable American: Layoffs and Their Consequences. Companies tended to avoid large-scale dismissals, because they violated a red line of publicly accepted practice and also could finger the company for blame. The United States was still in the age of company as community and societal patron, and even when workers went on strike, they were generally not replaced, because the optics would be bad.

But in 1981, President Ronald Reagan changed all that. Some 12,000 air traffic controllers went on strike, demanding higher pay and a shorter workweek. In a breathtaking decision, Reagan fired all but a few hundred of them. The Federal Labor Relations Authority decertified the controllers’ union entirely. The era of strong labor was over.

In the subsequent age of the no-excuses layoff, the number of major strikes has plunged. Starting in 1947, when the government began keeping such data, there were almost always anywhere from 200 to more than 400 big strikes every year. But in 1982, the year after the air traffic controllers debacle, the number for the first time fell below 100. In 2017, there were just seven. “There was damage to self-esteem every time there was a layoff. It took the militancy out of organized labor, and I don’t think it ever recovered,” Uchitelle says.

The past four decades have been perhaps labor’s weakest since the Industrial Age. For a half century, those working for hourly wages have won almost no real gains. The real average hourly wage in 2018 dollars adjusted for inflation was $22.65 in 2018, compared with $20.27 in 1964 — just an 11.7% gain, according to Pew Research. Real median hourly wages rose by only another 0.6% last year despite the sharp tightening of the job market and an increase in the minimum wage across the country, according to the Bureau of Labor Statistics.

The current revival of worker activism precedes Covid-19 in the unlikeliest of places. In 2018, West Virginia teachers, among the lowest paid in the nation and four years without a raise, went on strike for nine days in a demand for higher pay. That they won a 5% increase was one astonishing thing. But the walkout itself was stunning, specifically because of the state where it occurred — a former bedrock of ultramilitant coal miners who had repeatedly gone to actual war for better pay and safety but more recently were a bastion of worker passivity.

If teachers are an indicator of what is coming, Amazon, fast food restaurants, hospitals, and gig companies have a long, hot few years ahead.

Last year, the West Virginia teachers were on the picket lines again. This time, they stopped the state legislature from funding private schools in what they saw as an attempt to weaken their newly revived strength. Officials buckled after just a day. The strikes meanwhile spread to a dozen red and blue cities and states. Often wearing red shirts as the symbol of the strikes, the teachers were demanding more money — from 2000 to 2017, teachers’ real salaries actually shrunk by 1.6% nationally, according to the National Center for Health Statistics — as well as more supplies and help in the classroom. In Arizona, teachers won a 20% raise, and Los Angeles teachers won a 6% raise. That triggered more strikes through much of 2019, with Chicago teachers, for one, winning a 16% pay raise. Strikes seemed likely this year, too, in Detroit and Philadelphia, for starters.

If teachers are an indicator of what is coming, Amazon, fast food restaurants, hospitals, and gig companies have a long, hot few years ahead. On April 6 alone, the employees of a Los Angeles McDonald’s walked out when a co-worker was diagnosed positive for the coronavirus. For the second time in a month, workers at a Staten Island Amazon warehouse went on strike after 26 co-workers came down with the virus. And outside Chicago, employees of two plants walked out because management failed to immediately announce that co-workers had been diagnosed with Covid-19.

Across the country, workers are on the march over safety, pay, and sick days. The picture is jarring at a time when 16 million people are newly out of work. Companies and CEOs need to prepare for a new post-Covid-19 reality where workers will recognize their power — and use it.

 “Business models based on ridiculous labor rates plus arbitrage where you foist all your costs onto the employee are coming to an end.”

When the virus struck Hilton Hotels starting in January, its global occupancy plummeted to somewhere between 10% and 15%, and most of its 6,100 managed and franchised properties closed. Executives were convinced that the travel industry would eventually rebound, but from there they faced a conundrum: They did not want to lose a trained workforce, but they also knew they and their franchisees could not afford to keep their approximately 260,000 employees on the payroll. So, on March 24, the decision was announced to, in effect, loan them out.

Staff in Hilton’s human relations unit contacted counterparts at Amazon, Albertson’s, CVS, and Walgreens, says Nigel Glennie, vice president of corporate communications at Hilton. These retailers were experiencing Covid-19 boomlets and, combined, were in the market for hundreds of thousands of workers. Were they interested in some already trained workers, Hilton asked, who are expert specifically in catering to exceedingly particular customers? So an expedited hiring portal was set up, ultimately connecting Hilton’s workforce with 28 retailers that were suddenly responsible for almost the entire working economy.

The outcome was ideal for Hilton: It would not lay off but instead furlough its workers, thus allowing them to collect unemployment checks or work elsewhere. Once the crisis ended, they could return to Hilton. “We have a commercial interest in this decision. We know we have well-trained people who we want back,” Glennie says. “We wanted to make sure they were looked after. We want to do the right thing by our people.”

Jeff Lackey, vice president of talent acquisition for CVS Health, says his company was seeking 50,000 new employees at the time. Albertson’s says it was hiring 30,000. Neither know exactly how many of Hilton’s workforce are now working for their respective companies, but Lackey says the hiring process was being completed in as little as a single day. “I understand what it’s like to live paycheck to paycheck,” he says.

