Among the many impacts of the COVID-19 pandemic, its effects on mental health have proven to be widespread and substantial. In January 2021, four out of 10 adults in the United States reported symptoms of anxiety or depression disorder – a 400 percent increase from January 2019. Health care workers are particularly exposed: more than half of workers on the front line could be at risk for one or more mental health problems, alongside the health risks involved in working with COVID-19 patients.

Children are also facing a mental health crisis during the pandemic. Emergency department visits by children for mental health issues went up about 30 percent for kids ages 12-17 and 24 percent for children ages 5-11 between March and October of 2020. Unstable learning environments, prolonged isolation, housing insecurity, systemic racism, and various other factors are all making children vulnerable to burnout. Burnout is characterized by symptoms of physical or emotional exhaustion caused by long-term stress.

Children and health care workers of color are especially at risk, compounding the effects of systemic racism.

Physicians for Human Rights (PHR) hosted a discussion on the mental health impacts of the pandemic and solutions to expand and encourage access to mental health care as part of PHR’s COVID-19 webinar series. PHR Board Member Gail Saltz, MD moderated the discussion. She was joined by Felton Earls, MD, emeritus professor of human behavior and development at Harvard T.H. Chan School of Public Health and emeritus professor of social medicine at Harvard Medical School; Jessica Gold, MD, MS, assistant professor and director of wellness, engagement, and outreach at the Washington University School of Medicine; and Matthew Howard, DNP, RN, CEN TCRN, CPEN, CPN, director of scholarship and leadership resources at Sigma Theta Tau International Honor Society of nursing, part-time staff nurse in the emergency department at Eskenazi Health in Indianapolis, and nursing faculty in the graduate and doctoral programs at Northern Kentucky University.

Front Line Workers and Pandemic Burnout

In the webinar, panelists talked about how health care workers are especially susceptible to burnout. Health care work can be psychologically and physically draining, yet this often goes unnoticed. Even before COVID-19, physicians had the highest suicide rate among every profession, and nurses had higher suicide rates than the general population.

Only three percent of psychiatrists are Black, posing further barriers to Black health care workers looking for help.

“Most of us work 12-hour shifts at a facility or a hospital,” Howard, a frontline nurse, said. “We do see patients the entire time. One of the biggest things, in the emergency department at least, is, as we start, we’re gowned, we’re gloved, we’re masked, and we pretty much stay that way the entire time.” This can be extremely mentally and physically taxing, as being fully gowned, masked, and gloved can make someone more hesitant about attending to their own physical needs during their long shift.

Health care workers of color have been at a particular disadvantage during the pandemic, Dr. Gold pointed out. They are dying in more significant numbers than white health care workers and are less likely to seek out mental health services. Importantly, only three percent of psychiatrists are Black, posing further barriers to Black health care workers looking for help.

Much of the struggle comes from rapidly changing work environments, where health care workers are experiencing things that are painful to process. Many have never said out loud that what they are seeing is hard and “That they’re allowed to say that, that they’re allowed to have feelings, that they’re allowed to be struggling, and that coming to me is not a weakness in any sort of way,” Dr. Gold said.

Pandemic Burnout in Children

The pandemic has also left children, particularly those in Black and brown neighborhoods, without the usual mentorship and support they would receive from their communities, families, and educators, according to Dr. Earl. Accessibility is an important factor for children experiencing the pandemic, as a lack of resources can substantially change how children navigate online learning.

In wealthier neighborhoods, schools have the resources to accommodate children in safer ways, including the implementation of hybrid schooling. “Those students who are attending private schools and schools that are open more than closed are having their stress buffered more than those in neighborhoods dealing with racial injustice, at the same time the consequences of the pandemic, and the combined impacts of those two epidemics on children has to be considerable,” Dr. Earl said.

So, what can be done to support health care workers and children experiencing burnout?

One important step is building trust. “Having the experience and the belief that the organizations around you, the schools, the health care centers, the businesses, and government, are working for you and not against you is the most important single factor,” Dr. Earl said.

“Those students who are attending private schools and schools that are open more than closed are having their stress buffered more than those in neighborhoods dealing with racial injustice.”

Felton Earls, MD, emeritus professor of human behavior and development at Harvard T.H. Chan School of Public Health and emeritus professor of social medicine at Harvard Medical School

And while individual efforts to improve burnout are helpful, Dr. Gold stressed that real change needs to be enacted systemically. “The system has to acknowledge it has a problem,” she noted. “We have to say, hey, we’ve had a problem for a long time, and a lecture on burnout is not going to fix it.”

Instead, what is needed are long-term financial investments in addressing the mental health issues facing health care workers, alongside advocacy for more supportive work environments.

As for children, they must be supported in ways that respect their ideas and emotions, Dr. Earl suggested. The impact of the pandemic and systemic racism cannot be reversed or diluted, but there is value in honoring the ways children have been feeling during these difficult times.

This fact sheet was produced in partnership with Doctors for Camp Closure, Doctors for America, and Human Impact Partners.

