‘What’s weighing heaviest’

‘What’s weighing heaviest’

Indirect health consequences of the Covid-19 crisis
Key findings: 
  • While relatively few households that we interviewed had experienced Covid-19 infections as of summer 2020, the physical and mental health strains of the crisis have disrupted nearly everyone’s lives in unanticipated ways.
  • Most respondents expressed frustration with the lackadaisical precautions being taken by others; very few expressed skepticism about masks and related measures.
  • The pandemic exacerbates existing difficulties regarding healthcare access.
  • The financial stress and social isolation of the pandemic provoked psychological distress for many participants, and was especially hard for those with prior mental health challenges.
Jeremy Freese, Amy L. Johnson, Macario Garcia

Covid-19 has affected everyone, in ways large and small, whether through direct infection or all the measures taken to slow its spread. Americans are fearful of contracting the illness, infecting others, job loss and financial precarity, and, at the same time, creating strategies to cope with these struggles. Although the overwhelmingly universal impact of this pandemic is striking, perhaps more troubling is the way in which it has exacerbated existing inequities in health outcomes.

Before the Covid-19 pandemic disrupted everyday life in America, millions of people already lacked access to health, wellness, and preventative care, with many individuals using emergency room visits as their primary medical treatment.1 Access to health care is often tied to employment, social welfare programs, and private organizations such as Planned Parenthood and urgent care facilities. Unfortunately, these systems do not provide universal coverage, and access to quality care serves as a key driver of health inequality. Black, Indigenous, People of Color (BIPOC) disproportionally lack access to quality health care, while women and femme-presenting individuals often have access concerns as their health is politicized for heterosexist and misogynistic purposes.2

For those individuals lucky to have the capacity and ability to access health resources, the majority do so through employment-based insurance, and more than 10 million people have lost health insurance as a result of the economic recession since the start of the pandemic.3 At this moment, millions across the country continue to live with instability and precarity, with the most vulnerable peoples contending with historical violence that disproportionately impacts BIPOC.

The health consequences of the pandemic show similar inequities. Infection is unequally stratified by race/ethnicity, socioeconomic status, and location.4,5 According to Centers for Disease Control and Prevention data, BIPOC are contracting the virus, being hospitalized, and dying at higher rates than their white counterparts.6 These disparities are heightened by pre-existing barriers in healthcare access and racist practices that harmed and sidelined BIPOC. Historically, medical workers have experimented on BIPOC peoples, disrupted traditional health practices, and exploited labor for purported groundbreaking medical treatments that then rarely get equally distributed to historically marginalized peoples.7

Furthermore, as we explore below, other consequences of the pandemic (beyond infection) have widened inequalities in healthcare access, protective behaviors, and financial and psychological distress, further harming the most vulnerable.

This report recounts health consequences of Covid-19 as experienced by participants in the American Voices Project (AVP), a nationally representative qualitative study. It draws on a subsample of 135 AVP interviews conducted from July and August 2020, providing a snapshot of how Americans were affected by the pandemic at that time. Our respondents are racially, socioeconomically, and geographically diverse (see Table 1).

While some of our findings are universal across the sample, where relevant we call attention to how the consequences of the Covid-19 pandemic interact with existing axes of privilege and marginalization. First, we discuss the experience of infection. Although direct infection among AVP participants was still relatively rare at the time of these interviews, we describe protective measures and assessments of the government’s response. Then, turning to health inequalities during the pandemic, we discuss disruptions to healthcare access and factors leading to heightened psychological distress. In doing so, we demonstrate how the indirect consequences of Covid-19 are more substantial and far-reaching than anticipated. Across the interviews, respondents speak directly to their struggles (or lack thereof) during this unique moment, experiences that are influenced by pre-existing inequities. We see a pervasive mix of resignation and frustration with how the government and other major institutions addressed the pandemic. And although our interviewees also reveal considerable resilience, the coping strategies they described this past summer may not be sustainable over the long haul and in the face of structural failures.

Experience with Covid-19

By the beginning of August 2020, the United States had about 4.5 million confirmed Covid-19 cases and just over 150,000 deaths. The total population of the United States is 328 million, meaning that about 1 in 70 Americans had tested positive for Covid-19 and about 1 in 2,000 had died. Of course the number of both infections and deaths subsequently rose. But even the number of those who had been infected at that time is believed to be significantly higher, especially given that many infected people may have been asymptomatic and not been tested.

