COVID-19 effect on Urban Population

In the wake of the COVIC-19 outbreak, entire mankind across the Globe is suffering. Often, we protect ourselves from stress byways of outdoor activities, social gatherings, and meeting family and friends. But during the lockdown, social distancing and repeatedly changing numbers of deceased & people fighting for survival, add more stress to people in urban cities. Due to an increase in stress levels caused by the pandemic, people grip themselves in fear of losing jobs, ambiguous futuristic opportunities for survival, cost of living and maintaining their status in society. Some eminent personalities, including researchers worldwide, state that the lockdown is not the end, but the beginning of this problem. The Government of India is taking all necessary steps to ensure that they are prepared well to face the challenges and threats posed by the growing pandemic of COVID-19.

The Covid-19 disease was initially thought of as a viral infection and first time on 31 December 2019 World Health Organization's China office heard the reports of an unknown virus (hence the name novel coronavirus) behind a large number of Pneumonia cases, in Wuhan city of Eastern China. Apparently, the disease originated from a seafood market in Wuhan where wild animals, birds, marmots, rabbits, bats, snakes etc. are illegally traded. It is known that coronaviruses can jump from animals to humans, hence the first people to become infected with this disease are primarily from the seafood market who got infected from being in touch with animals. (WHO, 2020). Coronaviruses are a large group of viruses that are known to infect both humans and animals, and in humans cause respiratory illnesses that range from common colds to much more serious infections. The previous well-known case of a coronavirus epidemic was Severe Acute Respiratory Syndrome (SARS), which was first detected in southern China in 2002, and then spread to 26 countries resulting in many casualties.

COVID-19 has been declared by the World Health Organization (WHO) as an emergency of public health international significance in January 2020. WHO reported that COVID-19 is highly susceptible to spread to other worldwide countries. In March 2020, the WHO assessed the risk of COVID-19 and called it a global pandemic. The COVID-19 outbreak is being monitored by the WHO and public health agencies around the world. But such a pandemic causes stress across the population. The considerations outlined in this paper were established by “The WHO Department of Mental Health and Substance Use” as a set of information that can be used for interactions in diverse target communities to promote emotional and psychosocial health during the COVID-19 outbreak. As the coronavirus pandemic rapidly sweeps across the world, it is inducing a considerable degree of fear, worry and concern in the population at large and among certain groups in particular, such as older adults, care providers and people with underlying health conditions. It is frequent for people to feel anxious and concerned during any outbreak, and this is also true of the pandemic caused by the COVID-19 virus. Common stresses of people affected them both directly and indirectly.

“The fact there was no recent catastrophic pandemic in recent history does not mean there won’t be another one. And we are certainly not prepared for the next pandemic”. This statement by Bill Gates turned out to be true on 11th March 2020 when the WHO declared COVID-19 a pandemic.

This pandemic has hit hard on every country, and on all people irrespective of all differences. The world practically came to a standstill. By the 3rd of April 2020, half of humanity (approximately 3.9 billion people) around the world were in lockdown either compulsory or recommended. India was no exception to it and announced a lockdown to combat COVID-19 on 24th March 2020.

The lockdown brought a lot of challenges and gripped almost everyone. Every region, every stratum, every group and every person has faced unseen challenges where people were required to adapt to them almost immediately. Urban cities are the culmination of various segments of society into one. People in urban areas are from all regions of India, covering all financial status segments from rich to poor. 60-70% of COVID-19 cases are coming from major or densely populated cities. In times like this, major urban cities saw stress, unlike any other time.

With the imposition of restrictions in early March, workplaces started adapting to the safety norms, but with the announcement of the lockdown, there was a sudden halt to the operations of almost every sector. Within one week, the work was shifting from office desk to home with limited resources. People had a difficult time adapting to it. More than 60% of people had not ever worked from home, but corporates asked them to adapt to it very quickly, which put a lot of stress on employees.

Cities are home to most of the world's population and are centres of economic growth and innovation. However, the high concentration of people and activities in cities makes them vulnerable to various stressors such as natural and man-made disasters. Understanding this, over the past few decades, a vast body of research has been published on the impacts of a wide range of disasters on cities, and the necessary planning, recovery, and adaptation measures that need to be taken to deal with those disasters. However, while this is not the first time in human history that pandemics affect cities, limited literature related to cities and pandemics existed before the emergence of the COVID-19 pandemic.

