Abstract
COVID-19 has brought a new set of challenges at a time when poorer nations were struggling with existing burdens. However, the lockdown restrictions aimed at slowing the infection rate has created problems of their own such as increased unemployment, poverty, and mental health problems. While the lockdown approach may be effective for public health, there is concern about the way it is formulated, the empirical basis of some restrictions, and societal impacts. There is additional concern that COVID-19 and associated restrictions disproportionately affect marginalised groups. As a discipline primarily concerned with human behaviour, Psychology has much to contribute to addressing the pandemic.
A host of new words emerged in 2020, some that we never previously contemplated and others that we knew, but hardly thought we would need in our lifetime. Terms and phrases such as lockdown, self-isolation, social distancing, flatten the curve, herd immunity, and new-normal are used daily, and some are recent inclusions in the Oxford English Dictionary (2020). We have conversations that include abbreviations like PPE (personal protective equipment), WFH (working from home) and SARS-CoV-2 (severe acute respiratory syndrome coronavirus 2). Of course, we are referring to the COVID-19 pandemic that has caused untold havoc and forced us to develop our knowledge of the disease, regardless of our profession or occupation. Knowledge about the virus quickly became essential for health professionals and the public. Because treatment was not an option at the time of writing, prevention became the order of the day, with the main approach being a host of behaviour change strategies.
Coincidentally, it is one century ago that the world began picking up the pieces after the Spanish flu, caused by an H1N1 virus, which infected about 500 million and killed in excess of 50 million across the globe (Centers for Disease Control and Prevention, 2019). About one-third of the world’s population was infected between 1918 and 1919, and that was in an era when transnational and transcontinental travel was relatively infrequent. Other pandemics of the 20th century include the Asian flu in 1957 that killed an estimated 2 million people worldwide, and the Hong Kong flu that killed about 1 million people after it took hold in 1968 (Mackenzie, 2005).
COVID-19 has had a profound effect on our thoughts, emotions, and behaviour. Understandably, it has generated much fear and panic globally. Mental health correlates to the pandemic have been widespread and varied in presentation, related to vulnerability and premorbid functioning, with social and economic factors contributing heavily. Commenting on national survey data during COVID-19, the United Nations (2020) raised concern after studies showed distress prevalence ranging from 35% to 60%. A recent population-based survey found that 54% of South Africans viewed themselves as moderate to high risk for contracting the virus, suggesting some level of anxiety about their current situation (Human Sciences Research Council, 2020). Another community survey of over 12,000 respondents noted significant negative emotions including 33% of adults depressed and 45% fearful, with fear, stress, and depression more prevalent in those under 40 years of age than older persons (Orkin et al., 2020). More worrying, however, is that the increased mental health service needs are surfacing during a time of reduced mental health service provision due to the risks associated with in-person consultations. In attempts to limit the spread of infection, large numbers of mental health service providers have opted to offer telehealth and virtual consultations. The extent to which this mode of consultation is meeting the needs of all concerned in the current situation is yet to be determined, considering the diversity of those in need, especially in terms of age, educational level, technological sophistication, financial resources and numerous other variables – all an indication of just how egalitarian the virus is.
The mental health problems evident globally, however, are not all due directly to COVID-19. In some cases there is severe anxiety about being infected, obsession with prevention behaviours, and possible neuropsychiatric sequelae to the infection itself (Troyer et al., 2020). On the other hand, many of the mental health effects can be considered iatrogenic, being caused by interventions aimed at curbing a health problem. The lockdown, which was instituted in many countries to delay transmission in order to avoid overwhelming the health care system, has been imposed strictly in countries that opted for such an approach. All citizens were restricted to their homes, with educational facilities and all sectors of employment closed, except for essential services. The ‘stay home’ and ‘social distancing’ orders may have been tolerated initially but, having continued for several weeks and even months, it has had psychological effects to varying degrees with increased prevalence of depressive and anxiety symptoms (United Nations, 2020). A recent review in the Lancet on the psychological effects of quarantine noted symptoms of post-traumatic stress, anger, confusion, with some studies linking longer quarantine duration with greater distress, while food and water shortages were frequent stressors during quarantine (Brooks et al., 2020). It has been suggested that in instituting the COVID-19 lockdown on much of the global community ‘we are conducting arguably the largest psychological experiment ever’, that while authorities are setting up field hospitals to treat the disease there is a concomitant failure to set up the psychological care resources that will be needed, and that we will pay the price later (Van Hoof, 2020).