Given these prevalence rates as of summer 2020, it is not surprising that only one of the 135 respondents interviewed in July and August indicated that they themselves were both symptomatic and tested positive for Covid-19. That respondent said she had gone to her doctor because of a worsening cough: “I spent a lot of time in bed, and then I couldn’t have thin pillows because I felt as if my lungs were closing up… When I started coughing, I breathed from my stomach.” When the doctor suggested she be tested for Covid-19, she did not think it was possible because of all the precautions she’s taken: “I don’t even go out… I have a cloth with bleach to use before I open my car, when I close my car door. I clean the steering wheel, everything, how could I have got it?”

A notable aspect of this woman’s experience is that four of her siblings also had Covid-19, as did their mother (in her 70s and fortunately asymptomatic), a sister in-law, and a niece. Exactly who may have transmitted the disease to whom among this group was a matter of speculation, and, apparently unrelated to these cases, a nephew of hers had also died from Covid-19. The one respondent who had Covid-19, in other words, also had a series of immediate counterparts with the disease as extensive as that of all the other interviewees combined. Immediate family experience with Covid-19 was otherwise rare: Only four other respondents reported a spouse, child, or parent who had tested positive for the disease.

At least as of summer 2020, the disease itself was an abstract matter for most. Although public opinion data from this time reports over 40 percent of Americans said they personally knew someone who has had Covid-19, among the AVP interviewees, these were more distant, rather than immediate social ties.8 While efforts to contain the pandemic had altered everyone’s lives in some way, the actual occurrence of the disease was overwhelmingly experienced by AVP respondents as something happening to other people, at least at the time.

Prevention efforts

Many respondents described themselves as being diligent in their prevention efforts. Only two of the 135 respondents said things like, “I don’t believe in the mask and all of it,” or suggested the virus might be an election-related hoax. Of course, it is possible more share these views but did not voice them. Several respondents, meanwhile, expressed frustration with people who were not taking prevention more seriously. A woman in her late 20s described being angry because “my boyfriend’s very like flippant about it and nonchalant and like, he’ll come in the house from the store and I’ll be like, ‘Wash your [expletive] hands.’ And he’s like, he doesn’t get how serious it is. And I’m like, I am immunocompromised. He always thinks I’m overreacting and that I’m not as sickly as I say I am.”

The American Voices Project (AVP) relies on immersive interviews to deliver a comprehensive portrait of life across the country. The interview protocol blends qualitative, survey, administrative, and experimental approaches to collecting data on such topics as family, living situations, community, health, emotional well-being, living costs, and income. The AVP is based on a nationally representative sample of hundreds of communities in the United States. Within each of these sites, a representative sample of addresses is selected. In March 2020, recruitment and interviewing began to be carried out remotely (instead of face-to-face), and questions were added on the pandemic, health and health care, race and systemic racism, employment and earnings, schooling and childcare, and new types of safety net usage (including new stimulus programs). The “Monitoring the Crisis” series—which is co-sponsored by the Stanford Center on Poverty and Inequality, the Federal Reserve Bank of Atlanta, and the Federal Reserve Bank of Boston—uses AVP interviews conducted during recent months to provide timely reports on what’s happening throughout the country as the pandemic and recession play out. To protect respondents’ anonymity, all quotations presented in this series are altered slightly by changing inconsequential details. Learn more about the American Voices Project and its methodology.

Some were unhappy with the behavior of others living in their area more generally. A white respondent in North Carolina said that, while she was wearing a mask, “it’s really ugly here people fighting over [those who say] ‘I’m not wearing a mask.’ I even had a friend who says I’m a sheep for wearing a mask.” A different respondent in North Carolina noted that few people were wearing masks early in the pandemic when the rates were very low, but then people’s behavior didn’t really change when cases started increasing in the state. “Now that it’s here, maybe you’d think we ought to wear masks,” she said. “It boggles my mind.” Meanwhile, a white woman in Indiana talked about how “people in our area don’t tend to believe in masks” and that when she would forget her mask and run back to retrieve it, she would then feel silly because “you’re in the store grocery shopping, and you’re really the only person with a mask on.”

