Anxiety in the Era of Coronavirus

Update March 26, 2021

The coronavirus pandemic is an unprecedented global catastrophe that has affected all countries throughout the world in both the northern and southern hemispheres.

At the time of this writing, the Covid case rate per day in the U.S. is about 50,000. Though this rate appears to be a downward trend from the peak rate of 200,000 per day during the early days of January, as a result of a post-holiday surge, 50,000 new cases per day is still a very high number. At present slightly less than a fifth of the adult population has been fully vaccinated against the disease. On the positive side, the vaccination rate is likely to increase substantially over the next two months. On the negative side, new variants that spread very easily, such as the UK B.1.1.7 variant of the virus, are becoming prevalent across the U.S. Most experts concede the U.S. is in a race to get enough people vaccinated before the new variants (there are other variants in California and New York City) lead to a rampant increase in case and mortality rates, i.e., a fourth major surge of disease prevalence.

Since the last week of October 2020, the rate of Covid infections and number of hospitalizations trended sharply upward. A further acceleration in both case and mortality rates for Covid occurred in early 2021, with the average of 250,000 new cases per day in early January in the U.S. At the time of this writing, the approximate total number of Covid cases since the pandemic began in February 2020 stands at over 30 million, or about 10% of the total adult American population. The number of deaths that have occurred to date are slightly more than 550,000, a staggering number. For purposes of comparison, the total number of Americans who died in the 1918 Spanish Flu is estimated to be 650,000. Without a draw down in mortality rate soon, the total number of Americans who die of Covid by the end of the pandemic could approach the same number as that for the Spanish Flu one hundred and two years ago.

As of this time, the mortality rate for coronavirus in the U.S. is about 1500 people per day. This is a large improvement over early February, when on certain days the mortality rate reached 5000 per day. However, the daily mortality rate may return to somewhat higher numbers if there is a fourth surge of the pandemic, as predicted by a number of scientists at the present time in late MarchDividing the number of new cases by the mortality per day yields a 3% death rate among people who test positive for the virus. However, this statistic does not take into account much higher death rates in certain demographic groups, such a people over 65 as well as African-American and Latino populations (see below), and hotspot areas of the country such as Los Angeles and New York.

Apart from Brazil and Mexico, the U.S. has the highest number of cases among people of color (African Americans and Latinos). These people have been much more severely affected by the coronavirus. Access to healthcare and health insurance among people of color is about half of that for Whites. The mortality rate among persons sick with Covid-19 for African-Americans is 9-10%, about three or four times the rate for White Americans.

Mutations

Like all viruses, the coronavirus has a tendency to mutate. A new variant of the virus, due to several mutations, appeared in the U.K in late December. The new virus variant, called B.1.1.7, is about 70% more contagious, causing the virus to spread quite easily in crowded public settings. It has also been shown to cause more serious illness than the original Covid virus. This new UK variant has led to draconian shutdowns in Europe, first in London and the UK, and more recently throughout Europe. It has also been found to be increasingly widespread in the U.S. and will likely be the predominant strain in the U.S. by April. Two other variants of the original virus have been found in South Africa (B.1.351) and Brazil (P.1). These variants are not yet widely distributed in the U.S., but have been sequenced in several U.S. labs.

As mentioned, at the time of this writing, the prevailing situation has been described as a race. The race is between getting enough people vaccinated before the UK and other variants take over and promote a fourth surge of the outbreak in the U.S.

The three main vaccines, Pfizer, Moderna, and Johnson & Johnson would have a fair chance of overcoming the variants except for the fact that too many states, following the lead of Texas and Mississippi, have prematurely opened a wide range of businesses, including bars, restaurants, gyms, beauty salons, and hotels. The head of the National Institute of Health Infectious Diseases and Allergies Department, Dr. Anthony Fauci, has predicted that a fourth surge of the virus in the U.S. is likely, due to premature opening of too many businesses across the country.

Covid-19 Rates Outside the U.S.

Coronavirus has always been a global pandemic. While U.S. case and mortality numbers, respectively at 30.5 million and 550,000, are the highest in the world per capita, several other countries are not far behind. Based on the best estimates available, Brazil currently has over 12 million cases and 300,000 deaths. Most experts believe that published mortality rates in Brazil and Mexico are far below actual rates. India has approximately 12 million cases, more than Brazil, but a mortality rate of 160,000 due to a longer lag time between positive cases and reported deaths.

In Europe, France currently reports about 4.2 million cases with 92,000 deaths, and the UK has about 4.3 million cases with 126,000 deaths. Though these rates are much lower than the U.S., Brazil, and India, the populations of France and the UK are much lower. France and the UK have populations less than one fifth the U.S. population.

Meanwhile, most of the countries that have done very well with coronavirus are in the Far East. Three examples include Taiwan, reporting 1000 total cases and 10 deaths, New Zealand, 2400 cases and 26 deaths, and Singapore, 60,000 cases and 30 deaths. These three far eastern countries have done particularly well because they had early and comprehensive national lockdowns before the virus could gain momentum. Also, their regime of reopening businesses after shutting down was more gradual and prudent than most western countries. This well illustrates the fact that Covid can be limited if early shutdowns are enforced nationwide.

To conclude this section on Covid rates, the entire globe at the time of this writing in late March 2021 reports a case rate of about 122 million and a mortality rate of about 2.7 million. Sadly, these numbers are expected to increase during the next few months of 2021. Vaccine rollout for the entire world of over 7 billion people is expected to continue to at least the end of 2021 and likely into 2022.

Causes of the U.S. Covid Pandemic

Why does the U.S., by many measures the most technologically advanced country in the world, also has the highest coronavirus case and mortality rates per capita in the world? A book released on September 15, 2020 by Bob Woodward, entitled Rage, discloses the existence of a series of taped interviews with President Trump in which Mr. Trump admits to deliberately playing down the severity of the coronavirus pandemic despite early intelligence, in late January 2020, about the serious threat the virus posed to the U.S. Mr. Trump is currently out of office, replaced by President Joseph Biden.