A year after the Trump administration introduced a specious order using public health as a pretext to end asylum at the border, President Biden and the Centers for Disease Control and Prevention (CDC) continue to use the order to expel hundreds of thousands of asylum seekers to danger. Carried out under a provision of U.S. health law – section 265 of Title 42 – these expulsions cause extensive suffering and harm under the guise of public health. The Title 42 order was issued despite widespread objections from epidemiologists and health experts, who have refuted its public health justification and issued detailed recommendations on safely processing asylum seekers during the COVID-19 pandemic. At this moment, we have an opportunity to right the wrongs of the past by following science-based public health policies and ensuring the safety of children, families, and adults seeking asylum. The Biden administration must end this expulsion policy, restore asylum at the border, and welcome asylum seekers with respect.

What is the Title 42 order and how is it being used to block asylum seekers?

Early in the pandemic, the Trump administration exploited the emergency to completely close U.S. doors to asylum seekers at the border, while continuing to allow many other, non-asylum- seeking travelers across. On March 20, 2020, the CDC issued an order citing section 265 of U.S. Code Title 42 (U.S. health law), allowing the U.S. federal government to immediately turn away and expel people arriving at the border seeking asylum protection. Such actions constitute violations of U.S. and international law. The order, which can be rescinded at any time, has been used by the Department of Homeland Security to carry out more than 750,000 expulsions and to essentially eliminate asylum at the border, resulting in dire humanitarian consequences, such as the severe overcrowding of families in migrant shelters and encampments in northern Mexico.

There is no public health rationale to categorically exclude asylum seekers while millions of other travelers cross the border without testing or contact tracing.

The Title 42 order is not based on public health rationale or data. It was implemented despite objections from senior CDC medical experts and it has been widely criticized by public health and medical experts, who state that the order has no scientific basis as a public health measure. International borders remain largely open to other travelers. People fleeing persecution are protected under U.S. and international law, and the United Nations Refugee Agency (UNHCR) has confirmed that countries must not deny entry or discriminate against asylum seekers solely because of the COVID-19 pandemic.

However, in spite of promising to bring humanity to the immigration system, President Biden has yet to repeal the Title 42 order; on May 19, 2020, it was extended indefinitely, with the CDC director stating the order will continue “until I determine that the danger of further introduction of COVID-19 into the United States has ceased to be a serious danger to the public health, and continuation of the Order is no longer necessary to protect the public health.” More than 70 million pedestrians and vehicle passengers were permitted to enter the United States through ports of entry on the U.S.-Mexico border from April to December 2020 without testing or tracing, while a much smaller number of asylum seekers have not even had the chance to have their case heard.

Banning only asylum seekers asking for protection in the United States is discriminatory, racist, and puts thousands of lives at risk.

The harsh consequences for children, families, and adults

The Biden administration has used the Title 42 order to block or expel asylum-seeking families and adults from Burkina Faso, Cameroon, Cuba, El Salvador, Ethiopia, Ghana, Guatemala, Haiti, Honduras, Jamaica, Mexico, Nicaragua, Nigeria, Russia, Somalia, Venezuela, and Yemen. According to reports, there have been at least 492 violent attacks, including kidnappings, rapes, torture, physical assaults, and verbal threats, against asylum seekers turned away or stranded in Mexico during the current administration. Since February 2021, the U.S. government has put the lives of Haitians in direct danger by sending 27 airplanes with more than 1,400 adults and children, including asylum seekers, directly back to Haiti despite the political instability and violence there.

Shortly after children were exempted from the order due to pressure and litigation, parents stranded in northern Mexico were forced to make the difficult decision to send their children to the United States alone, as that was the only way they could ensure their safety, effectively causing new family separations and increasing the number of unaccompanied children in custody.

Although the Biden administration has started to accept 250 asylum seekers a day, effectively exempting them from the Title 42 order as part of negotiations in a federal court case, the Title 42 order must be revoked completely.

What is the alternative?

Instead of unlawfully shutting down access to asylum, the Biden administration must uphold U.S. values and refugee laws, listen to the guidance from public health and refugee experts, and welcome migrants with respect.

Scientific and medical research continues to show that social distancing, wearing masks, and home isolation are the most effective measures to limit the spread of the outbreak. Science- based public health measures can be implemented at U.S. borders that both protect the health of the American public, U.S. border officers, and communities on both sides of the border, as well as safeguard the lives of those seeking refuge and safety.

How you can take action

The Title 42 order relies on the justification that denying asylum access is good for public health. As such, the expertise of health professionals is crucial in correcting the narrative and demanding an end to the Title 42 border expulsions and this systematic violation of human rights. Here’s how you can take action:

• Sign our petition: Tell Biden that the Trump administration’s weaponization of the pandemic to expel asylum seekers under the guise of public health must be rescinded now.
• Tweet or share resources on your social media accounts.
• Share the reports “The Invisible Wall: Title 42” from Haitian Bridge Alliance and “Failure to Protect” from Human Rights First
• Write an op-ed or letter to the editor of your local newspaper to share your perspective, as a health professional, on the importance of restoring asylum.
• Raise the misuse of Title 42 in relevant professional forums such as conferences, association meetings, and webinars.
• Volunteer as a clinician or non-clinician with Refugee Health Alliance in Tijuana.