Included here are the major psychological and social consequences of loss of employment and the broader economic crisis caused by the lockdown. As history has shown, alcohol and other substances are often used as a way of coping in times of distress. However, the ban on the sale of alcohol and tobacco products in South Africa has created much anger and frustration, with looting of liquor stores and also legal action threats by liquor sales groups arguing that the ban is unreasonable and unconstitutional (Mlamla, 2020). There were also frustrating restrictions that seem to have very little to do with prevention (e.g., not being allowed to buy open toed shoes or a short sleeved top unless of a knitted fabric) and in some, instances, may work against prevention, for example, crowding during restricted exercise times allocated for public spaces.
An extended lockdown, as has been the case in many countries, has also led to distrust about its effectiveness. Critics have argued that lockdowns will not achieve the desired impact on infections in high-density areas because the interventions are simply not possible. This is especially true for poorer countries and those on the South American, African, and Asian continents. For example, how do people practice social distancing in crowded living conditions? How do people practice handwashing with limited water? This, together with the extreme force by law enforcement officials mostly directed at the poor and marginalised, has led many to question the overreach of government actions that impede human rights. Governments need to pay particular attention to the precarious balance between instituting restrictions that are necessary and which will achieve the goal of reducing the infection rate, while not treading on the basic rights of its citizens.
Interestingly, researchers from the Oxford Group found that, relative to the severity of outbreak, poorer nations imposed more severe lockdown measures than wealthy nations (Gibney, 2020). Perhaps an unexpected finding, but whether this approach is advantageous is yet to be determined. The phenomenon could reflect on the health resource inadequacies in poorer countries and a resultant panic about whether they will cope with a pandemic, hence their haste towards a cautious approach. Adopting an early, robust planning strategy is not to be derided. However, in the face of some of the restrictive measures that appear so arbitrary, one cannot but question their validity and scientific basis. It leads inevitably to concerns about the extent of social control that governments have been known to use in other contexts, like curbing dissenting political views (Wheat, 2019) and restricting freedom of speech. Such overreach is destined to evoke severe reactions and serves to alienate the populace from its leaders at a time when a unified stance is essential.
What can a critical, responsive, and socially engaged psychology offer?
South African psychologists and allies from other disciplines have been active in important ways. They have quickly adapted to teaching and practicing psychology virtually. Professional societies have lobbied medical aids to support online consultations and teletherapy. They have alerted the authorities to the immense mental health burden of lockdown on individuals and on stretched public health practitioners. Some psychologists have been active in the media, conveying valuable messaging and information to help the public cope with the stresses of the lockdown and anxieties related to the disease. They have enhanced help facilities for people struggling with mental health issues and gender-based violence. Psychologists have highlighted how behavioural sciences can help frame public health interventions (Tomlinson & Young, 2020). Many have been actively involved in local and international research projects to understand the psychological impacts and determinants of health-related behaviour. These efforts should be commended.
Importantly, scholars have pointed out the uneven impacts (both of the disease and lockdown) of COVID-19 on the marginalised, for example, unemployed or low-income earners, women, migrants, disabled communities, LGBTI (lesbian, gay, bisexual, transgender and intersex) communities, and those in abusive relationships. COVID-19, like previous crises, has highlighted long-standing social fractures such as poverty, inequality, xenophobia, racism, patriarchy, ableism, and unequal health care access. For example, of concern has been the significant racial disparity in the way the virus has affected communities. The Centers for Disease Control and Prevention (2020) noted that the disproportionate over-representation of African, Hispanic, and Latino Americans among those becoming severely ill and dying relates to a number of factors that make them more vulnerable, including living conditions, work circumstances, underlying or comorbid health problems, and inadequate health service access. In South Africa, race and class have historically been associated with food insecurities, inadequate housing and poor health care access, among other disparities. However, even in the post-apartheid era, factors such as race and socioeconomic status dictate health access, with Black Africans, the poor and rural communities having most difficulty (Harris et al., 2011). With South Africa being one of the world’s most unequal societies, a large portion of its people are extremely poor, dependent on social grants and informal sector employment, and the lockdown effects have been overwhelming (Orkin et al., 2020).
