Even in normal times, mental health is a chronically overlooked and under-resourced area of global health, nearly everywhere in the world. The COVID-19 pandemic’s toll on mental health – for patients, their families and caregivers, health providers and the general public – is magnifying these challenges given the growing demand for services but limited access to care. A study by the Kaiser Family Foundation found that 45 percent of people feel that worry and stress related to the pandemic has had a negative impact on their mental health, up from 32 percent in early March. Researchers are emphasizing that the pandemic’s effects could lead to increased risk of suicide, stemming from new stressors such as economic burdens and strict social isolation.

The mental health needs of families dealing with grief and loss are stretching an already over-burdened health system. “This is the greatest crisis to ever hit community mental-health and addiction-treatment providers,” said Chuck Ingoglia, President and Chief Executive of the National Council for Behavioral Health. “The nation will experience a profound aftershock of widespread anxiety and post-traumatic stress disorder.”

In this moment, essential workers – especially healthcare providers – are at heightened risk of burnout and mental health disorders – on top of risks to their physical health. The National Academy of Medicine notes that prior to the pandemic, many clinicians already faced burnout, stress, anxiety, depression, substance abuse and suicidality. The crisis and its associated challenges are compounding these symptoms and conditions.

This week’s issue of Rabin Martin’s COVID-19 Industry Briefing focuses on the impending mental health crisis. We recognize that a person’s health extends beyond physical well-being and we encourage everyone to seek the support they need during these challenging times. See more of Rabin Martin’s COVID-19 Industry Briefings here.

On Tuesday, April 14, the Trump Administration decided to halt funding to the World Health Organization in the midst of a pandemic. Global reactions to this announcement include:

“It is not the time to reduce the resources for the operations of the World Health Organization or any other humanitarian organization in the fight against the virus…Now is the time for unity and for the international community to work together in solidarity to stop this virus and its shattering consequences.”

António Guterres, United Nations Secretary-General
Tuesday, April 14

“Halting funding for the World Health Organization during a world health crisis is as dangerous as it sounds. Their work is slowing the spread of COVID-19 and if that work is stopped no other organization can replace them. The world needs @WHO now more than ever.”

Bill Gates, Co-founder, Bill & Melinda Gates Foundation
Tuesday, April 14

“During the worst public health crisis in a century, halting funding to the WHO is a dangerous step in the wrong direction that will not make defeating COVID-19 easier…Cutting funding to the WHO – rather than focusing on solutions – is a dangerous move at a precarious moment for the world.”

Patrice Harris, President, American Medical Association
Tuesday, April 14

“COVID-19 does not discriminate between rich nations and poor, large nations and small. It does not discriminate between nationalities, ethnicities or ideologies. Neither do we. This is a time for all of us to be united in our common struggle against a common threat – a dangerous enemy. When we are divided, the virus exploits the cracks between us.”

Dr. Tedros Adhanom Ghebreyesus, Director-General, WHO
Wednesday, April 15

Mental Health at a Critical Juncture

With the urgent focus on saving lives, it is likely that mental health will be neglected in the global response to the COVID-19 pandemic. Given the myriad mental health challenges at hand and on the horizon, various organizations are stepping up their advocacy to ensure appropriate services are available. The National Council for Behavioral Health and American Society of Addiction Medicine have requested $38.5 billion in emergency funds “to avert a large-scale public health calamity.” Calls for international cooperation to address COVID-19 related mental health challenges are also emerging.

Social distancing makes in-person counseling support inadvisable. Virtual mental healthcare and telehealth services have been proposed as a potential solution. But with demand for mental health services far outstripping supply, virtual care can only fill part of the gap.

Africa’s silent epidemic: A Note from Amref’s Global CEO, Dr. Githinji Gitahi

On the frontlines of the COVID-19 response

Q: In returning to the practice of medicine during this crisis, what has really surprised you about what you’re seeing in the response?
A: The way COVID-19 has taken over the hospital. They have had to increase ventilator bed capacity about five-fold, creating ICUs in the Emergency Department, cardiac step-down and elsewhere. They have had to find additional space for COVID-19 patients who don’t require ICU level care. The pediatric ward is now housing adult COVID-19 patients.