Like the woman frustrated with her boyfriend, some respondents specifically tied their prevention efforts to their higher risk of a bad outcome if they did become infected. After outlining the various precautions she’s taking, a respondent in her early 70s said, “I know that sounds a little paranoid but I have underlying health conditions. I’ve had open heart surgery and I have COPD ... I just can’t take those foolish chances.” At the same time, not everyone was able to protect themselves as much as they thought they should. One respondent reported, “Because I’m diabetic and I also have a different rare autoimmune disease too, I’m just really worried about it. But also, I have to go to work. I’m in an economic situation where I have to go to work. So, that sucks.” These stories show how more vulnerable Americans may need to risk their health in order to meet immediate economic needs, and are forced to rely on the precautionary measures taken by others.

Having older relatives was also recurrently described as a reason for being extra cautious. One woman said about her family, “We [are] all trying to be careful again because my mother is 77 now, and she got congestive heart failure.” Another said, “My mom is 62 and she does home health care. So she is around the elderly 24/7 for the past eight weeks. So out of respect and concern for her and her livelihood, I wear masks everywhere I go.” Several respondents indicated that they were not able to visit loved ones in nursing care or the hospital. A Black woman in her early 70s said about her mother, “We didn’t see her for a month and then she passed away.” In this way, despite the lack of direct experience with Covid-19, the virus still weighed heavily on respondents.

Assessment of the government public health response

Across the board, our interviewees voiced discontent with how the U.S. government has handled the coronavirus response. Frustration with the government response has led to substantial stress and anxiety, including financial difficulties, economic worries, and, as mentioned above, exasperation with other Americans for not taking precautions seriously. As a white Rhode Island woman in her late 20s put it, “It’s just an extra layer of stress and anxiety of the unknown and not knowing how long it’s going to last, like what the specifications are, obviously, like every state has been doing wildly different things.” She went on to say:

I just think there needs to be more transparency and consistency across states as far as the plan for dealing with the global pandemic. I just think we were significantly unprepared [...] [there is] no unity and collaboration as far as what the plan is in dealing with this and it’s just getting a lot of mixed messages. Which I think in total is just making this pandemic last much longer than it needs to. I think we should be taking notes from other countries, too. They’re really doing much better than us and they don’t have increasing numbers at certain hotspot areas.

In the eyes of this respondent and others, inconsistent messaging—including variation across states and regions and changing rhetoric from the federal government and the president—is harmful not only for personal wellbeing, but has also led to the United States being worse off than other countries.

When asked what the U.S. government should do differently, some respondents described a need for increased regulation to protect people from the virus. While some want stricter lockdowns and stay-at-home orders, more highlight the importance of mask-wearing. Even many who advocate for reopening due to economic and mental health concerns still emphasize mask-wearing, and a few want a national mask mandate: “There should be a nationwide response, a nationwide mandate to wear [a] mask. It should be just a nationwide coordinated response, instead of having it vary by state.” Another group of respondents believe the government should prioritize economic reopening due in part to the mental and physical toll of forced closings. As one respondent from New York put it:

This isn’t going away as far as hunkering down and hiding away from it. It’s not like the virus is going to disappear. It’s still going to be there. So, as far as shutting down the economy and everything, I don’t agree with [that]. I think we should be spending more time on educating people and how they can interact in the world without spreading it more. [...] I think they need to work more on that instead of just shutting [businesses] down and… you know you’re destroying everybody mentally physically and economically.

Overall, despite division on what exactly should be done, there is a general sense from respondents that the United States is not doing the right thing, for public health or for the economy.

Healthcare access

Few respondents in our sample had received Covid-19 testing. Those who had were split between those tested as a consequence of their jobs (i.e. working in medical care), and those tested as a result of a connection to someone who had tested positive. There were not any instances in our data of someone saying they had wanted to be tested for Covid-19 but not being able to, although again this may reflect the low overall exposure of our participants than accessibility per se.

Nevertheless, even for respondents who did not seek Covid testing or treatment, experiences with health care have changed since the pandemic began. Covid precautions have led to many health appointments being moved online or to telehealth. Some respondents have appreciated this; as a white man in his late 60s from Ohio described, “My doctors have been very easy to get a hold of. Just the normal going in to see a doctor has changed to telephone communications. [...] Actually, it’s even better.” Yet virtual and phone appointments are not universally available, and they can only address a portion of patient needs.