Less flattering attention has gone to companies that have violated an unwritten set of rules that have emerged for corporate behavior. Hospital management has been upbraided for suspending nurses who try to protect themselves by buying their own equipment and disciplining those who speak out. Former employees of Bird, the scooter company, described drawn-out hours of uninformed dread prior to an announced Zoom meeting, followed by a short announcement by someone they did not know. And Dig Inn, the fast-casual chain, sprung the news by text.

Sephora, too, has been faulted publicly by recently laid-off employees. At first, the retail beauty chain closed but promised to keep paying everyone for as long as the stores remained shuttered. Then, on March 31, it laid off part-time staff anyway. The decision caught a lot of Sephora employees by surprise. In tweets and online videos, some workers said they had been on calls with their managers that very day discussing the opposite — how they would go ahead in the new environment. Suddenly, though, employees received texts saying that in 15 minutes, they were to participate in a mandatory audio call.

When Lydia Cymone, a Sephora makeup artist in Alpharetta, Georgia, heard the call, she was right in the middle of videotaping a makeup tutorial and posted the tearful video. Brittney Coorpender, who did facial treatments at a Sephora store in San Jose, California, told me in an email exchange that she felt misled. “Women/men who forgot to mute themselves could be heard sobbing right before I ended the call,” Coorpender wrote. “They promised and promised us we were fine and gave zero indication we weren’t, until that call.”

In response to a request for comment, Sephora sent the March 31 statement it posted to its website. Dan Davenport, president of recruiter Randstad RiseSmart, says, “If you’re making a statement that you’re not going to be laying anyone off, you better be right about that.”

If corporate America does face a post-Covid-19 reckoning from workers, the gig economy seems like one of the top probable targets. Jim Chanos, president of Kynikos Associates, a hedge fund that shorts stocks, was made famous in the early 1990s for blowing the whistle on Enron. Today, Chanos is shorting Uber and Grubhub, among other gig companies. In an interview, he said he had already been shorting the two companies but has added to these bets since the virus struck.

What makes them weak, in Chanos’ view, is the optics of their business model, which is based on paying an arguably miserly cut of revenue to their workers and a refusal to make them actual employees. While allowing these companies to avoid a lot of the conventional costs of doing business, the strategy has also always left the gig companies at risk of their workers and the public turning against them. Chanos predicts that’s exactly what’s going to happen in the post-coronavirus era. The public is “going to look askance” at companies that have relied on taxpayers to fully cover their workers’ jobless benefits, since they do not pay into unemployment insurance funds. “Business models based on ridiculous labor rates plus arbitrage where you foist all your costs onto the employee are coming to an end,” he says.

Until the virus, the notion of unionized tech workers was just that — a notion that seemed to violate the very spirit of Silicon Valley. It’s still hard to imagine unionized software engineers. But it’s equally difficult to say where the boundaries of the possible lie.

White-collar tech activism goes back two years, when Google workers around the world walked off the job in a protest against sexual harassment. More workers are griping now. Last month, some Instacart workers walked off the job in a bid for a higher share of the revenue and better safety; in some cities, they are starting to join unions like the United Food and Commercial Workers local in Chicago. In San Francisco, Uber and Lyft drivers protested last month in front of Uber headquarters.

The tremors, though, will be felt not just in the gig economy but also tech at large: In February, employees at Kickstarter, the crowdfunding platform, voted to unionize, becoming the first white-collar tech company staff to do so, according to a database at Cal Berkeley. The Teamsters are making an open run at organizing other Silicon Valley workers. If you put Covid-19 out of your mind, the move is mind-blowing. Until the virus, the notion of unionized tech workers was just that — a notion that seemed to violate the very spirit of Silicon Valley. It’s still hard to imagine unionized software engineers. But it’s equally difficult to say where the boundaries of the possible lie.

The biggest fish of all in terms of tech unionization is Amazon. The e-commerce giant is beset with worker complaints just as it has begun to transcend its barbarian image, repositioning itself as a public good at the very center of the U.S. economy. An issue that has drawn particular heat is its decision on March 30 to fire Chris Smalls, a worker at an Amazon warehouse on Staten Island who loudly complained about health safety. On April 8, a group of Democratic U.S. senators wrote a letter to Amazon CEO Jeff Bezos raising skeptical questions about Smalls’ dismissal and Covid-19 safety generally at company warehouses. Amazon has seemed generally conflicted: On one hand, it has responded with added pay and off-days for sick employees. But Amazon has also repeatedly fired workers it has deemed disloyal — three employees just over the past week who had criticized health conditions. Whole Foods, too, owned by Amazon and run by John Mackey, the devotee of “conscious capitalism,” faced a sick-out in March and look, now a number of Amazon facilities are seeing sick outs. In a statement, an Amazon spokesperson said the points raised in the senators’ letter were unfounded and that Smalls was dismissed for violations of social distancing guidelines. “Nothing is more important than the safety of our teams,” the spokesperson said.

Robert Shiller, the Nobel Prize–winning economist at Yale, compares labor’s newfound position to its stature in the Great Depression, when workers also suddenly were conferred with vast public sympathy.