Q: What are your greatest concerns for health providers at this time, especially the mental health toll? 
A: I’m so proud of the residents, nurses and the hospital leadership. They have been working nonstop for three weeks. Everybody is all in – nobody is complaining. There could be a sense of futility because of the overwhelming number of deaths frontline workers across the county are experiencing, but no one is giving up.

Right now, everyone is just dealing with what is in front of them – saving the next life. We will as a community need to create the time and space for frontline workers to process what they are experiencing. I think we are all shell-shocked right now, but a lot of support will be needed, especially for the residents. It is hard to see so many deaths and feel helpless to stop them. It is also hard to see people dying alone. A charge nurse who is managing one of the ICUs shared with me how she is also making sure that staff can take a time-out if they need to. She’s on the lookout for how people are coping.

If you’re a health worker, you are assuming you had COVID-19, you have it now or you’ll get it. You just hope you are one of the ones who get a mild version of the disease.

Q:  How are hospitals preparing?
A: I think that people have underestimated how much of an operations exercise this needs to be. It’s about modeling and planning for supply chain – including staff. About logistics and engineering and reconfiguring space. Managing and integrating surge workers, getting everyone trained, ID badges, lockers, scrubs. It’s about the supply chain for the supplies that are needed – not just ventilators and PPE. Medical teams can’t be responsible for that. Having a dedicated team solely responsible for operations is critical. How to bring in hundreds of staff is a complicated job and you can’t do it on top of caring for patients.

Q: What are you bringing back to your colleagues at Merck from this experience? What’s important for them to know about what’s happening on the frontlines?
A: Although the curve may be flattening, right now in NYC it is flattening at a very high level and every day still sees more new admissions and intubations. We are still having to increase capacity every day because patients are on the ventilator for a very long time. There is also likely to be increasing pressures on critical supplies and we will need efficient supply chains and supply chain experts to rationally allocate resources.

Although we’re seeing many COVID-19 patients with co-morbid disease – obesity seems to be a big risk factor – we are also seeing patients without discernible risk factors as well as young patients. At least half my patients were under 60, if not under 50, and you can see the social determinants of health at play.

Q: What else is important to let people know?
A: I know that despite all the media reports I followed, I was not prepared for the reality of the frontlines in the hospital – and I’ve worked in public clinics at the beginning of the HIV/AIDS pandemic in sub-Saharan Africa. The volume, the noise, the chaos, the unpredictability, the destructiveness of the disease, being under all that PPE, seeing patients remain alone – all of it was previously unimaginable.

I’ve also seen a lot of informal learning between hospitals to share best practices and protocols since no one has seen anything like this before, and we are all trying to make sure we have the latest information at our fingertips since our current armamentarium is so limited. Often it has been low tech interventions like proning – having people lay on their stomachs – that seem to make a difference in improving people’s oxygenation levels.

Public sector city hospitals are bearing the brunt of COVID-19 because the patients and communities they serve are disproportionally affected by the disease. They are taking care of patients with multiple chronic conditions – many who also have social needs. We also see this dynamic in the emerging data on the impact of COVID-19 on black, Hispanic and immigrant populations.

I don’t think that health systems in low-income countries will be able to deal with the resource needs and capacity pressures for inpatient management that COVID-19 is creating. We will have to do everything we can to limit spread by focusing on prevention and mitigating the impact.

Mental Health Resources

• Coping in Times of Crisis: Mental Health Resources, de Beaumont Foundation
• Stress and Coping, CDC
• Mental Health and COVID-19 Information and Resources, Mental Health America
• COVID-19 Mental Health Resource Hub, Psych Hub
• Strategies to support the health & well-being of clinicians during the covid-19 outbreak, National Academy of Medicine
• Mental health and psychosocial considerations during the COVID-19 outbreak, World Health Organization

Private Sector Insights

On Thursday. April 16, Rabin Martin, as the Secretariat for the Private Sector Roundtable for Global Health Security (PSRT), hosted an eighth call in a series on the latest health impacts of COVID-19. The call featured two experts on the COVID-19 situation in Africa.