As a result, many respondents describe foregoing medical appointments. Sometimes this is to avoid the risk of infection; as a Black woman from North Carolina explained, “So, I was going to go to the dentist. Here comes pandemic, nope oh, no, not going.” Another respondent from New York joked, “I’m like, I’m not going to no doctor with corona going on like this.” Other times, however, Americans cannot access health care despite wanting or needing to. A middle-aged white man described, “I mean for obvious reasons, it’s difficult to get appointments. There’s just no capacity right now. For minor ailments or anything of that nature, you’re pretty much on your own. Doctors are backlogged and it’s just hard to get access to the doctors.” Another respondent said her clinic had stopped her prescription because it required an in-person doctor visit, “so if I don’t go to the doctor they don’t renew it, so therefore I have been without my medicine for like six months and it was definitely causing health problems.” She explained having to pursue a laborious process of contacting her insurance provider to get an extended prescription and then finding a new pharmacy.

Referring to his difficulties accessing mental health care, a middle-aged white man from Minnesota summarized the added layer of complexity imposed by the pandemic:

I wasn’t able to see my therapist anymore. And that made me give up on trying to go to the therapist. So, it’s just frustrating that health care is so complicated, and it can get messed up so easily. And the other issue I have right now is because of Covid, I just don’t think about going to the doctor anymore. It’s not that I’m afraid to go, but I just feel like it would be a big hassle and that there’d be like a mountain there’ll be more hoops to jump through to get to the doctor.

Overall, the Covid pandemic has exacerbated existing challenges and inequalities associated with American health care, including insurance, high costs, and long wait times for appointments. Within our sample, respondents across demographic and socioeconomic groups described similar changes to health care during the pandemic.

Yet Americans are differentially able to accommodate new complications: For those who may have lost their job, and associated health insurance, pandemic-related healthcare barriers may be insurmountable.

Several respondents spoke openly about healthcare inequities in the United States as the result of the current economic system. One respondent in his 70s advised that “…it is perfectly and obviously idiotic to tie health care to your employment… And it’s because of corruption and I’m afraid it’s probably mostly because of the capitalist system we got…[.]” A Hispanic woman from Washington also spoke about the difficulties securing health insurance, “I don’t have medical insurance is because my husband doesn’t earn enough in order to afford insurance, and since I don’t work, I can’t get it either.” But there are others who believe that the current economic system is the best option as long as everyone works efficiently. A Black man in his early 40s from Massachusetts suggested that if everyone would “take responsibility” for themselves and their families, working people wouldn’t be in such dire circumstances. For these respondents, their problem wasn’t the economy or medical care systems, but rather, people taking advantage of social welfare policies that were not available to everyone.

Some respondents spoke directly about intersectional injustices regarding health care and the Covid-19 crises. Referring to the possible Covid-19 vaccine trials, a Black woman in her early 60s from Missouri advised, “For Black women? Well, to me, that gets into another thing that I have been listening to and paying attention to. I don’t like the experiments that they wanna do. We’re the first ones they wanna experiment on…And of course, Black people, we’re always like, ‘Don’t look at me to experiment on.’” In this statement, the respondent connects contemporary health concerns to historical anti-Black violence often rendered invisible in medical care systems.

Others worried that the pandemic affected BIPOC disproportionately. When speaking about how her social group constantly takes extra precautions to avoid contracting Covid-19, a Florida woman who reported being “mixed” race/ethnicity stated, “It’s really a scary time and most people know that a lot of minorities actually are getting it along with other people. Mainly my friends just don’t wanna put ourselves in a predicament where we might get exposure by not being extra cautious.” As these statements demonstrate, not only are access to medical care and pandemic-related changes to access unequally distributed across the American population, but many Americans worry about social justice as it relates to health and medical care access.

Financial and psychological distress

Respondents acutely felt the deep and widespread economic consequences of Covid-19, and experienced emotional distress and mental health challenges due to financial anxieties exacerbated by the pandemic. Above, we described how social and healthcare inequality compound; below, we add mental health outcomes to the equation.