Mr. Trump’s stated reason for minimizing the potential severe impact of the virus that originated in Wuhan, China is that he wanted to avoid causing panic.

In fact, Mr. Trump, in a later interview, admitted that he wanted to continue to downplay the impact of the virus, despite its increasingly massive case and mortality rates, to prevent excessive disruption and fear in the U.S. The “panic” or disruption Mr. Trump was referring to is less the perilous health consequences of the pandemic and more the effect of any panic or disruption on financial markets. 

At no point during the pandemic did Mr. Trump take a leadership role in guiding the country. Instead, he delegated responsibility for handling the pandemic to the states and cities, leading to a patchwork response throughout the country that exacerbated case and mortality rates. Throughout entire year of 2020, Mr. Trump continued to give mixed messages about the importance of wearing masks to reduce the spread of the disease, and many of his followers took his messaging further by actually refusing to wear masks in crowded public situations such as the President’s rallies. While he expressed interest in the potential of vaccines, Mr. Trump continued to largely ignore the nationwide emergency of spiraling cases going forward. After the November presidential election, Mr. Trump’s primary focus was on the fictitious notion that he won the election and that President-Elect Biden’s apparent win was due to fraud on the part of the Democratic Party. The Trump administration launched over 60 lawsuits in fifty states trying to contest or overthrow the results of the November 6 election, all to no avail. Virtually all of the suits had no merit due to lack of evidence of systemic fraud in the election tallies of any of the fifty states. Despite this, Mr. Trump held on to his fictitious notion of a “stolen election,” seeming quite possibly deluded into thinking it was actually true. This culminated in the President’s fomenting of a two-thousand person riot upon the Capitol of the U.S. on January 6, 2021. Since the riot, which has been deemed an insurrection, over 400 perpetrators have been arrested.

On the other hand, President-Elect Joseph Biden, who won the November 3 presidential election decisively (despite protestations by Mr. Trump and his close associates) put together a coronavirus team prepared to go into immediate action for a national, top-down set of standards as of inauguration day, Jan. 20. Mr. Biden has exceeded his own goal of vaccinating a hundred million Americans within the first hundred days of his office. In fact, this goal was reached after 58 days in office. Mr. Biden’s administration and Democrats in Congress have also succeeded in passing a 1.9 trillion dollar “rescue plan” to provide funding for the population in general ($1400 dollars to every adult), continued unemployment compensation through September, child tax credits, help for state and city governments, and industries severely affected by the pandemic such tourism, among many other things. An attempt to raise the minimum wage universally to $15/hour, originally part of the plan, did not make it through the Senate, however.

Another key factor reported in Western countries, particularly the United States and Brazil, has been a tendency to disregard safe health practices by younger people in the 20 to 40 year-old age group. 

Because youth feel less vulnerable to severe disease relative to older age groups (which by and large is true), they are prone to relinquish responsibility for infecting older people by engaging in overcrowding in bars, restaurants, nightclubs, mass protests, and other party environments such as discos and raves. Some of these millennial and Gen Z youth groups have become sick and died of Covid, in those cases where they had underlying health conditions such as diabetes or early heart disease, but many them have escaped severe illness. With the new U.K B.1.1. 7 variant becoming widespread in the U.S. a larger number of young people appear to be getting ill.

During late August and September 2020, colleges were in a serious bind about whether they could safely reopen their campuses and minimize Covid infections among students. Many campuses which did reopen saw precipitous spikes in Covid infections among students, often attributed to off-campus parties where students, due to their young age, failed to observe social distancing and mask guidelines. While health guidelines have directed colleges to keep sick students sequestered on campus, many infected students returned home during the Thanksgiving break as well as the Christmas break. After returning, many of them restarted their classes virtually at home rather than at their campuses, and put their parents and especially grandparents at risk of infection. 

At the time of this writing in late March 2021, many youngsters are returning to elementary schools, which have recently been deemed safe if young children consistently wear masks. However, there has been pushback from teachers’ unions, and not all elementary schools are opening. 

Origins if the Pandemic in the U.S.

Originally it was believed that the Covid-19 virus—or SARS-CoV-2—originated in open markets that sell raw meat in Wuhan China. It is thought that the virus originally spread among bats, and that the bats bit animals called pangolins, a scaly anteater-like animal found across parts of Asia and Africa. Pangolin meat is considered a delicacy in China and is sold raw at Wuhan food markets.

A competing view that has become popular more recently is that the virus did not emerge from open markets but was due to an unintentional leak from one of the labs at the Wuhan Institute of Virology. It is now known that the Institute was experimenting with a variety of coronaviruses obtained from bats. The Chinese government has failed to provide sufficient evidence that would allow scientists outside of the country to definitively establish which of these two views about the origin of the virus is correct. 

How did America acquire Covid-19 from Wuhan, China in the first place? Some people believe that the pandemic in the U.S. was primarily imported from Europe. However, the truth is that there were over 70 flights from Wuhan, China (the place of origin of the coronavirus as early as late December 2019) to the United States before the President put into effect a ban on flights from China to the U.S, effective on February 2. While these flights were occurring, they seem to have been widely ignored (many people landing in the U.S. were minimally screened, if at all), and U.S. public health announcements early on made an enormous error in assuming the pandemic would be confined to China. Through much of February, flights continued from Europe to the U.S., even though Italy, Spain, and France became hotspots for coronavirus infections. Arriving passengers were told to self-quarantine, but there is no way of knowing how many did. In short, the prevalence of air travel helped spread the coronavirus from China and Europe to the U.S during the early days of the pandemic. Many (but not all) areas in the U.S. went into lockdown in late March and April to curb the increasing spread of Covid. The major problem was that many places which shut down in the Spring reopened too quickly in late May and June, allowing the virus to resurge and continue to spread widely throughout the country. As the virus spiked in the South during the summer and in the Midwest during the fall, enthusiasm for re-imposing widespread lockdowns waned due to a pervasive attitude that the economic costs of another major shutdown were too high, in spite of the risk of disease and death to human life.