While complaints and denunciation of Amazon abound, no one has gone so far as to try an old-style shutdown of any of the company’s operations — the kind of display of strength that typified unions in their heyday. For that matter, no rabble-rousing worker is known to have recently banged on the desk of a major company executive — or a leading politician — and demanded the production of a plant be kept open and workers on the job. Even if one did, would the public go along? Would large numbers of people stop shopping at Amazon? If they did, Amazon would have to concede quickly, just as railroad workers shut down transportation across the country in labor’s peak. “If you could really shut down a warehouse, that would really shock Amazon and get them to address the worker concerns,” says Steven Greenhouse, author of Beaten Down, Worked Up, a history of American labor.

Robert Shiller, the Nobel Prize–winning economist at Yale, compares labor’s newfound position to its stature in the Great Depression, when workers also suddenly were conferred with vast public sympathy. “The narrative was that it wasn’t their fault. There was something in the system,” Shiller told me. “This is another case where obviously it’s not their fault. And there is heroism in how they are delivering to us through this.”

In a way, labor’s resurgence is not all that surprising. The age of Trump and Brexit is, at its crux, an uprising against globalization, the movement that, after Reagan and his contemporaneous British counterpart, Margaret Thatcher, diminished labor and championed worldly capitalism at whatever the local cost. If we are spurning globalization, it stands to reason that the local comes back into focus. And what is more local than the grocery bagger, the postman, the nurse?

Where workers have advantage today has been in keeping their demands modest, drawing the public to their side, and making it very difficult for management to refuse. Worker efforts could be blunted by high unemployment, at least until jobs return. But their pluck, beaten out of them by the years of layoffs, has returned with Covid-19.

A class war? A global power shift? A world isolated? How experts see the future after coronavirus.

Joel Shannon noted that what will “normal” be like after coronavirus? Experts imagine a different world.

The coming weeks hold plenty of uncertainty as the world reels from the coronavirus pandemic, but some experts are already thinking about how the current crisis will impact society for years to come.

A report from Deloitte and Salesforce released this month presents four scenarios for the next three to five years — and they all tell a story of a world radically changed by the virus with the intent of helping leaders prepare for a variety of possible futures. “Even their best-case scenario looks pretty bad,” trends expert and keynote speaker Daniel Levine told USA TODAY.

Rather than making specific predictions, the scenarios in “The world remade by COVID-19” report focus on what we don’t know at this time, Andrew Blau — managing director of Deloitte Consulting and a leader on the project — told USA TODAY.

When will life return to normal? Expert says US testing is too far behind to know, expects second wave of cases. The end result: An intentionally fuzzy picture of several possible futures, varying based on how several unknowns — such as the duration of the pandemic — unfold. Those possible futures highlight trends that may soon define our times.

On one end of the spectrum: A short-lived pandemic that will batter small and medium-sized businesses. It leaves consumers — grateful to once again gather with friends, loved ones and coworkers in person — reevaluating some of their pre-pandemic habits. On the other end: A prolonged, nearly impossible to contain virus that leaves the world isolated, distrustful and suffering.

Levine, who was not involved with the project, said the report approached the difficult task of looking years into the future the right way. While none of the scenarios described in the report are likely to pan out as authors imagine them today, Levine said the future will likely hold a mix of them. 

Here’s the authors’ four scenarios:

The passing storm

In this possible future, our fight against the virus goes better than expected — but still at great economic cost, especially to the middle class and small businesses.

The pandemic “leaves its mark on society, but doesn’t change everything,” Blau said. 

Governments’ plans to contain the virus generally work and citizens comply with the measures. The success leads to a greater trust in our institutions, but class tensions simmer as the lower and middle classes bear the brunt of the economic damage. 

What might life be like in this future? In many ways, daily life would remain relatively stable, Blau said. Life under lockdown will remind many people about the value of community and companionship. Weeks of increased teleworking and online retail will lead many people to alter some of their behaviors. 

Sunrise in the east

Authors note the possibility that China and other East Asian counties will be able to manage the virus more effectively, through what western nations may see as heavy-handed tactics. Aggressively enforced lockdowns and surveillance technology have shown promise in multiple East Asian countries’ fight against the virus. If western countries’ uneven response proves less effective, global power could shift to China and its neighbors, authors speculated.

What might life be like in this future? The political impacts of this are hard to pin down for Blau, although he suspects eastern Asian countries would be looked to as a positive example in how western governments are run. Clearer to him: Our relationship with technology could change. For years, many people have held deep privacy concerns and a suspicion of artificial intelligence. If technology proves invaluable in our fight against the virus, those perceptions could evolve.

Good company

This scenario imagines a world where many factors — such as the severity of the disease and the economic impacts — are not as bad as they could be, but only because corporations stepped up when governments were ineffective.

It’s an expansion of a trend seen to some extent in the today — public-private partnerships where big corporations step in when governments can’t handle the crisis alone. There are threads of this in the daily news of today: Tech companies fixing broken ventilators for the government; Apple and Google developing apps to help fight the pandemic.

What might life be like in this future? Corporations would play an even bigger role in our lives than they currently do — and Blau suspects we would come to embrace that, since those companies helped us through the crisis. The report says this future could lead to an era of greater corporate responsibility and trust.

Lone wolves

This is the future “no one wants to happen,” Blau said. This scenario could happen if the virus proves impossible to contain and spreads in long-lasting waves around the globe. “Mounting deaths, social unrest, and economic freefall become prominent,” the report says. 