Urban research related to previous pandemics is mainly focused on issues such as inequalities that make poor and marginalized groups more vulnerable to pandemics. The recent pandemic has brought to the fore the issue of urban vulnerability to pandemics and has resurrected interest in this topic. As various forces such as climate change and human encroachment into natural wildlife habitats may increase the frequency of pandemics in the future, better knowledge of the underlying patterns and dynamics of pandemics, their effects on cities, and necessary preparation, response, and adaptation measures are needed. In this regard, the recent pandemic offers an unprecedented opportunity to understand how cities might be affected by pandemics and what actions are needed to minimize the impacts and enhance urban pandemic resilience.

Mental Health

Mental health is amongst the top public health concerns worldwide. Globally, it contributes to around 14% of the overall burden of diseases, as per American Psychological Association. Mental health is the means to be able to adjust to the different experiences and situations in life – being adaptable and maintaining a sense of purpose. It is also defined as the ability of an individual to maintain balance and harmony between oneself, their surroundings and the people around them. It is a necessity to ensure that the person is functional, and can conduct themselves effectively as an individual as well as a part of a community. It is important for the maintenance of one’s own health as well as the health of one’s family and dependents.

In a country like India where unemployment was a major concern, a pandemic situation and lockdown posed a severe threat to employment. Overnight a huge segment of the workforce found themselves unemployed. Tragically people who lost jobs at an early stage were from a weaker financial segment of society. People had no more income and were uncertain of getting anything new in such tough times. The money crunch has been one main reason for stress in this pandemic situation.

Sadly, with the passage of time and the extension of lockdown, many corporations faced a financial crisis and resorted to manpower cutting. This further increased the percentage of unemployment in India. Money crisis with little hope of getting anything new hits hard on people. Since we live in an integrated world where the lockdown in other countries resulted in many job losses of independent workers as well.

Anxiety

Anxiety is primarily a feeling of strong trepidation, uneasiness, discomfort, or panic. Anxiety attack builds slowly for many people and it changes from mild to worse as the situation escalates or the event approaches. It differs from developmentally normative fear or anxiety by being excessive or persisting beyond developmentally appropriate periods. It is only diagnosed when the symptoms are not attributable to the psychological effects of a substance or medication or another medical condition.

Anxiety disorders are also associated with an increased prevalence of several medical conditions including asthma, chronic pain, hypertension, arthritis, cardiovascular disease, and irritable bowel syndrome (Roy-Byrne et al., 2008).

According to the American Psychological Association, anxiety is an emotional state which is indicated by feelings of intense tension, and thoughts related to worry, which is often accompanied by physical changes like a sudden spike in blood pressure. A person with anxiety disorder would suffer from recurring intrusive thoughts and concerns. It would be difficult for the person to ignore these thoughts – even though the thoughts would create physical and emotional discomfort for them. To then avoid these thoughts, the person would start avoiding such situations of discomfort – so that they do not have to worry. When exposed to situations of discomfort, they can have physical symptoms like rapid palpitations, sweating, increased blood pressure, trembling, rapid beating of the heart, dizziness, etc.

Anxiety is a key part of several different disorders; they are defined as follow:

• ●  Generalized Anxiety Disorder: Involves persistent and excessive worry that interferes with daily activities. Can be accompanied by physical symptoms, such as restlessness, feeling on edge or easily fatigued, difficulty concentrating, muscle tension or problems sleeping.

• ●  Panic Disorder: In this, the person experiences repeating panic attacks on different occasions and usually they live in fear of the next panic attack. The core symptom of this type of disorder is chronic and repeating panic attacks, along with an overwhelming combination of physical and psychological distress. The symptoms can be so severe that a patient who experiences a panic attack may assume or feel as if they are having a heart attack and would go to a hospital ER.

• ●  Phobias, Specific Phobia: The person develops excessive fear of a specific object, place, situation or activity that is generally not harmful. Even though the patient may be aware that their fear is excessive, they are unable to overcome it.

• ●  Social Anxiety Disorder (earlier known as social phobia): In this, the person develops an irrational fear of being judged by others in social situations. When someone is facing social anxiety disorder, they have significantly high anxiety and discomfort about being embarrassed, humiliated, rejected or looked down upon in social interactions. As a result,

   

they avoid being in a situation where they would experience such anxiety. They may have an extreme fear of public speaking, meeting new people or eating/drinking in public.

• ●  Separation Anxiety Disorder: Such a person has excessively fearful feelings or anxiety regarding separation from the people they are attached to. The excessive fear of separation is not age appropriate for the person. They may experience physical symptoms of distress like sleeplessness and nightmares, which are often developed in childhood but can carry throughout adulthood.