The impact on women, particularly poor women, cannot be ignored. The impact of unemployment on poor Black women (already the highest unemployed) is likely to be severe. Women, across class strata, experience increased domestic and child care burdens as well as increases in domestic violence. Reports of gender-based violence and domestic abuse to the police in the first 2 months since the lockdown began numbered 1426 in the Gauteng province of South Africa, meaning the actual prevalence is much higher given that many women do not report violence and abuse (Seleka, 2020). As a result of increased domestic and other demands, employed women have also reported lower productivity compared to men during lockdown. For example, publication productivity has been significantly lower for women academics compared with men (Fazarkerley, 2020). The added pressures that accompany the lockdown restrictions have been significant, with schools closed, but also child-minders and domestic helpers have been prohibited from working. The latter scenario plays out a further economic disaster because domestic workers in South Africa are mainly poor women who rely heavily on this source of income. Private households have been known to provide around 1.3 million such jobs (Statistics South Africa, 2018), and by the time of this publication, the majority have been without work for over 2 months. The recent survey by Orkin et al. (2020) noted significant mental health impact on women during this period, with feelings of depression and apprehension reported by 36% and 50%, respectively. That study also highlighted hunger as the most significant predictor of overall psychological distress, revealing that those who are hungry experience 9% more sadness, 12% more anger, 15% more stress, and 17% more depression than those who are not hungry.
Lockdown has also had severe impacts on LGBTI people. There have been reports of increased stigmatisation, discrimination, and violence against this group (Office of the United Nations High Commissioner for Human Rights, 2020). In Peru, for example, the government has allowed men and women out on alternative days with no accommodation for transgender people leading to stigmatisation (Perez-Brumer & Silva-Santisteban, 2020). Similarly, the lockdown has had profound impacts on migrants who are in precarious positions due to unstable work, xenophobic attitudes, lack of access to services (e.g., health care), susceptibility to unscrupulous law enforcement practices, and mobility restrictions. The mental and physical impacts on people with disabilities are particularly acute and are deserving of attention (McKinney et al., 2020).
In addition, scholars have long cautioned us about the political consequences of health behaviour change (Barnes, 2015). Health behaviour change tends to place the blame and remedy for COVID-19 on the marginalised. Becket (2020) writes about how in the United States, the COVID-19 discourse has shifted the blame on the unhealthy lifestyles of the marginalised. The argument put forward by the US health secretary was that the reason for the high morbidity and mortality was because of unhealthy lifestyles and comorbidity such as diabetes among African Americans. Not only does this have racist and classist undertones, it ignores structural determinants of COVID-19 such as poverty, inequality, environmental injustices, poor leadership (in that country in particular), and poor health care that governments have failed to address.
It is important for psychologists to continue the important work related to COVID-19 in terms of research, teaching, and practice. It is important for organised psychology to continue to draw attention to inadequately resourced mental health care systems and to strengthen partnerships with other sectors, disciplinary allies, and activist organisations. It is important to speak out against human rights violations that have been reported in several parts of the world. It is equally important to highlight upstream issues that governments around the world, but ours specifically, have failed to address. COVID-19, like previous social crises, offers another opportunity for psychologists to actively speak up for marginalised groupings in pursuit of a more just and equal society.
Psychology, as a behavioural and human science, has much to contribute in shaping and reinforcing behavioural interventions and public health strategies in times of pandemics like COVID-19. In addition, it is well placed to advise on necessary social policy development especially considering that societal support is essential for governments to effectively manage a pandemic. To this end, the South African Journal of Psychology together with the Psychological Society of South Africa (PsySSA) and partner publishing outlets, will do everything it can to be an avenue for psychological contributions on COVID-19. As a discipline, Psychology has witnessed many global challenges including wars, famine, economic crises, fascism, racism, and disease – it is vital that we consider carefully what we learn from this pandemic; how the world responded; what our failings were; and how we all can think and behave differently in a post-COVID-19 world.
Footnotes
Declaration of conflicting interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors received no financial support for the research, authorship, and/or publication of this article.