By far the trickiest aspect of Covid spread is the fact that 63% of transmission comes from pre-symptomatic carriers, i.e., people who don’t even know they are sick and could potentially infect others.

Economic Consequences of the Pandemic

The second edge or “prong” of the pandemic has been economic. Massive numbers of people worldwide who lost their jobs were caught unprepared and subsequently forced to rely on precarious sources of income in order to prevent family starvation. In the U.S., such people have either turned to long waits to access food banks, or risked shopping in big box discount stores under conditions that preclude social distancing from other people.

Worldwide losses in jobs varies from country to country, but in the U.S., where at least 40 million people had lost their jobs by early June, the economic downturn tracks more closely with the Great Depression of 1929-1932 than the Great Recession of 2008-2009. Economic activity throughout the world was essentially shut down over a period of weeks, not over a period of years or many months as with previous major economic downturns. The sudden massive loss of jobs was especially traumatic for millions of people who had no economic resources on hand, living paycheck to paycheck.

In the U.S., the Cares Act provided economic stimulus to many people in May and early June, approximately $1200 per adult and $500 per child to families who (for both spouses) reported annual incomes in 2019 or 2020 of less than $150,000. Unemployment benefits for workers laid off or furloughed were extended through July. While these infusions of cash helped many unemployed people escape complete financial ruin, they only offered a brief respite from the effects of unemployment.

A second round of stimulus payments and additional financial assistance to local governments was planned for the second half of the year. However, a trillion dollar gap between congressional Democratic vs. Republican proposals could not be resolved in August through November, with the result being that essentially no additional federal stimulus income was provided to individuals, small businesses, health care systems, and state and local governments. In short, the federal government left everyone to fend for themselves with the exception of those people able to extend modest unemployment benefits for a second period of three months or to the end of 2020. A second stimulus bill was finally passed by Congress in December 2020, providing $600 per adult and child in every household whose annual adjusted gross income was $150,000or less. Since this payment was merely half of the spring stimulus payment, the general consensus was that it was “too little, too late.” Finally, a wide-ranging 1.9 trillion dollar Covid relief bill was passed by the Biden administration and Congress in early March 2021, bringing much needed help to a wide range (though not all) of the population.

At the present time, about 40,000 Americans are in the hospital with coronavirus. This is a substantial decline from hospitalization rates in early January, which reached as high as 130,000. Whether the present hospitalization rate will hold is questionable because of the prospect of a fourth surge in viral infections due to premature opening up of many businesses in a context of new viral variants. At the time of this writing, rates of Covid cases are increasing in 20 states, with particularly large increases in Michigan, New York and New Jersey.

Lest these facts be seen merely as numbers, it’s important to keep in mind the anxiety and distress suffered by families with loved ones in the hospital or especially the ICU, not to mention those who have lost a loved one to Covid.

These numbers are not expected to get better in the near term. They are largely driven by people gathering in groups in places like restaurants, bars, gyms, beauty salons, public transportation, and airports, in states and counties where these venues have been reopened or were never locked down. Gatherings of friends in private homes also contributes to increasing numbers of Covid infections. Despite repeated warnings from health experts to avoid gathering in groups larger than one’s own immediate family, many people still participated in family gatherings at Thanksgiving and Christmas. These gatherings contributed in no small way to the large spike in Covid cases seen in the first three weeks of January 2021.

A truly critical problem is that many hospitals in the U.S. reached or exceed their capacity in early 2021, both in the general hospital and intensive care units. In some areas, seriously ill patients were airlifted far from their homes to distant hospitals. During January, the situation in Los Angeles County hospitals was particularly desperate, with seriously ill people waiting many hours to be admitted to emergency rooms and ambulances lining up for hours before they could drop off patients. During these waits, some seriously ill patients succumbed to Covid or other critical medical emergencies such as heart attacks, strokes, or severe injuries.

Treatments and Vaccines for Covid-19

Despite the tragedy of the pandemic, there is a positive side of the story: 1) improved treatment of the disease, and 2) Covid vaccines becoming available in February and March of 2021. 

Although several antiviral drugs have been tried against coronavirus, the only one to show efficacy to date has been remdesivir. Remdesivir is primarily used with patients already hospitalized for Covid. In a majority of cases, it shortens patient recovery time. 

The way remdesivir works is complicated. However, it comes down to a few basics. Every coronavirus carries instructions for replicating itself in the form of an RNA strand. Viruses are simple and don’t contain DNA like human cells, just a single strand of RNA. Remdesivir works by introducing genetic components into the viral RNA strand, breaking the virus’s code for self-replication. In short, remdesivir has a capacity to “gum up the works” for the ability of a coronavirus to self-replicate and thereby spread.

A second intervention used in coronavirus treatment is steroids, specifically corticosteroids. Patients with severe Covid disease tend to develop inflammation in their lungs and eventually other organs. Steroids such as dexamethasone (or prednisone or methylprednisone) directly reduce such inflammation. In fact, sterioids have been used against all kinds of inflammation for decades. 

Dexamethasone works best if it is administered at a fairly late stage of the disease, after patients are receiving supplemental oxygen or in cases where the patient is intubated (having a respirator with a tube entering the bronchial areas to automatically enable the patient to breathe).

It’s important to note that during the course of the pandemic, there has been an increasing tendency for doctors to try to avoid mechanical ventilation. Once a patient is intubated and on a ventilator, they have about a 20% mortality risk. As treatment methods have evolved, doctors have increasingly tried to reduce the use of ventilators and simply use supplemental oxygen to provide breathing capacity for patients. Another helpful technique has been to invert patients so they lie on their stomach, which assists with improved oxygen intake.

In sum, steroids are best used at the point where a patient is already suffering from acute inflammation in their lungs (and possibly other organs). The steroid is given to reduce inflammation.