Dr. John Nkengasong, Director, Africa Centers for Disease Control and Prevention, reported that there are currently 18,000 cases among 52 countries on the African continent – a 6 percent increase since last week – and that deaths are approaching 1,000. While those numbers may not seem as high as expected, he noted that the situation can change very quickly as it did in the U.S. and U.K. He emphasized that it’s dangerous to talk about flattening the curve: “This is a treacherous virus. If you become complacent, you will be in deep, deep trouble.”

Dr. Nkengasong briefly described a new continental strategy that 36 Ministers of Health agreed to following an emergency meeting convened by the African Union in February. The three pillars are 1) limiting transmission, 2) limiting deaths and 3) limiting harm.

The Africa CDC is supporting countries in the following areas: scaling up diagnostics; training on infectious disease control; surveillance and screening; risk communication; and commodities distribution. Dr. Nkengasong asked that the private sector consider supporting countries either on a bilateral basis or more broadly through a new Africa COVID-19 Response Fund, a partnership with the African Union. Reflecting on the global nature of the pandemic (as opposed to localized Ebola outbreaks), he asserted that this is a global fight: “COVID-19 will not be declared over anywhere unless it is declared over everywhere in the world.”

Dr. Githinji Gitahi stated that the response to COVID-19 has to be “government-led and community-owned.” He emphasized that people need to understand what social distancing means across the diversity of community contexts in Africa. The government imposing a lockdown and expecting people to obey is unlikely to be effective unless communities understand the potential impact of the crisis on their daily lives and own their response.

He added that the private sector has played an important role in the response – from setting up hand washing stations in areas where there is a lack of water, or donating advertising space (billboards, radio and TV spots) to the government for public service announcements, to supporting a “FlexiFund” to enable the quick purchase of items that the government does not have on hand or is unable to make.

Dr. Gitahi also highlighted the “interdependency” of global health security and universal health coverage. He noted the disturbing trend of people hiding COVID-19 symptoms because of the financial implications of testing positive. In some countries, individuals pay for the cost of being quarantined and the care needed. In addition, people do not want to be prevented from working and losing income. He added that removing financial protection, especially for the most vulnerable, will hinder access to care, which will have a dire impact.

“If the response is not managed properly, economies will fail given the informality of the economy in Africa, with many people losing jobs, salaries cut and daily wage-earners unable to work.” Both speakers noted that COVID-19 must be viewed as an acute infection – “If it is chronic, we will not survive because we cannot continue to lock down economies.” They noted that there is a double-edged sword to the response: a strong need to support people’s health, but the danger of reducing taxes to mitigate the economic impact of the pandemic.  Summarizing this challenging situation, Dr. Gitahi posed the questions: “When is the curve flat enough? What is the cost of a flatter curve? At what point is the cost of flattening the curve too much?”

John Nkengasong reminded everyone of what’s at stake in his closing remarks: “We have to win this fight for the continent to survive.” With a strategy of coordination, collaboration, communication and partnership – with both the private sector and civil society – Africa is planning to win.

Pandemic Spread

COVID-19 Global Cases (Center for Systems Science and Engineering at Johns Hopkins University) 

Severe mobility restrictions are helping to “flatten the curve,” but the virus continues to spread rapidly, hurtling the world past the inauspicious milestone of over two million cases. The U.S. has earned the unfortunate title of having the largest number of deaths (31,002) attributed to COVID-19, surpassing China where the virus first took hold three months ago. There are now 640,014 reported cases of COVID-19 in the U.S., accounting for nearly a third of the global burden. Worldwide, as of Thursday, April 16 at 9:00am ET, the Center for Systems Science and Engineering at Johns Hopkins University reported 2,088,425 confirmed cases and 139,419 deaths attributed to COVID-19.