Respondents experiencing financial stress often tie this burden to occupational concerns. Many describe a reduction in work hours, loss of employment, or underpaid labor. They fear that these occurrences will impact their ability to care for themselves and their families, often exacerbating pre-existing economic anxieties that are stratified by race, gender, and socioeconomic status. A Black Floridian in her late 20s explained:

…it just seems like the jobs are more harder to come by. I thank God that I have a CNA license because they’re always hiring for that, but it’s just I was out of work for so long since the corona hit… I’m trying to get back on my feet and I have so much things that I have to catch up on, that I feel like when am I going to get a piece of air, because it’s like I’m suffocating in bills in debt. You know what I’m saying?

Like this individual, many respondents speak about the lack of employment opportunities in their communities and are concerned with making ends meet, often using adjectives such as “suffocating,” “stressed/desperate,” and feeling like one is on a “roller coaster.” Others note that their financial concerns reflect their worries about losing their job in the future, with many stating they work more hours because they want to prove their necessity and because they fear they have no other options. Those in occupations affected by local closures and openings also experience increased vulnerability to and anxiety around job loss. Overall, respondents’ existing economic fears and anxieties have been exacerbated by the uncertain economy during the pandemic.

In addition to economic concerns, other sources of psychological distress include disruptions to social relations and the constant fear of contracting or spreading the virus. The pandemic has forced many respondents to evaluate how to simultaneously maintain both their social relationships and preventive behaviors. Forty-six respondents, approximately 34 percent, advised that they were feeling isolated from others. The most common problem was feeling disconnected from friends and family and, often, people altogether. A white Oregonian in his late 30s explained:

I would say just companionship is a big need that is absent because of just distancing from other people. It’s hard to have physical contact, which is an important thing. As humans, we’re not designed to live in bubbles. When occasionally you’re able to give someone a hug, it feels really important.

Another respondent, a Hispanic woman from Texas in her early 30s, advises that “I guess that’s what’s been weighing heaviest is just physical connection. I do see my family. I’ve arranged for outside hours so that we don’t have so much contact. I don’t really feel like we talk about anything really deep. I don’t know.” Underlying these responses and many others are contradictory feelings about contact and safety. Health professionals assert that Americans need to “social distance” from each other and prevent unnecessary contact. But many respondents are highlighting the mental health distress that comes from these safety practices. For many AVP respondents, social distancing and other preventive measures equate to a lack, something missing in their lives that they may not have understood as important until it was gone. For these individuals, it has become quite apparent that the physical presence, and often physical touch, of others has always been a social necessity. As a result, many respondents are experiencing distress due to preventive measures meant to keep people safe and healthy.

Many respondents reported an increase in emotional stress because they worry about being infected by strangers or someone in their social group, or they experience anxiety about infecting others. “I’m scared when I walk out my door now,” said one respondent, “I feel like my anxiety levels go up to 100.” A Black woman in her late 60s from Missouri explains:

I’ve been very afraid. I was really afraid when it first came out. I wouldn’t let nobody in and I wouldn’t go out I even wouldn’t…. I was afraid to let my daughters come in. I was afraid to let my granddaughter in. I told her, she’s my caretaker and I was afraid to let her in because she got other clients. So, I was really, really afraid and I was calling my primary doctor almost every day...Well, my doctor told me to stop reading about the virus....

These participants, and others, reported an almost constant concern about contracting Covid-19. A Hispanic woman from the state of Washington said:

The change in our daily routine is the fact that you stop going out, out of fear of getting infected and also due to the fact that, in my case I don’t want to go to a hospital and just think about it, if I get sick, how could I handle that? Paying for hospitalization or a doctor’s appointment. That’s changed me as well, since now I’m very concerned and careful, using face masks and hand sanitizers, that has changed a lot too.

Notably, not all Americans are equally able to practice Covid-19 protective measures. Respondents who were considered essential workers described the anxiety-inducing balancing act between maintaining stable employment and keeping themselves safe. Earlier we provided an example of a woman with diabetes and a rare autoimmune disease who was very worried because she still needed to go to work. A Black woman from North Carolina said bluntly, “I haven’t been social isolating. I work at Walmart.” The heightened health stress caused by the pandemic thus overlaps with financial concerns, pre-existing conditions, and other factors, causing heightened anxiety for more vulnerable respondents who may be forced to put their health at risk to earn a living.