A relatively newer treatment for coronavirus is the use of monoclonal antibodies. Monoclonal antibodies are synthetically made antibodies that mimic your immune system’s natural antibodies used to fight off all kinds of infections from the common cold to Covid. A specific drug, Bamlanivimab, has shown positive results for treating Covid, especially in patients who are at high risk for progressing to severe Covid. Unlike steroids, monoclonal antibodies work best at an early stage of disease progression before hospitalization or required use of supplemental oxygen. The FDA (Federal Drug Administration) approved monoclonal antibodies for clinical use on November 9, 2020, though the technique had been used on an emergency authorization basis before November. This treatment, in addition to remdesivir and steroids, was administered to President Trump during his hospitalization for Covid in October. The combination of all three approaches, rarely available in practice, likely explains why the U.S. President recovered from Covid quickly.

Vaccines that actually protect people from contracting Covid are starting to come on line at the time of this writing in March 2021. Four major vaccines have received publicity in the U.S. over the past few months. Other countries are developing other vaccines, such as Russia’s Sputnik V and China’s Sinovac. The companies who manufacture the “big four” to be used in the U.S. include:

  • —Pfizer and BioNTech
  • —Moderna
  • —Johnson & Johnson
  • —AstraZeneca

As of November 9, Pfizer announced preliminary results showing 90% efficacy in preventing Covid. On November 16, Moderna reported 94.5% efficacy for their vaccine on a preliminary basis. These high efficacy rates held up during early population trials over the initial months of 2021. The Pfizer vaccine requires two doses and is difficult to work with because vials need to be maintained at 95 degrees below zero. The Moderna vaccine has an advantage over the Pfizer vaccine in that it only needs to be stored in a standard refrigerator freezer.

The Moderna and Pfizer vaccines use a new technology involving mRNA, or messenger RNA. The mRNA used in the vaccine carries the genetic code (or a sufficient amount of the code) for the spike protein on the coronavirus. After the vaccine reaches the body’s cells, the cells read the mRNA and create analogue coronavirus spike proteins. The proteins are then transported to body cell surfaces where they provide a robust antibody immune response necessary to provide continuing immune protection.

The vaccines developed by Johnson & Johnson and AstraZeneca completed their own final stage of experimental trails by late December and January, though AstraZeneca was not fully approved in the U.S until March 19, 2021. Emergency use authorization of the AstraZeneca vaccine is pending at the time of this writing. During March 2021 there was an observed correlation between AstraZeneca vaccination and blood clots in Europe, causing a number of countries to temporarily pause the vaccinations. After investigation, it turned out that the correlation was merely coincidental, with no evidence of causation, so the AstraZeneca vaccination program was resumed in most European countries. No vaccine is perfect, and rare “breakthrough” cases of Covid have been seen in people who are fully vaccinated.  In most cases, the severity of disease is reduced and does not require hospitalization.

The vaccination program in the U.S. started in early January, with medical personnel and first responders being the first to receive the vaccine. The next major groups were seniors over 65 and younger people with health conditions such as diabetes or immune disorders. At the time of this writing, the U.S. vaccination program is well underway with about 142 million doses given and about 42 million Americans fully vaccinated. With a population of over 250 million adults, the U.S. is approaching about a 20% vaccination rate. The goal of “herd immunity,” when approximately 75-80% of the population is fully vaccinated, making it more difficult for the Covid virus to spread, is expected to be reached by July 2021. Public education campaigns are underway to reduce vaccine resistance, which is more prevalent among minority groups as well a certain percentage of Republicans who still support Donald Trump and are suspicious of the Biden administration. If the goal of 80% of the population vaccinated can be reached, we can expect life to begin to return to normal afterward, likely during the late summer and early fall of 2021. From its beginning in March 2020, the expected time frame for the course of the pandemic is approximately 18 months.

Pandemic Anxiety

The pandemic has fostered a collective anxiety reaction among large numbers of people. For those who already suffered from anxiety disorders such as panic disorder, generalized anxiety disorder, phobias, or OCD, their problems have increased.

For the remaining 80% of the U.S. population unaffected by a diagnosable anxiety disorder, anxiety increased in response to multiple uncertainties: 1) uncertainty about their vulnerability to the coronavirus just from leaving their homes to shop for groceries or medications, 2) uncertainty about the health outcomes for loved ones who have caught Covid-19, particularly parents and grandparents. (Mortality rates for the illness increase with age, though a surprising number of people under age 45 have succumbed to it), 3) economic uncertainty due to the sudden loss of employment, 4) uncertainty posed by obstacles and delays in receiving supplemental income from the government, and 5) widespread despair and anxiety about being able to maintain mortgage and rent payments in the absence of funds, although the recent rescue bill of 1.9 trillion has contributed to reducing this stress. Currently, in most places, moratoriums on evictions have been put in place, but this passes financial pressure on to landlords and owners faced with paying mortgages on their buildings. 

Projections for the length of the pandemic and necessity for social distancing vary widely. Back in May 2020, a decision was made for a phased reopening of the American economy to prevent further economic disruption, even at the cost of exposing large numbers of people to high-risk indoor situations. The general nationwide lockdown that started around mid-March was discontinued in late May to early June. Each state in the country enforced a different schedule and pace for reopening businesses. There was no uniform coordination of the reopening from a government level. Guidelines varied not just from state to state but among different counties within states.

A majority of states reopened too quickly, and people were left to fend for themselves (apart from those who had to return to work) in regard to how much they could shelter in place at home vs. going out and engaging in public activities. Because a large number of people decided to throw caution to the wind and proceed to enter bars, nightclubs, restaurants, crowded shops, malls, public transportation and other risky situations, the number of positive coronavirus cases surged from May to July. Though there was a relative plateau in case rates during the summer when many people could be outdoors, a new surge in cases began in late October and November, as many people moved their activities indoors due to the onset of winter.

As of mid-November several states started to reimpose restrictions on utilization of restaurants, bars, gyms, and other crowded public places. West coast states discouraged interstate travel except for essential reasons. So did much of New England and the state of New York. The problem with most of these guidelines is that they were highly recommended but voluntary rather than mandatory. Unlike guidelines in some of the hard-hit countries of Europe such as France and the UK, American guidelines in most cases (with a few exceptions) have not been mandatory. The standard recommendations of mask wearing, social distancing, and hand washing are repeatedly reinforced on both the media and by public health officials in the U.S. However, with certain exceptions, there are few penalties for failure to cooperate with health recommendations. American “exceptionalism” seems to extend to every single family and individual. The freedom to do whatever we please, including gathering in groups for holidays, seems woven into the fabric of the American consciousness. Individual rights are considered more sacred than social and community responsibility not to infect others in our communities.