Experts say that widespread testing and contact tracing will be instrumental to reeling in viral spread. Updated models by the Institute for Health Metrics and Evaluation show the epidemic in the U.S. is slowing, but leveling off at a very high rate. Predictions have increased the estimated death toll to 68,841, up from last week’s projection of 60,415. Although these projections reinforce the importance of maintaining strong public health countermeasures to mitigate the spread of the virus and flatten the curve of new infections, President Trump is now arguing for opening the U.S. economy within weeks. Moving too quickly creates a real risk of making it possible for the rate of infections and hospitalizations to accelerate. As the University of Minnesota’s Michael Osterholm has often observed, “We’re only in the first inning of a nine-inning game.” Health experts – and most state governors, who are on the front lines of the fight – agree that trying to re-open the economy prematurely may have the unintended consequence of re-igniting transmission.

Projected Deaths Attributed to COVID-19 in the United Sates (Institute for Health Metrics and Evaluation)

This week proves once again that COVID-19 does not discriminate. Whether you are a frontline health worker or a political leader, you are at risk for contracting COVID-19. On Monday, April 13, U.K. Prime Minister Boris Johnson was released from hospital and is continuing his recovery from COVID-19. In a video message, he thanks the National Health Service for saving his life, calling the agency “this country’s greatest national asset.”

Industry Developments

Responding to calls to lead the global response with unity and solidarity, global stakeholders are pursuing novel collaborations to accelerate research and development of COVID-19 treatments and vaccines. On Monday, April 13, a group of scientists, physicians, funders and manufacturers convened by WHO announced their commitment to working together to develop a COVID-19 vaccine.

• Initial data released on Monday, April 13, suggests that remdesivir, Gilead’s investigational COVID-19 treatment, is highly effective in inhibiting a key enzyme involved in the coronavirus replication mechanism. Results from Phase 3 clinical trials on patients with severe disease are expected in late April.

• Merck KGaA announced on Tuesday, April 14, that it used its manufacturing platforms to re-engineer the manufacturing process for the Jenner Institute’s COVID-19 vaccine candidate and shorten the cycle from one year to two months. Large-scale manufacturing is critical to providing sufficient product for use in current clinical trials and for global consumption if the vaccine proves efficacious.

• On Tuesday, April 14, two leading global vaccine manufacturers, Sanofi and GSK, announced a collaborative effort to develop a COVID-19 vaccine. Combining Sanofi’s recombinant-based COVID-19 vaccine candidate with GSK’s adjuvant technology, the partnership aims to create an effective vaccine that can be manufactured at scale.

• On Wednesday, April 15, Abbott announced it is launching a third test, a laboratory-based antibody blood test, to detect COVID-19 infection. Shipping is set to begin this week with the aim of distributing 4 million tests in April – and 20 million tests per month going forward – in the U.S.

From the Experts

“WHO wants to see restrictions [on social mobility] lifted as much as anyone. At the same time, lifting restrictions too quickly could lead to a deadly resurgence.”

Dr. Tedros Adhanom Ghebreyesus, Director-General, WHO
Friday, April 10

“Behind every death is a friend, a family member, a loved one. As a city, it is part of the healing process to be able to grieve and mourn for all those [who] have passed because of COVID-19.”

Dr. Oxiris Barbot, Commissioner,
New York City Department of Health and Mental Hygiene
Tuesday, April 14

“It is increasingly clear that the world’s response to this pandemic will not be effective unless it is also equitable. We have a responsibility to meet this global crisis with global solidarity. In addition to contributing to the development of diagnostics, therapeutics, and vaccines, these funds will support efforts against COVID-19 in low-and-middle-income countries.”

Melinda Gates, Co-founder, Bill & Melinda Gates Foundation
Wednesday, April 15

Supporting the Response

At Rabin Martin, in addition to supporting our clients with their response efforts, our employees are volunteering their time. If you are looking for ways you too can get involved in local New York City efforts, the New York Academy of Medicine is maintaining an ongoing list of opportunities.

Additional Resources