• ●  Obsessive-compulsive disorder: Recurring fallacious thoughts that lead a person to perform precise, repeated courses.

• ●  Illness anxiety disorder: Also known as hypochondria, here the person develops anxiety about their health.

• ●  Post-traumatic stress disorder (PTSD): It usually follows a traumatic event that has affected the person's life intensely, could be an accident, war veteran or bad childhood memory.

The risk of suicide appears to be highest in individuals with a comorbid mood, and anxiety, Anxiety's main cause is a combination of factors that play a role to trigger parts of the brain that control fear. It is also impacted by genetic and environmental factors, as well as brain chemistry.

Depression

Depression is a prevalent mental disorder that manifests with depressed feelings, lack of interest or desire, reduced energy, emotions of guilt or low self-worth, disrupted sleep or appetite, and poor attention. Furthermore, depression often comes with symptoms of anxiety. These problems can become persistent or repetitive and lead to substantial impairments in a person’s capacity to take care of his or her normal responsibilities. At its worst, depression can lead to suicide. 

Almost 1 million lives are lost yearly due to suicide, which translates to 3000 suicide deaths every day. For every person who completes suicide, 20 or more may attempt to end their life (WHO, 2012). There are various developments of depression that a person can suffer from, with the most general distinction of depression in people who have or do not have a history of manic episodes. While depression is the leading cause of disability for both males and females, the burden of depression is 50% higher for females than males (WHO, 2008). 

According to the American Psychological Association (APA), Major Depressive Disorder – or commonly known as depression – is a very common yet serious medical condition which adversely affects how one feels, the way one thinks as well as the way one acts. Though it is a treatable condition, it needs to be taken up as seriously in terms of treatment as any other physical illness. Depression can cause a deep sense of inherent sadness in the patient along with a loss of interest in every activity as well as activities that the person once enjoyed very much. This may lead to several emotional and physical issues. In severe cases, it may also render one non-functional, i.e., they may be unable to carry out even the most menial of tasks by themselves, despite having no apparent physical disability. This can impact one’s life both professionally and personally.

Some of the common symptoms are below:

• Sleep disturbances, insomnia or sleeping too much
• Feelings of sadness, tearfulness, emptiness or hopelessness

• Angry outbursts, irritability or frustration, even over small matters

• Loss of interest or pleasure in most or all normal activities, such as sex, hobbies or sports • Tiredness and lack of energy, so even small tasks take extra effort
• Decreased appetite and weight loss or increased cravings for food and weight gain
• Slowed thinking, speaking or body movements
• Feelings of worthlessness or guilt, fixating on past failures or self-blame
• Trouble thinking, concentrating, making decisions and remembering things
• Frequent or recurrent thoughts of death, suicidal thoughts, suicide attempts or suicide
• Unexplained physical problems, such as back pain or headaches

A few or more of the above symptoms should last at least 2 or more weeks for it to be considered depression. Also, it should lead to an observable change from the earlier level of functioning for the patient to be truly diagnosed with depression.

It is important to note here that some physical illnesses, ex: thyroid problems, vitamin deficiency etc. can also have similar symptoms as above to a certain extent. It is therefore necessary to first rule out these conditions before diagnosing a patient with depression.

According to APA, depression is affecting approximately one in every 15 adults per year. Moreover, one in 6 people has experienced depression at some point in their lifetime. Though it can occur at any point in time, it mostly starts to appear during adolescence to mid-20s. It is also worth noting that women are at higher risk as compared to men in terms of being affected by depression. Studies have indicated that one-third of women experience a major depressive episode in their lifetime.

Stress

Stress comes in many forms and affects people of all ages and all walks of life. It can be defined as any type of change that causes physical, emotional, or psychological strain. Stress is your body's response to anything that requires attention or action. Everyone experiences stress to some degree. The way we respond to stress, however, makes a big difference to our overall well-being.

According to the American Psychological Association, stress is a usual reaction to day-to-day pressures a person faces in everyday life. Though a regular level of stress is normal and necessary, it can turn unhealthy when it reaches a level that starts impacting one’s everyday functioning. A high amount of stress can lead to anxiety and depression. It is therefore important for individuals to balance the level of stress they should manage daily. An increased level of stress would not only impact the mental wellness of an individual but also impact the physical well-being of the person. It is reported by APA that more than three-quarters of adults report physical or emotional symptoms of stress, such as headache, feeling tired or changes in sleeping habits.