During 2020 the federal government largely avoided giving any top-down, centralized guidelines for reopening businesses in order to avoid economic destabilization. The decision of where to draw the line between saving lives vs. saving jobs was largely left to state governments. The result was a patchwork of highly variable rates at which each state (or even counties or cities within a state) reopened during Spring and Summer, as well as highly variable rates at which restrictions for limiting access to restaurants, bars, gyms, public transportation and other crowded public places were reinstated in November and December. With the new surge in January, further restrictions have been imposed in a scattershot manner. As has been repeated throughout this essay, this patchwork approach is largely responsible for the U.S. having the highest per capita Covid case and mortality rates in the world.

Uncertainty breeds anxiety. The large number of uncertainties in connection with the pandemic has led to an undercurrent of anxiety among huge swaths of both the U.S. as well as global populations. Uncertainties about one’s own life, the life of loved ones, the ability to sustain finances for a potentially long duration of the pandemic, and finally questions about when vaccines for Covid-19 will be available at scale, particularly in third world countries, are rampant.

Resources for coping with anxiety of this magnitude are limited. People can be quite resourceful in coming up with their own ways to cope while staying isolated to whatever extent possible in their homes, but the availability of direct professional help has been either highly limited or non-existent. Teletherapy utilizing FaceTime or Zoom has become increasingly available. Online sources of information and books have also been stepping in to fill the gap. If you are reading this essay, you can purchase a copy of the 7thEdition of The Anxiety & Phobia Workbook by the author, released on May 1, 2020 or a shorthand version of this book, Pocket Therapy for Anxiety, released November 1, 2020.

The year long duration of the pandemic has created a phenomenon of pandemic fatigue. Many people have become bored and restive with long-term restrictions on their mobility and have given up on staying home all the time. This boredom and fatigue is especially prevalent among younger people and adolescents. Unfortunately, the virus doesn’t care about boredom and fatigue, and people who visit public places outside of home, especially without masks or social distancing, are at as great a risk of contracting Covid now as at any previous time during the course of the pandemic. For those who have been fully vaccinated, the risk is mitigated, with the chance of severe illness or hospitalization being significantly less.

Risk Assessment

Health experts have defined four different types of situations according to their relative risk of causing you to catch Covid-19.  A very brief summary of these risk groups follows:

Low Risk: Staying home alone or with immediately family members, and ordering as much food, prescriptions, and other goods as possible online to be delivered to your door.  Do not let strangers enter your house, or, if they must, insist they wear masks and gloves.

Moderate Risk: Being outdoors (weather permitting) with a few people in relative proximity. To protect yourself, wear a mask and maintain at least six feet distance from other persons.  Increase to ten feet if somebody is sneezing. Avoid touching shared surfaces (such as playground equipment or park benches). Change your clothes and take a hot, soapy shower as soon as you return home.

Higher Risk: Outdoor gatherings of several to many people. To protect yourself, participate in such gatherings infrequently. Observe all of the guidelines under ‘Moderate Risk.’  In addition, be sure to wash or sanitize your hands before you enter an outdoor gathering, and, while there, be scrupulous about not touching your face with your hands. Again, as soon as you’re home, change your clothes and take a hot, soapy shower.

Highest Risk: Indoor gatherings of several people. Observe all of the guidelines mentioned under lesser risk scenarios, with particular emphasis on wearing one or two surgical masks or KN95 or N95 masks (if available) and maintaining at least a six foot distance from the nearest person, even if the situation is designed to be social. Increase your distance from anyone sneezing (face shields add further protection to face masks in situations where people are sneezing). Open windows if possible for further ventilation. Avoid indoor crowds as much as is feasibly possible for the duration of the pandemic. It’s recommended that you expose yourself to an indoor group of non-family people no more than once per month.

Finally, to reduce your risk, find out how much coronavirus is circulating in your particular county.  In most cases, it’s possible to do a google search for coronavirus case and mortality rates for your particular county or major city on any given day. Also, you probably already know whether you are in a high-risk coronavirus group, i.e. seniors over 65, people under 65 with significant underlying health conditions such as heart disease or diabetes, African American or Latino people living in crowded urban areas of large cities, or having to use public transportation such as buses, trains, or subways. Travel by plane, train or ship is not recommended at this time. 

Groups Affected Differently by the Pandemic

It’s possible to distinguish several groups among Americans facing the pandemic: 

  1. People with assets or income to endure many months of nationwide economic shutdown. This is the most fortunate group and skews toward white, middle to upper class families who have retirement savings.  It’s this group that can practice full social distancing, stay at home, and order their food delivered, which have the best odds of emerging from the pandemic relatively unscathed, apart from the illness or mortality of loved ones and friends.

  1. People with limited assets who have had to depend on federal or state assistance through stimulus payments (initially $1200 per adult and $500 per child in April-May 2020; then $600 per adult and child in December 2020, and again $1200 per adult in March 2021).  Many people have received these payments  by direct deposit to their checking accounts or by paper checks. Extensions of moratoriums on eviction from apartments or mortgage payments on households prevented large numbers of people from becoming homeless.

  1. A third group is made up of first responders: nurses, doctors, paramedics, hospital staff, firemen, and others including grocery store staff.   This group has been confronted with the major stressor of having direct exposure to COVID-19 patients for many hours at a time, increasing their risk of contracting the disease.  Even more stressful, particularly in the early months, was the  limited availability of PPE (personal protective equipment), such as N95 masks, face shields, gowns, gloves, and even sanitizer, putting those who choose to go into hospitals without full protection at substantial risk of infection. Statistics on the number of health care workers who have been infected and even died directly illustrate this issue. Such people can be compared to soldiers going into the battlefield, with only some fully protected and others not.   