Overall, most respondents expressed anxiety that stemmed from living with the indirect effects of Covid-19. Economic anxieties, disruptions to social groups, and constant worry about contracting or spreading the virus weighs heavily on people across the country, suggesting that Covid-19 infection rates are only part of the pandemic crisis. Americans are grappling with how to live with the consequences of a global pandemic that disrupts economic and social resources.

Exacerbating mental health distress

Millions of Americans live with mental health histories that include psychiatric disorders, cognitive differences, disability, and trauma. With the onset of the Covid-19 pandemic, health professionals and social welfare organizations advised that mental health distress would dramatically increase as a result of social isolation, economic instability, fear, and anxiety. As we demonstrate above, this assertion may be accurate, but data also show a concerning trend: The Covid-19 pandemic is exacerbating pre-existing mental health distress.

Of the 135 individuals interviewed, 29 people, or approximately 21 percent, advise that the current pandemic is negatively impacting their pre-existing mental health concerns. These participants clearly state that they already lived with at least one of the following diagnoses before the onset of the pandemic: depression, anxiety, PTSD, or self-described forms of trauma. They must now contend with the added stressors of the pandemic, such as financial instability due to unemployment, underemployment, and lack of a living wage, fear of catching or spreading Covid-19, social isolation, and the resilience required to complete everyday tasks.

Most respondents detailed a clear escalation in mental health symptoms at the onset of Covid-19, including increasing anxiety levels, malaise, and concerns that their life was getting worse. These respondents were uncertain about the exact timeframe, stating only that they felt worse when Covid-19 began. In regard to her mental health, a white Pennsylvanian in her late 60s told us, “I would say since the virus started, I felt that I was struggling even more, I’ve been struggling [since] that whole corona thing started like it’s got are worse, like hard to get through the day and it’s just worse.”

Respondents with existing mental health concerns were particularly affected by feelings of isolation. A white woman in her late 80s from Ohio advised, “I was very depressed, I screamed, I cried, I was alone. And I didn’t want to be alone, I wanted somebody to be beside me and hold my hands and rub my back be with me and there just isn’t anybody.”

Many respondents also had difficulty distinguishing between pre-existing mental health distress and distress caused by the pandemic. When asked how she has felt over the past year, a Black woman in her 40s from Indiana replied:

It seems like with this corona, you’ll just be tired sooner than, you know, you’ll be tired soon and then when you take a nap or whatever, now you’re up all night. And I think it’s a lot of that going on with the corona...Yeah, I just started having panic attacks. I didn’t know what that was. I couldn’t deduce whether it was panic attacks or anxiety because they kind of got the same symptoms. But it’s more of a panic attack because it’ll come on out of the blue.

Like others, this respondent describes a fluidity between ongoing and new mental health concerns, which makes isolating the effect of the pandemic on mental health more difficult. Nevertheless, our data demonstrate that the coronavirus pandemic has led to mental health concerns, broadly and particularly for Americans already experiencing mental health distress.

Coping and resilience

In the face of mental health challenges resulting from the pandemic, respondents have shown tremendous resilience, drawing on a multitude of strategies to ward off negative mental health consequences. Coping strategies fall under two categories: collective and individual. On the collective side, Americans have found solace in each other. Spending more time at home with family, although not without its own challenges, appears to have centered the family unit as an important source of emotional support. A middle-aged Black woman from Virginia described her family’s dynamic, “We pretty much enjoy ourselves around each other, so we don’t get on each other[’s] nerves... so we pretty much don’t have a problem, like we keep each other up, so nobody get[s] depressed.” Similarly, a middle-aged white man from Rhode Island who was able to spend more time with his son as a result of the pandemic described how “that’s been the most sane thing going on, is having him, you know to [spend time] with and goof around—that’s been a godsend for me mentally.” As a Hispanic woman in her 40s summarized, “This whole pandemic thing has actually brought the family structure, us closer together because we’re all looking out for each other.”

Even outside of the family unit, Americans are relying on each other for support. A white Oregon man in his late 30s described how the pandemic brought people together within his community, “And because of the recent pandemic, there’s just a lot more communication as well, just checking in on people and I’m seeing kind of emotional support in general. Just human communication.”