As a result, nations turn inward and limit contact with the outside world in the interest of national security. It’s a future where even allies feel like they cannot trust each other.

What might life be like in this future? Different nations will feel the impacts in different ways, but Blau imagines we’d live in a less connected, less trusting, less prosperous world, focused on survival. It’s a “dark scenario” where technology is used for surveillance and control, nations limit trade with each other and paranoia is common among citizens.

Will any of these scenarios actually happen?

The good news: The future isn’t written yet, and we have a say in how it plays out.

Report authors listed how citizens of nations responded to the crisis as one of their top unknowns. Nations that work together and “think big and act fast” will fare better, they predicted.

The scenarios in the report are meant to confront you with a possible reality that might surprise or unsettle you — and that’s part of the point, Blau said. The goal is to get readers thinking and mentally preparing for a wide variety of possible futures, even ones that don’t seem intuitive.

Instead of believing specific predictions for the future, he suggested embracing the uncertainty we are all living at this moment.

“We’re all imagining the future,” Blau said. “None of us actually know.” 

Coronavirus Forces Organizers to Cancel San Diego Comic-Con

Brakkton Booker reported that the continued spread of the coronavirus claimed yet another big event on the 2020 entertainment calendar this Friday, when the San Diego Comic-Con announced the annual entertainment and comic book convention would be postponed until 2021.

In a statement on its website, organizers said it is “with deep regret that there will be no Comic-Con in 2020,” marking the first time in the event’s 50-year history it would not be held.

“Extraordinary times require extraordinary measures and while we are saddened to take this action, we know it is the right decision,” said Comic-Con spokesperson David Glanzer. “We eagerly look forward to the time when we can all meet again and share in the community we all love and enjoy.”

The event, which was expected to draw more than 100,000 people, was scheduled to be held July 23-26. It will now take place almost a year to the day later, kicking off July 22-25, 2021.

Comic-Con — which launched as a small comic-book themed event — is now a powerhouse summer festival that attracts major figures from movies and television. It’s one of the biggest fan events of the year; last year more than 135,000 people attended, and not just for comics, but for interactive experiences, signings and big announcements about the latest Marvel movies.

SDCC officials said fans who bought passes for Comic-Con 2020 can either request a refund or transfer their badges to next year. The same offer is being made to the event’s exhibitors.

Organizers also announced that a previously postponed event, Anaheim WonderCon — originally set for April 10-12 — will also be pushed to 2021. It will be held at California’s Anaheim Convention Center from March 26-28.

The spread of the coronavirus has decimated the festival and sporting calendar, with many states implementing broad social distancing guidelines and stay at home orders that have shuttered all but essential businesses from operating.

In March, California governor Gavin Newsom issued a stay at home order, and banned gatherings of more than 250 people.

What will happen next as more and more states consider “getting back to “normal” and as more and more groups push back with non-social gathering demonstrations. Don’t be idiots and follow science and our public healthcare teams!

The questions are when will this end, which prediction model do we believe and what will the new normal be?

In isolation, worries and stress are magnified During the Coronavirus Pandemic. COVID-19 could lead to an epidemic of clinical depression!

Jonathan Kanter wrote in the Conversation that Isolation, social distancing and extreme changes in daily life are hard now, but the United States also needs to be prepared for what may be an epidemic of clinical depression because of COVID-19.

We are clinical psychological scientists at the University of Washington’s Center for the Science of Social Connection. We study human relationships, how to improve them, and how to help people with clinical depression, emphasizing evidence-based approaches for those who lack resources.

We do not wish to be the bearers of bad news. But this crisis, and our response to it, will have psychological consequences. Individuals, families and communities need to do what they can to prepare for a depression epidemic. Policymakers need to consider – and fund – a large-scale response to this coming crisis.

A perfect storm of depression risks

Most of us know the emotional components of depression: sadness, irritability, emptiness and exhaustion. Given certain conditions, these universal experiences take over the body and transform it, sapping motivation and disrupting sleep, appetite and attention. Depression lays waste to our capacity to problem-solve, set and achieve goals and function effectively.

The general public understands depression as a brain disease. Our genes do influence how easily we may fall into clinical depression, but depression is also, for most of us, substantially influenced by environmental stress. The unique environmental stressors of the COVID-19 crisis suggest that an unusually large proportion of the population may develop depression. This pain is likely to be distributed inequitably.

Stress and loss

Exacerbating the widespread stress of this crisis, many of us are suffering significant personal losses and grief reactions, which are robust predictors of depression. The ongoing and unpredictable course of these stressors adds an additional layer of risk.

As this crisis unfolds, death tolls will rise. For some, especially those on the front lines, acute experiences of grief, trauma and exhaustion will compound the stress and place them at even greater risk.

Interpersonal isolation

Prolonged social isolation – our primary strategy to reduce the spread of the virus – adds another layer of risk. Our bodies are not designed to handle social deprivation for long. Past studies suggest that people forced to “shelter in place” will experience more depression. Those living alone and lacking social opportunities are at risk. Loneliness breeds depression.

Families, who must navigate unusual amounts of time together in confined spaces, may experience more conflict, also increasing risk. China experienced an increase in divorce following their COVID-19 quarantine. Divorce predicts depression, especially for women, largely due to increased economic hardship over time.