APA defines 3 types of stresses:

• ● Acute Stress: It is the most common form of stress. It arises from recently occurring demands and pressures or anticipated demands and pressures in near future. Though it can be thrilling for a few people in small doses, beyond a point, it can take a toll on mental health. Therefore, excess of these short-term stresses can lead to psychological distress, tension headaches, upset stomach and other symptoms. Though it is very common, it is also short-term and treatable/manageable.

• ●  Episodic Acute Stress: The people suffering from this disorder have disordered lives and are always in chaos and crisis. Even though they are always in a rush, they are also chronically late. They take up too much on their plate and are unable to fulfil the demand it brings. They can be over aroused, short-tempered, irritable, anxious and tense. They have a lot of nervous energy. Both work and interpersonal relationships become difficult for them to manage because of this.

• ●  Chronic Stress: This refers to the grinding stress that exhausts the person suffering from it in the long term. It has a negative impact not just on the mental but also physical aspects of a person. The person suffering from this condition never seems to find a way out of a miserable situation. It’s the stress of unrelenting demands and pressures for seemingly interminable periods. Eventually, the person gives up and stops looking for solutions altogether. Chronic stress may lead to suicidal tendencies, violence, cardiac issues, stroke and nervous breakdown. Stress can be short-term or long-term. Both can lead to a variety of symptoms, but chronic stress can take a serious toll on the body over time and have long-lasting health effects.

  Some common signs of stress include:
  • Nervousness, anxiety
  • Changes in eating habits including overeating or under-eating (leading to weight gain or loss),

• • Loss of enthusiasm or energy
• • Mood changes, like irritability and depression.
• • Dizziness, Low energy
• • Frequent sickness
• • Grinding teeth
• • Muscle tension, especially in the neck and shoulders • Headache, gastrointestinal problems, and fatigue.
• • Racing heartbeat
• • Trembling

Anxiety, Depression and Stress frequently co-occur in individuals and have been linked through the tripartite model as components of a larger construct of negative affect (Clark & Watson, 1991). It has been demonstrated that anxiety, responses to stress, and depression have a unique profiles. Anxiety and stress are natural responses to everyday stressors. If the feelings of anxiety are extreme and begin to interfere with one's daily life, then it may be a sign of an anxiety disorder.

Previous research performed during the initial phase of the coronavirus outbreak has revealed more than half of the respondents rated the psychological impact as moderate-to-severe, and about one-third reported moderate-to-severe anxiety.

Accessibility to health care in urban cities during this pandemic has become very difficult. It is seen urban areas have seen a large number of COVID-19 cases, therefore more stress on health facilities. It became a tough task to access health care as the chances of getting a virus increased with visits to hospitals.

Patients with long-term ailments were unable to consult doctors physically for their problems. Either they had to resort to telemedicine or take the risk of visiting a hospital. Moreover, lifesaving treatments like dialysis were inaccessible for a long time. Also, patients and attendants referred from rural health centres found it struggling to manage basic amenities like food, stay etc. in this phase.

Mobility flows have become a key dynamic in the rapid urbanisation process of Indian cities with urban transport infrastructure constituting the skeleton of the urban form. Logistics is another challenge for the urban area. People heavily depend on them for their survival. Due to COVID-19, transport in cities are stopped, and people have faced lots of problems in travelling. This caused a lot of trouble for people as almost all local transport in urban areas is hauled and shows any signs of resuming shortly. During this phase, people found themselves with no personal vehicle to travel. Imagine something which was the lifeline of a city was immediately put to a sudden halt. How much trouble it must have cost those who relied on them, which led to stress among people.

One of the most neglected aspects of this COVID-19 phase is mental health. A lot has happened in a short span of time. This lockdown has been taxing emotionally, physically and mentally. People overnight lost their jobs or were required to adapt to a new working style. Working from home has brought the office ease of home environment but has taken self-time from people.

The work timelines are increasing to 15 hours without any proper break. Additionally, people are deprived of those little joys of eating out, hanging out with friends etc. which were like a breath of fresh air in their hectic lives. The confinement to four walls of the home is taking a toll on mental health. Humans are social animals and with bare minimum interaction with people like earlier is pushing them towards stress and anxiety.

In this crisis situation of lockdown amid the Covid-19 pandemic, health and mental health professionals face challenges due to very little information regarding the psychological impact and underlying mental health conditions of the general public. There is a looming uncertainty due to an outbreak of such unparalleled magnitude affecting individuals across the globe. Researchers are busy exploring the genomic characterisation of the virus, identifying the epidemiology and clinical characteristics of infected patients and the challenges faced by healthcare authorities and functionaries. However, less focus is being paid to the impact of Covid-19 on the mental health of individuals in India. (MOHFW, 2020)