  1. A fourth group is non-essential workers who have been forced to go back to work by their employers or have chosen to work rather than face economic peril.  This includes people such as “mow and blow” personnel with their loud machines and on-site construction workers. These employees are largely people of color and immigrants, either documented or not. 
  1. People living in rural areas.  While case rates have been somewhat lower in rural areas, so has access to hospitals.  In recent months, the   spread of Covid-19 in these areas has increased.  However, getting to a doctor or hospital could involve a very long drive.  Some of these people may be too sick to leave home and ultimately succumb to the infection. 

  1. Nursing home residents.  Such people have the highest mortality rate in the U.S. and elsewhere.  Because of their frailty and age, nursing home residents are particularly susceptible to severe cases of coronavirus. If they have to go on a ventilator, their risk of survival further decreases.

Coping with Anxiety and Stress During the Coronavirus Pandemic

In order to begin to deal with the coronavirus pandemic, perhaps the first thing to keep in mind is that you are not alone. Everyone is having to deal with the pandemic to varying degrees and in different ways, depending on their particular situation. Over 60% of the American population is reporting disruptive levels of anxiety due to the pandemic. The incidence of mood disorders and depression is similar.

Adolescents have been particularly affected. Months of social isolation and virtual learning, without normal peer social life, has led to high rates of anxiety and depression for teens.

Each of the six groups previously described faces a different situation, requiring a different response.

  1. People who are able to stay home and not go out need to deal with boredom and cabin fever. Unless you live in a large apartment building with crowded elevators, short walks outdoors to move about and get fresh air are entirely safe. Just be sure to avoid any crowds of people. While indoors, creative projects are a great antidote to boredom. Besides working from home, hands-on crafts and hobbies can be helpful. Follow your desire to stay in contact with family and friends by phone, email, text, social media, and FaceTime, Skype or Zoom. To fill long stretches of time, look to good books or magazines or, if that doesn’t quite fit, web and social media surfing.

    Realize that it’s important to have a structure to each day. Even if you repeat the same sequence of activities each day: preparing meals, childcare, reading emails, physical exercise, and perhaps deferring TV until late afternoon and evening, having a set structure to your day will help alleviate anxiety and boredom.

    As far as TV, web news, and social media are concerned, try to avoid excess attention to negative news about the COVID-19 pandemic. As far as possible, focus on positive news or at least give it equal time with negative news about the pandemic. Effective treatments such as remdesivir and steroids (for inflammation) are increasingly available at most hospitals.

    Along with structure, it’s important to give yourself breaks during the day. Take out time where you disengage from structured activities and relax with light reading or simply listening to music. During these stressful times it’s alright even to take an hour or longer out for a nap. If you lay down to rest, close shades or curtains and use eye shades or earplugs to shut out all extraneous stimulation. Practicing silent meditation for twenty minutes or longer is also a good way to unplug from stress and worry.

  1. If you are someone with limited financial resources, you are likely to be faced with significant anxiety and stress. If you are unable to borrow money from relatives or friends, you need to cope with the basic necessity of keeping fed. If you are unable to afford basic groceries or order out from local restaurants offering takeout food, the last resort is utilizing food banks, which often require long waits. While waiting in line, if you aren’t conversing with someone, be sure to have music or reading material in your car to pass the time. As challenging as dealing with food banks may be, keep in mind that you aren’t likely to face starvation in the U.S., unlike some people in third world countries in Africa or in Bangladesh.

  1. If you are a nurse, doctor, paramedic, fireman or other first responder, you are having to deal with an existential threat to your health and well-being.  Realize that you are universally considered to be the heroes of the pandemic.  Your safety is highly dependent on having adequate PPE (personal protective equipment) such as a surgical or preferably an N95 mask, goggles or eye protection, face shields, gloves, gowns  (if you work close to coronavirus patients), and lots of hand sanitizer carried in your pockets or nearby.   Whether through necessity or courage you choose to go into work, realize that contracting Covid-19, as bad as it is, is not a death sentence. Mortality rates have widely been reported to be 2-3% in the U.S. out of the total number of cases testing positive. 
  1. If you are a “nonessential” worker still forced to go into work—especially working in a group—the only reason for reporting to work is that the alternative is having no income to purchase food or basic supplies. If losing your job means long-term loss of income, and you have no resources from family or friends, then you need to work.  Wearing protective equipment, especially face masks (if at all possible KN95 or N95  masks), goggles or other shields to protect your eyes, and gloves if you have to touch surfaces, can go a long way toward protecting you from disease.  Be careful, if possible, to maintain a six foot distance from coworkers, refrain from touching your hand to your face, and, when you return home, remove all of your clothes, throw them in the laundry, and take a hot, soapy shower. 
  1. If you live in a rural area, consider your situation to be the same as those living in urban or suburban areas.  The virus has likely already reached your area, and you need to think about taking some precautions such as staying at home as much as possible, maintaining social distancing, and wearing masks if you must go out to work or for shopping.

  1. If you are a nursing home resident or employee, you are in the highest risk group.  If discharge and staying in a two-week quarantine at a friend or relative’s home is possible, be prepared to do so.  If not, insist on residential staff wearing masks and allowing you, the patient, to wear a mask as well.  Try your best to maintain social distancing of at least six feet from other people, in group spaces and particularly at meal times.
Specific Coping Strategies for Anxiety

As mentioned previously, uncertainty breeds anxiety. The many and various types of uncertainty posed by the coronavirus pandemic were described in the previous section “Pandemic Anxiety.”

This section presents an overview of various types of coping strategies to reduce or manage anxiety. All of these strategies are described in more detail in the author’s book, The Anxiety & Phobia Workbook7th Edition. For each set of strategies described here, relevant chapters of the book are given, where much more detailed descriptions of such strategies are provided. As The Anxiety & Phobia Workbook is a large book, you may be interested in a recent condensed version, Pocket Therapy for Anxiety.