Financial difficulties

The biggest stressor for many is financial. Unemployment and economic losses will be severe. Research on past recessions suggests that rising unemployment and financial insecurity lead to increased rates of depression and suicide. debt and financial deprivation during recessions are at significant risk for depression due to increased stress and difficult life circumstances. Minority-owned businesses may be at particular risk for buckling under the strain.

Recovery will be harder

Home foreclosures during the 2008 recession produced a 62% increased risk of depression among those foreclosed.

The mental health burden of economic recession will be distributed inequitably. When the stock market crashed in 2008, the rich experienced large wealth losses but not increased rates of depression. In contrast, those who experience unemployment,

While the COVID-19 crisis increases risk for depression, depression will make recovery from the crisis harder across a spectrum of needs.

Given depression’s impact on motivation and problem-solving, when our economy recovers, those who are depressed will have a harder time engaging in new goal pursuits and finding work. When the period of mandated social isolation ends, those who are depressed will have a harder time re-engaging in meaningful social activity and exercise.

When the threat of coronavirus infection recedes, those who are depressed will face increased immunological dysfunction, making it more likely they will suffer other infections. Depression amplifies symptoms of chronic illness. The inequitable distribution of the burden of the crisis will exacerbate existing racial health disparities, including disparities in access to depression treatment.

What to do?

Self-help suggestions are readily available. A good list, more evidence-based than most, is here. It is our experience, however, that such self-help encouragements for depression are not enough, and at times even insulting, for those who are truly struggling.

We need higher-level shifts in policy and how we approach the problem. Economic relief measures from the federal government are crucial responses both to economic recession and psychological depression. We call for a public health campaign to increase awareness of depression and treatment options, and for improvements in mental health sick-leave policies and insurance reimbursement to minimize barriers to treatment access.

How we talk about depression must change. The distress we feel is a normal human response to a severe crisis. Acknowledging and accepting these feelings prevents distress from turning into disorder. Describing depression solely as a brain disease increases helplessness and substance use among those who are depressed and decreases help-seeking. Emphasizing the causal role of our environmental context, in contrast, matches how depressed individuals across different ethnicities view the causes of their suffering, decreases stigma and increases help-seeking.

Finally, we recommend specific treatment options be prioritized. As we have discussed elsewhere, easy-to-train, cross-culturally applicable and effective treatment options exist. We wish for an army of practitioners to be trained and embedded in community and treatment centers across the country, and this army should represent the great diversity of our country.

Some specific suggestions to help us all:

Protect Your Family’s Mental Health During the COVID-19 Pandemic. 

Begin the Day with Gratitude

Before your feet hit the floor in the morning, think of something that you’re grateful for. Making this a focus for yourself, and teaching your kids to do the same, can have a significant impact on your emotional health. The heaviness of our current situation can quickly weigh us down, and if we begin our day with doom and gloom, then we have set the negative feeling pendulum into full swing.

A study published in the journal Psychotherapy Research found that writing a gratitude letter can improve a person’s outlook and emotional well-being. It even seems to change brain activity in a positive way, based on MRI scans of study participants.

Get into a Routine and Make a Daily Schedule

Depression and anxiety can keep you from feeling in control of your life. One way to counteract that feeling is by making a regular schedule and sticking with it. When you organize and structure your life, you know what to expect. Make sure you have a family routine.

Remember, kids are used to routine and structure in schools. Many thrive on having consistency in their lives, which consequently helps them feel in control, something kids need now more than ever.

Not only will having a plan can help you stay centered, it will keep you focused on the tasks at hand. A study published in the Annual Review of Psychology on psychological habits showed people rely on their routines and habits when they are stressed. That helps them get through difficult times, suggesting that establishing healthy routines could help with physical, emotional and mental health during difficult times like these.

So, go ahead and make a schedule. The first item on the list should be to make your bed. According to a survey by OnePoll and Sleepopolis, which provides mattress reviews, people who make their beds regularly tend to report feeling happier and more productive. Plus, if making your bed is on your to-do list, you can accomplish your first goal of the day.

How to Cope with Coronavirus Anxiety. 

Get a Good Night’s Sleep

According to the National Sleep Foundation, adults need between seven and nine hours of sleep each night. And research shows the amount and quality of sleep we get has a significant impact on mental health. The amount of sleep kids need varies considerably by their age. That ranges from newborns snoozing away most of the day (14 to 17 hours recommended), to preschoolers splitting time awake and asleep (11 to 13 hours in la la land recommended), to teens who are advised to get eight to 10 hours of sleep daily, though they rarely do.

Researchers have discovered that those suffering from mental health conditions, such as anxiety and depression, are at an increased risk of insomnia. And not getting adequate rest can raise one’s risk for mental health problems.

So, during times of high stress, sleep is of utmost importance. In addition to following a routine, another way that you can ensure a healthy night’s rest for you and your kids is by making sure the whole family is active during the day.

Go Outside

Research from Sweden suggests that being outside is associated with a lower risk of developing psychiatric disorders. In a separate study published in the International Journal of Environmental Health Research, researchers showed that spending about 20 minutes in the park can improve your overall well-being.

Even if you can’t get to a park, just getting some fresh air – while keeping 6 feet from others outside your household – can do you a world of good.