Since the pandemic began, communities of color have been impacted by COVID-19 at an alarmingly disproportionate rate: upon contracting the disease, Black Americans are twice as likely to die compared to their white counterparts. Pacific Islanders are 2.6 times more likely, Latinx are 2.4 times more likely, and indigenous people are 2.2 times more likely to die of the virus in comparison to the white population.

But what is behind these numbers? Many are now attempting to understand the root cause of racial inequities in access to healthcare, tracing them all the way back to the foundations of the U.S. healthcare system. Increasingly, advocates are helping us understand that it is racism – rather than race – that has been the real cause of why COVID-19 has taken such a devastating toll on communities of color.

“[Communities of color] are looking at a healthcare system that has consistently and persistently demonstrated that their lives are valued less than others, based on the poor outcomes we have seen over and over again and done nothing about.”

Dr. Giselle Corbie-Smith

Today, as the United States continues its nation-wide vaccine roll-out, many people are beginning to see a light at the end of the tunnel. For communities of color, however, pervasive inequities in access to vaccines are just the latest in a long history of systematic degradation and racism in the U.S. health system that they have experienced for generations.

As part of Physicians for Human Rights’ webinar series on the health and human rights aspects of COVID-19, PHR hosted a discussion on the impact of structural racism and systemic inequalities on communities of color. The discussion was moderated by Olugbenga Ogedegbe, MD, MPH, director of the Institute for Excellence in Health Equity at NYU Langone Health, professor of medicine, and director of the division of health and behavior in the department of population health at the NYU Grossman School of Medicine. Expert panelists included civil rights activist and hate violence expert Eric Ward; Giselle Corbie-Smith, Kenan Distinguished Professor of Social Medicine at the University of North Carolina; and Monik C. Jiménez, assistant professor of medicine at Harvard Medical School and associate epidemiologist in the department of medicine at Brigham and Women’s Hospital,

Watch the discussion here:

Comorbidities in Communities of Color

In the webinar, the panelists acknowledged that inequities within the U.S. healthcare system was a reality even before the pandemic hit. Early in 2020, in the face of a looming international health crisis, people of color and marginalized groups in the United States failed to receive adequate information in order to protect themselves from the coronavirus.

“The failure in the early days was the failure to understand the role that inequality and racial bias always plays in the case of emergencies,” said civil rights strategist Ward. “I want to situate the coronavirus and the pandemic and the quarantine alongside other natural disasters, whether we [are] talking about hurricane Katrina, whether we are talking about flooding in Florida, or whether we are talking about the deep freeze that hit Texas.”

Marginalized communities were not given adequate access to supplies, such as masks and personal protective equipment, despite the government’s responsibility to do so. Panelists pointed out that the deaths of nearly 600,000 people from the coronavirus in the United States, many of whom were people of color, were a direct consequence of the government’s negligence.

It’s time that government officials as well as the public acknowledge and take responsibility for the major missteps of history and make the changes that so desperately need to be made.

The failure of the U.S. government to effectively communicate the severity of the pandemic also directly impacted the carceral system, a system in which Black, indigenous, and Latinx people are disproportionately incarcerated and detained to begin with. Those in the system are also exposed to extreme levels of overcrowding, unsanitary living conditions, and little access to healthcare, conditions which remained unchanged even as cases of COVID-19 soared. The rate of COVID-19 in the U.S. prison system is five times that in the general population, with mortality rates three times higher.

“There was no question from the beginning that COVID-19 would be devastating for incarcerated and detained people. That was not a surprise,” said Dr. Jiménez of Harvard Medical School. “And inaction early on to center decarceration efforts was quite honestly irresponsible and a complete failure of our systems.”

The panel also emphasized the urgency of addressing vaccine hesitancy among communities of color. Dr. Corbie-Smith pointed out the feelings of uncertainty and mistrust among African American, Indigenous, Asian-American, and Latinx populations of the United States healthcare system.

“[Communities of color] are looking at a healthcare system that has consistently and persistently demonstrated that their lives are valued less than others, based on the poor outcomes that we have seen over and over again, and done nothing about,” she said. With the announcement of the COVID-19 vaccine, these views translated into vaccine hesitancy.

So, what can be done?

Pivotal in improving the health of communities of color, the panelists agreed, is transparency and the reallocation of resources. Elected officials should also expand programs for underserved communities, like the National Institute of Health’s Rapid Acceleration of Diagnostics initiative, in which underserved communities across the nation are given adequate access to testing, vaccinations, and trusted information. As the world continues to understand more about the coronavirus, it is vital that institutionalized systems are put in place to address chronic illness, disease, and disaster, to better prepare at-risk communities for what may come.

Ultimately, equity in all forms begins where inequality ends. As Dr. Corbie-Smith put it, “inequality is not simply a Black and brown problem, this is all a problem for all of us.” After a year in which our health seemed more interconnected than ever, addressing the many existing structural and institutional inequalities in our health systems could not be more urgent. It’s time that government officials as well as the public acknowledge and take responsibility for the major missteps of history and make the changes that so desperately need to be made. Our lives depend on it.