  1. Relaxation Strategies

Learning to achieve a state of relaxation is a foundational skill in managing anxiety. Relaxation skills begin with abdominal-breathing—learning to inhale slowly, pause, and then exhale slowly from your belly. Your stomach should rise every time you inhale. Keep up the process up for at least five minutes at a stretch, two times per day. Regular practice of abdominal-breathing daily over several weeks will help to gradually bring down your level of anxiety.

Muscle relaxation is a basic relaxation technique to relieve tightness and tension in your muscles. You can achieve this by practicing progressive muscle relaxation, selective tensing and relaxing sixteen different muscle groups in your body (starting with your wrists and upper arms, proceeding to your forehead, eyes, face and neck, and finishing up with your abdomen, thighs, calves, and feet). Or you can practice passive muscle relaxation, listening to a guided visualization that instructs you to consecutively relax each muscle group in your body.

Finally, time management (not crowding too many activities into a single day) and learning to pace yourself slowly (not rushing through your day, even if there is a lot to do) are essential to learning to relax. 

All of these strategies are described in chapter 4 of The Anxiety & Phobia Workbook. You can also do a google search for any of the techniques just described.

  1. Exercise

Regular physical exercise is a potent remedy for both anxiety and depression.  The optimal form of exercise is aerobic, such as light jogging, swimming, or brisk walking outdoors.  If you prefer to exercise indoors, you can use a stationary bike, treadmill, or stair stepper.  Exercise needs to be maintained for at least fifteen to twenty minutes per day, every day if possible. If you have any health conditions that preclude vigorous exercise, consider simply walking for a half hour outdoors or indoors on a treadmill, with the permission of your doctor.  Exercise strategies are described in chapter 5 of The Anxiety & Phobia Workbook.

  1. Disruption Strategies

Disruption strategies are useful during the early stage of an anxiety surge (including panic attacks) or worry surge.  The goal is to recognize a resurgence of anxiety or worry early on before it starts to gain momentum.  Then you implement a disruption strategy to diffuse the development of higher levels of anxiety or worry.  Disrupting anxiety is not the same as trying to distract yourself from it.  You proactively take action to interrupt the increasing anxiety (disruption) rather than trying to escape it (distraction).  Trying to escape anxiety only makes it worse.  Examples of disruption techniques include:  1) physical exercise, 2) talking to a supportive person directly or over the phone, 3) involving yourself in hands-on activities such as arts and crafts or chores such as cooking or house cleaning, 4) working on jigsaw or crossword puzzles to distract your mind from anxious thoughts, 5) utilizing visual diversions such as online movies, researching topics online, video games, or uplifting reading, or 6) healthy rituals such as reciting a list of coping statements or affirmations.  Examples of coping statements can be found in chapter 6 of The Anxiety & Phobia Workbook (Coping with Panic Attacks).  A list of affirmations can be found at the end of chapter 9 of the Workbook (Mistaken Beliefs) and in several other places throughout the book. When you recite a list of coping statements or affirmations, do so slowly and with feeling.  Or you can play them back slowly from a recording made on your smart phone. 

  1. Changing self-talk and unhelpful beliefs

Retraining your mind away from the habit of fearful, “catastrophic” thoughts toward constructive, supportive thoughts is a critical anxiety reduction tool.  This process is at the core of what is called cognitive behavioral therapy, a term with which you may be familiar.  It is the most common type of therapy used to treat all anxiety disorders.  First, you identify your own personal scary thoughts, such as: “I’m going to lose control,” “I’m going to go crazy,” “This will never end,” or “I’m going to have a heart attack.”  Then you compose and practice counterstatements to each of these fearful thoughts, such as: “I can handle these sensations and symptoms until they subside,” “I’ll ride this through—there is no need to let it get to me,” or “These are just scary thoughts, not reality.”  After enumerating a list of constructive thoughts to counter scary ones, you need to rehearse them on a regular basis (preferably daily). You can do this either by reading your positive counterstatements slowly from a written list.  Or you can play them back slowly from a recording made on your smart phone or some other device.  With time and practice, you gradually become able to supplant your fearful thoughts with constructive ones.  Cognitive behavioral therapy is described in detail in chapter 8 (Self-Talk) and chapter 9 (Mistaken Beliefs) in The Anxiety & Phobia Workbook.

  1. Anxiety-Provoking Personality Traits

People with anxiety tend to have personality traits that aggravate their situation, such as perfectionism, excessive need to please or gain approval, fear of loss of control, and so on. Strategies for dealing with these unhelpful traits are described in chapter 11 of The Anxiety & Phobia Workbook 7th Edition. This chapter is entitled ‘Personality Styles That Perpetuate Anxiety.’

  1. Learning to be assertive

People who are prone to anxiety tend to make requests either in a submissive or passive aggressive way.  Sometimes they even use aggressive tactics.  Developing the ability to be assertive involves learning how to ask for what you want and say no to what you don’t want in an assertive fashion, without putting off or insulting the other person. Strategies and exercises for learning to be assertive are provided in the chapter ‘Being Assertive’ in all editions of The Anxiety & Phobia Workbook

  1. Nutrition

Good nutrition is essential to overcoming anxiety.  Reducing caffeine, sugar, junk food or food which causes you allergies in your diet is the first, fundamental step to take.   Additional guidelines for maintaining a “low anxiety diet” are provided in detail in the chapter on nutrition in all editions of The Anxiety & Phobia Workbook (including any editions you may have that are prior to the 6thand 7th.) These previous editions, 1st through 5th, though older, provide quite a bit of the information on nutrition contained in the newer editions, with only modest changes.

  1. Medication

Medication is often a part of the treatment plan for anxiety.  Approximately half of my clients take one or more prescription medications, including various types of antidepressants (which are equally effective in treating anxiety disorders), tranquilizers, beta blockers, or mood stabilizers.  The pros and cons of these various types of medications are described in detail in the chapter ‘Medication for Anxiety’ in both the 6th and 7th Editions of The Anxiety & Phobia Workbook. The 7th Edition also addresses the use of cannabidiol and ketamine in treating both anxiety and depression.