Eat Healthy

During this stressful time, it’s important to watch what you eat. That’s because what you put into your body will affect how you think and feel. Research has long documented the positive impact nutrition has on mood and that eating well is associated with lower levels of anxiety and stress.

Research has demonstrated the benefits of eating unprocessed food and having a diet that’s high in vegetables, fruits, unprocessed grains, with fish and only modest amounts of lean meats and dairy. Studies suggest that those who eat this way have depression rates 25% to 35% lower than those who consume a traditional Western diet characterized by processed foods, lots of red meat and high intake of unhealthy fats and carbs. The saying “you are what you eat” applies as much to mental health as it does to your physical health.

In a time of uncertainty, you need to take care of your mental health. Sure, you may be more confined than you usually are, but you don’t have to let anxiety and depression consume you. Make your mental health a priority by following the measures outlined above.

Also, if you need professional help, please reach out, as there are trained professionals who would like to assist you. Don’t forget, with COVID-19, you are not alone in how you are feeling. More importantly, remember this, too, shall pass.

Depression costs the U.S. economy US$210 billion yearly. That is under normal conditions. An epidemic of depression requires a multi-faceted, multi-level response.

Are We Only Going to See More Substance Abuse and Bad Behavior Including Gambling?

I was amazed that when our Governor of the great state of Maryland shut done businesses yesterday that the liquor stores were exempt, but not my medical offices. I also noticed that the substance abuse/methadone clinic next store to my office was still open for business and as usual, very busy. I continued to wonder when my oldest daughter asked how the pandemic will affect individuals suffering from substance use problems, particularly now that many of these individuals are in forced isolation.

Yale University professor Adrian Bonenberger noted that the coronavirus quarantine means different things to different people: A necessary inconvenience. A fusion of work and home life. A leap into social media, or virtual meetings once held face-to-face. For some, it’s possible to see a silver lining: more time with one’s family, and a change to the regular routine. But for people who suffer from substance use disorder, gambling addiction, or problematic video gaming—otherwise known as internet gaming disorder—the quarantine is fraught with danger.

“People will likely be practicing social distancing per the government’s recommendation,” said Marc Potenza, Ph.D., MD, HS, professor of psychiatry, who directs Yale’s Center of Excellence in Gambling Research, the Women and Addictive Disorders Core at Women’s Health Research at Yale, and the Yale Research Program on Impulsivity. “Oftentimes stress is linked to addictive behaviors, and there can be little question that the social distancing around coronavirus or COVID-19 has been a stressful interruption of routine for many.”

For people in treatment for substance use disorder, COVID-19 could lead to the type of stress and isolation most likely to result in risky behavior.

“Everyone is trying to protect the vulnerable from COVID-19, and the only way to make that happen is social distancing,” said Ellen Edens, MD, MPH, associate professor of psychiatry. “But social distancing can also be especially harmful for people with mental conditions or substance use disorder.”

According to Edens, there is a related concern: those who depend on medications to treat a substance use disorder may fall through the cracks. Like those with an opioid use disorder who take methadone or buprenorphine, both of which block cravings, treat opioid withdrawal and prevent opioid overdose; or those with a prescription for disulfiram, a medication that causes people to become sick if they drink alcohol and is most effective when taken under direct observation. Disulfiram is unavailable nationwide, according to Edens, though the intensively monitored in-person treatment often required for best outcomes, particularly early in treatment, is also unlikely in the current context.

Edens also notes that the most vulnerable moment for someone with substance use disorder is at the beginning of treatment, when they are deliberately and intensely plugged into group therapies and peer support groups like those popularized by Alcoholics Anonymous or AA. “With social distancing, one of the key components of addiction treatment—the reforging of family, social, or professional connections that may have been severed, exemplified by ‘network therapy’ or a ‘community reinforcement approach’—is lost,” she said. “The psychiatric community is doing what it can to make up for the sudden disruption of tested and effective in-person programs with things like old fashioned telephone calls. But between the technology gap with older patients and specific challenges faced by patients for whom disconnection is essentially the greatest danger, it’s difficult. Many AA groups that have closed their doors to comply with the injunction against gatherings of numerous people, and while it’s certainly prudent, it also leaves many attendees adrift.”

Another possible fallout from COVID-19 stems from the shutdown of casinos across the United States, coupled with the postponement or cancellation of professional sporting events including the NBA, NHL, MLS, and MLB (suspended), the Masters (postponed), the Boston Marathon (postponed), and the NCAA men’s and women’s basketball tournaments (canceled). Although gambling and sports gambling have been online and lightly regulated for years, there has never been an absolute vacuum of physical gambling locations. It’s likely that in the absence of a physical space in which to gamble, and without many of the typical outlets for gambling in place, some people with gambling addition will make their way to the internet.

The rise of e-sports is one possible place where online gambling and problematic video gaming could converge. A growing field with audiences for a single event in the millions, and over $1 billion in revenue as of 2019, e-sports, in which people play video games online competitively, requires no crowds, and can be accessed by anyone with a smartphone or laptop.

“A quarantine, particularly at home, may lead to bingeing on video games, alcohol, or drugs given the significant change to routine life. It could also lead to a relapse for those who had been doing well previously. Second, those who may have been considering coming to treatment now may suddenly be hesitant given possible exposure to the virus in a hospital or treatment setting and have decided to delay getting help,” said Brian Fuehrlein, MD, Ph.D., FW ’13, associate professor of psychiatry and director, Psychiatric Emergency Room, VA Connecticut Health Care System. Fuehrlein was careful to echo his colleagues in underlining the necessity of home quarantine and the importance of following it, and was unequivocal about the dangers posed to vulnerable populations like those who will be significantly economically impacted by social distancing.

There has already been an observable change in normal behavior at the VA, according to Fuehrlein—and the opposite of what one might expect, which is more cases. Fewer patients have been coming in for any reason, which does not bode well for long-term mental wellness. “Currently, we are seeing an uptick in those who were considering treatment for substance use disorder but have now decided to stay home instead (and thus are likely continuing to drink or use). Our census in the psych ER has actually been running lower than average,” said Fuehrlein.

In the long run, this will almost certainly turn into a large problem, or even a secondary epidemic for people already suffering from the various diseases of addiction. “I think in the long run we will see a sharp increase in depression, anxiety, and addictions of all types as a direct consequence of the current pandemic,” said Fuehrlein. “This may be due to the death of a loved one, a financial crisis, the loss of a job or housing, or some related tragedy. At the moment those consequences have yet to play out.”

Potenza echoes Fuehrlein and Edens’ concerns for people suffering from substance use or gambling problems at home, away from the usual forms of treatment. He brought up another population that will be at risk—in addition to the tens of millions of American workers (over 18% of the work force, according to an article published March 17, 2020 in the Los Angeles Times), millions of school children who have been cut loose with weeks of unstructured time. Without supervision, these groups will be especially vulnerable to what the DSM-5 defines as internet gaming disorder, on top of the better-known associated substance use disorder.

Said Potenza, “Oftentimes, it appears that people who are experiencing negative mood states or life stressors may turn to gambling, gaming, or use various substances including alcohol and drugs. COVID-19 is almost certainly creating more stress, and while health professionals and the government are mobilizing to address the threats posed by the virus, some of the recommended actions like social distancing and staying at home seem likely to lead to more gambling, more gaming, and more substance use.”

Almost 20 million American adults suffered from substance use disorder in 2017, while nearly 10 million American adults struggled with a gambling problem as of 2016. Both groups, in which there is almost certainly some overlap, rely on a therapeutic model that relies on person-to-person meetings. Potenza, Edens, and Fuehrlein all agreed that patients suffering from mental illness and substance use disorder could receive effective treatment via phone or computer, and that technology was racing to keep up with the changing demands of quarantine and the patient population. Any mechanism by which a connection could be forged, according to them, was preferable to isolation during the search for an effective vaccine and perhaps a cure.

“Ultimately,” said Potenza, “we don’t know what will happen. And that’s a source of stress for most if not all of us.”

It’s stockpiling, but not as you know it. Why coronavirus is making people hoard illegal drugs

Ms. Emma Reynolds of London (CNN) wrote that it’s not just toilet roll that people are panic buying. Some illegal drug users are reportedly stockpiling their substance of choice as restrictions intended to stop the spread of coronavirus disrupt the international supply chain.

And the consequences could be devastating, with experts concerned that people will adopt riskier habits, substitute unfamiliar drugs or enter withdrawal, which can be dangerous if unmanaged. Since heavy users often have other health problems, this could mean increased strain on services that are already near breaking point.

UK drug policy and crime experts told CNN they were worried over a growing number of reports of shortages and escalating prices for drugs, as international borders close and supply lines are cut off.

“There are reports coming through of people stockpiling their favorite drug or their drug of choice, and of course, that just creates a shortage, which has inevitably led to price increases,” Ian Hamilton, senior lecturer in addiction and mental health at the University of York, told CNN. He said he expected to see heroin “disappearing very, very quickly” in the UK.

Steve Rolles, senior policy analyst at the Transform Drug Policy Foundation, told CNN there was “anecdotal evidence of price rises… and that doesn’t seem surprising.”

“It does seem likely that the supply of drugs that these people are using, in particular heroin, is going to be restricted … it’s going to be more challenging to move drugs around.

“As weeks stretch into months, I think we’re likely to see a drought, a heroin drought.”

Alex Stevens, criminal justice professor at the University of Kent, told CNN that in areas including Birmingham and Bristol, users of heroin and synthetic cannabinoids “are reporting that they’re getting less in a £10 ($12) bag than they would have done four or five weeks ago.”

But this is an industry that operates on supply and demand. The dark web and sites including Craigslist are still active, with many users buying drugs through the mail at a time when police are not focused on monitoring post, according to several experts. “If the heroin isn’t available, they will probably find another route, whether it’s alcohol or inhalants, or benzodiazepines or something else,” said Rolles.

Rolles has even heard reports of dealers dressing in nurse’s uniforms and supermarket uniforms to make deliveries unnoticed.

What happens during a drought?

When the UK last experienced a heroin drought in 2010-11, the drug’s purity at “local dealer level” fell to 18%, according to the National Crime Agency. Street prices reportedly increased, and there was a reduction in the number of deaths involving heroin and a simultaneous (but smaller) increase in deaths involving methadone.

That may sound positive, but the experts say the effects could be different this time. Users may move from less dangerous drug-taking methods to injecting. They may use lethal combinations of drugs. They may use too much of their stockpile. And they may be more likely to overdose alone because of social distancing.