  1. Personal Meaning

A sense of personal meaning is also important in being able to overcome anxiety. It’s important to have a sense of your own unique life purpose as well as some kind of answer to fundamental questions about the nature and meaning of human life.  In attempting to answer these questions, you may rely on spiritual or non-spiritual answers.  The chapter ‘Personal Meaning,’ the last chapter in the both the 6th and 7th Editions of The Anxiety & Phobia Workbook, is important for everyone dealing with anxiety, especially in this current time of dealing with the Covid-19 pandemic. 

The author’s attempt to grapple with fundamental questions about life is taken up in detail on his website: Journeysofthemind.net. This site is distinct from the author’s anxiety site Helpforanxiety.com.

There are many other types of interventions relevant to overcoming anxiety not mentioned here. These include learning to deal with excessive feelings of anger, grief or despair; cultivating self-esteem, and preventing yourself from relapse after having received effective treatment. All of these topics and many more are covered in The Anxiety & Phobia Workbook.  The step-by-step strategies and exercises presented in the book can be utilized on your own. However, you may also decide to work with a therapist in learning and practicing numerous coping strategies in the book. At the present time, to comply with social distancing, many therapists are working virtually utilizing apps like Skype, FaceTime or Zoom. 

The next section attempts to foresee how the coronavirus pandemic may unfold. 

Possible Outcomes of the Coronavirus Pandemic

Best Case

Among the best case outcomes are those areas of the world who reached  their peaks by early August, followed by a gradual drawdown in case and mortality rates and no resurgence of cases in November (for example, Taiwan and New Zealand).   PPE (personal protective equipment) was scaled up to be available to all medical personnel and first responders.   Effective drugs to treat coronavirus, such as remdesivir are widely available.  Vaccines come online and are scaled up in the first quarter of early 2021.

Mid-Range Case

As has been the case, many American states reopened for business prematurely and too fast, and a new surge in case and mortality rates appeared across the southern U.S. in the July-August period. A nationwide resurgence of cases appeared in the late fall as people moved indoors due to the onset of winter. A third resurgence appeared after the holidays in early January.  In the U.S., this means numbers such  as  thirty  million cases and more than  550,000 deaths by end of March, 2021.   In vulnerable countries in Europe, such as Italy, Spain, France, and the UK, a similar resurgence of case and mortality rates occurred due to premature lifting of social distancing measures and a late fall resurgence, followed by a new resurgence in the beginning of 2021.    In response to these resurgences, social-distancing measures have been reinstated until case rates fall and remain low for a month (hopefully by Easter 2021).  Pandemic fatigue has led to protests throughout Europe, particularly in France and Germany.

Worst Case

The worst-case scenario adds some aggravating factors to the mid-range case just described.

Due to rapid reopening of many states for business, a large resurgence of the pandemic occurs in the winter months of 2020. Only some states reinstate social distancing measures and close businesses subject to crowding, such as bars, nightclubs, restaurants, and hair and nail salons. In many states these businesses are allowed to stay entirely or partially open,. In those areas where restrictions are not systematically put back into place, coronavirus case and mortality rates soar to very high levels by Spring 2021, leading to many thousands of new cases and a substantial increase in mortality. The national rate of Covid cases exceeds about 50,000 new cases per day. A fourth surge of the pandemic develops during the Spring months due to premature opening of public places in many states. Hospitals and intensive care units are once again overwhelmed in some places by April 2021

Experts come to realize that COVID-19 confers only temporary immunity to future recurrence of the illness, and the coronavirus acts like other coronaviruses such as those related to the common cold—possible to catch and re-catch again on a long- term basis. At the very least, an effective “booster” vaccine inoculation will have to be repeated on an annual basis for everybody for years. To manufacture such a larger amount of vaccine is daunting to say the least.

Widespread recognition that the virus is not going away leads to an economic meltdown on the scale of the Great Depression, lasting 6 months to a year (shorter than the Great Depression, which lasted 6 or 7 years). The U.S. government (and a majority of other governments) are unable to sustain cash infusions to the population indefinitely. Many people end up in overcrowded shelters or become homeless. 

Parts but not all of the worst case scenario have come to pass in the U.S. at the time of this writing. Too many businesses have opened too soon in a number of states, and pandemic fatigue has led to a state of relative indifference on the part of increasing numbers of Americans.

Post-Traumatic Phase

During the period of time following a reduction in infections and withdrawal of social distancing measures, there will be a widespread uptick in incidence of post-traumatic stress disorder. Some intensive care patients who recover are unfortunately still prone to neurological, cognitive, muscular, or kidney aftereffects that can last from months to years. Those “long haul” patients may require ongoing care either in rehabilitation facilities (which are in some places already maxed out) or home-health nursing care. Most will be able to return home but need continuing care at some level.

The greatest milestone in overcoming the pandemic will be the effective vaccination of most people against Covid-19. At the time of this writing, about 47 million or more than 14% of Americans have been fully vaccinated. As vaccinations continue to ramp up, the goal is to have a majority of the population fully vaccinated by sometime in July.

Even after widespread vaccination is achieved, many people will remain traumatized by the loss of loved ones, by the loss of basic financial security, and by the duration of the period of being homebound and in an almost total state of uncertainty about life and livelihood. As the U.S. and other nations move through this period, resources for dealing with post-traumatic stress will gradually begin to appear in many forms, such as online and in-print information offering comfort and hope, as well as therapists of all stripes offering help to people with significant symptoms such as flashbacks, nightmares, panic attacks, and feelings of numbness and depersonalization.

It is only after this period of post-traumatic stress following the pandemic has been completed that humanity will begin to return more fully to normal. It is difficult to estimate a date when this point will be reached. The date will vary widely across countries, provinces, counties, and even cities as well as widely among people with different experiences of the pandemic and different levels of resiliency to cope with it (elders, people of color, people living or working in overcrowded conditions, etc.) It’s important for everyone to realize that most of humanity will ultimately cross this treacherous valley and emerge on the other side intact. Historically, humanity has prevailed through numerous widespread catastrophes. Many of us are survivors and a majority of us will live to see a better day.