Women are using code words at pharmacies to escape domestic violence during lockdown

One vital difference between 2010 and 2020 that is causing anxiety among the experts is the proliferation of fentanyl, a synthetic opioid that is up to 50 times stronger than heroin and can therefore be transported in much smaller quantities. The drug has not yet become widespread in countries including Britain, but is wreaking havoc in the United States.

Fentanyl is the drug most often involved in overdoses in the US, according to the National Center for Health Statistics. The rate of overdoses involving the opioid skyrocketed by about 113% each year from 2013 through 2016. If you’re used to heroin and you take fentanyl, “the risk of overdose is extreme,” said Hamilton.

The drug is often manufactured in China, but little is moving out of the original coronavirus epicenter. It is also manufactured in Mexico and possibly Eastern Europe.

With many drug users dealing with mental health issues such as depression and anxiety, coronavirus isolation presents an unprecedented challenge.

“People who have an active disorder, addiction disorder, they’re going to look for ways to get a drug,” Cynthia Moreno Tuohy, executive director at NAADAC in the US (National Association for Alcoholism and Drug Abuse Counselors), told CNN.

Asking for help

The suicide rate in the United States has seen sharp increases in recent years. Studies have shown that the risk of suicide declines sharply when people call the national suicide hotline: 1-800-273-TALK.

There is also a crisis text line. For crisis support in Spanish, call 1-888-628-9454.

The lines are staffed by a mix of paid professionals and unpaid volunteers trained in crisis and suicide intervention. The confidential environment, the 24-hour accessibility, a caller’s ability to hang up at any time and the person-centered care have helped its success, advocates say.

The International Association for Suicide Prevention and Befrienders Worldwide also provide contact information for crisis centers around the world.

Tuohy expects more “poly-use” of readily available marijuana and alcohol, which is already seeing increased consumption worldwide.

It takes longer to build up data on illegal drug consumption, but analysts are watching closely.

Federal confidentiality laws in the US have been relaxed to allow people to access counseling and peer support faster. NAADAC is offering telehealth training, and resources to help clients find services available in their state.

“Whenever there’s a natural disaster, we know that relapse goes up, because of anxiety, the fear of the unknown,” said Tuohy. “Now we have an ongoing, natural disaster, if you will.

“The longer a crisis goes on, the less hope that people see … it doesn’t feel like there’s going to be a light at the end of the tunnel.

“Long term, we’re likely to see suicide go up as a result of depression. So I know that the suicide centers are gearing up and the suicide hotlines already are taking calls.”

A vulnerable population

Any disruption to the illicit drug supply will have the biggest effect on the most vulnerable populations. Heavy drug users are more likely to live with multiple people, have respiratory or other health issues or be homeless — and are therefore more at risk of contracting Covid-19.

“They are in a double tier of vulnerability in that they’re more likely to get the virus and they’re more likely to be affected negatively by it,” said Rolles. “So there’s a big responsibility, I think, on society to look after and protect those populations.”

If that doesn’t happen, hospitals and treatment facilities will face a huge additional strain, he warns.

Governments are conscious of the risks. The UK government has asked local authorities to house all homeless people. Low risk and pregnant prisoners are being released across the world.

Facilities in the US, UK and Canada are allowing stable users to pick up supplies of addiction treatment medications like methadone and buprenorphine once a week or every two weeks instead of daily, but this also presents risks.

Mat Southwell, a drug user and global advocate from Bath in southwest England, told CNN he was delivering a methadone prescription to a woman who cannot pick it up for herself, is suicidal and self-harms. She had gone three days without it.

Coronavirus is revealing how badly the UK has failed its most vulnerable

Will Haydock, from Public Health Dorset also in southwest England, told CNN that UK clinics were seeing an increase in people accessing treatment. He said this was encouraging but warned that for providers already making “significant changes to service design” this was adding to pressure. “It’s going to be a real challenge to deal with that influx of people who want support,” he said.

“This is a particularly vulnerable group of people, and you’re looking at services that are already really stretched.

“If we’re not able to offer the kind of level of support that we would like to, we will see more people die earlier than they need to.”

A spokesperson for the UK’s Home Office told CNN it is “monitoring the impacts of coronavirus” and law enforcement are “continuing to prevent drug trafficking and are successfully disrupting the drugs supply within the UK.”

The world was already facing a drug crisis before the coronavirus pandemic. The US is in the throes of an opioid epidemic. An estimated 10.3 million Americans ages 12 and older misused opioids in 2018. In 2017, there were more than 70,200 overdose deaths in the US and 47,600 of those deaths involved opioids.

The UK has seen near-record levels of drug-related deaths for six years in a row, and Scotland’s death rate is the highest in the European Union.

“I’m very apprehensive about what’s happening right now and what’s going to happen over the next few weeks to this group of our society who are extremely vulnerable, who’ve been exposed to adverse experiences, neglect and abuse from childhood onwards, and now risk being put at the back of the queue for support when in fact, they should be in front of it,” said Stevens, from the University of Kent.

The coming weeks and months will be crucial in identifying the effects of coronavirus on illegal drug use, alcoholism, suicide, domestic abuse, anxiety, and depression — and what it means for all of us as well as how we need to compromise, care and treat each other.