In addition to collective coping mechanisms, respondents also described individual strategies for managing their mental well-being, which often involved extending and adapting prior strategies to the current situation. As a Black woman in her early 60s put succinctly, “I’ve been learning to cope forever and a day. So, that really hasn’t changed. Improvising here, improvise there and that’s it.” Most commonly, respondents turned to religion and faith. A Hispanic man in his 50s from New York described relying on faith as he waits out the pandemic: “I have been supported by and I have found refuge, more than ever, in God’s love and mercy, until the situation reverses and becomes normal and things return to their normal course.” Similarly, a white man in his 20s from Oregon explained, “I think that’s the effect that being religious or spiritual adds to this is that you don’t feel like your world’s ending because whatever’s going on in your life isn’t your whole world.” In the absence of organized religious services, respondents primarily described their individual faith, although some mentioned the importance of regular (virtual) church services.

Additional coping strategies included mindfulness and meditation, baking, cooking, gardening, spending time outside, cleaning, and generally staying busy and finding ways to fill time at home. For respondents who self-identified as “homebodies,” the stay-at-home orders were less distressing than for others who were more outgoing. As a respondent from Arizona described, “I know some people, with all this Covid stuff going on, they’re going crazy, oh my god, I’ve got to stay in the house, and they’re going out, and I’m not staying in with our kids because they’re driving me crazy. No, I’m personally cool, calm and collected.” Importantly, respondents did acknowledge that these strategies are in fact coping mechanisms for dealing with an unprecedented situation: “I’ll be honest with you because of the whole Covid thing, like I just I don’t know, we’re eating like way too much ice cream... because this Covid situation just sucks, and I’m just going to eat as much ice cream as I want.” This raises the crucial point that, although Americans are coping, both individual and collective coping strategies can be exhausting to maintain and may not work forever. Furthermore, although respondents in our sample rarely mentioned maladaptive coping mechanisms such as overeating, alcohol use, or drug use, the need to cope with such elevated stress and anxiety is likely leading some to harmful behaviors and adverse health outcomes. (It is also possible that the people most likely to engage in these behaviors were least likely to agree to be interviewed, or that our respondents were reluctant to bring up these behaviors.)

Yet, despite significant mental health challenges, Americans are doing their best to remain positive and hopeful. A white woman in her 60s describes the importance of maintaining hope: “I miss my family. I miss being able to socialize, those kinds of needs but, these are temporary. This will not last forever. And, I know a lot of people feel like they are lasting forever but they’re not.”

Conclusion

The coronavirus pandemic is a health crisis, but its consequences extend beyond infection with the virus itself. Covid-19 is unequally distributed across the country. In some families and social networks, it is a real, everyday presence and threat; in others, coronavirus is still a hypothetical risk, or something that happens to other people. Nevertheless, as these in-depth interviews with a sample of Americans demonstrate, Covid-19 has affected the nation’s health (particularly mental health) and health care, leaving people frustrated with the government’s response and seeking comfort where they can find it. While our respondents have shown tremendous resilience, there is still substantial room for institutional intervention, particularly given that the indirect consequences of the virus are most harmful for more vulnerable Americans, such as essential workers, BIPOC, the unemployed, those who live alone, and individuals with pre-existing mental health conditions. Above, we discuss several consequences of the pandemic for health outcomes. Here, we reflect on those consequences and make recommendations for future research and policy development.

A first key takeaway is that, beyond the significant and concerning infection rate and death toll, a substantial portion of the health impact of the pandemic may result from protective measures instituted to slow the spread of the virus. Within the healthcare system, hospitals and medical practitioners have made changes to keep their patients and employees safe. This has resulted in disruptions to healthcare access, preventing some people from seeking or receiving medical care. Social isolation practices are also negatively impacting respondents’ mental health. Financial stresses and occupational anxieties, often due to the economic consequences of coronavirus response measures, in turn have their own health consequences as they negatively affect Americans’ mental health as well as their access to insurance and ability to pay for health care. Preventative measures like social distancing and remote work have been instrumental in reducing viral transmission, and interview responses demonstrate a desire and need for broader and more consistent measures as well as more extensive public education and outreach to ensure folks are engaging in protective behaviors. But our report also demonstrates that these measures can have detrimental and unequally distributed side effects for mental health and healthcare access. Overall, policymakers should consider potentially harmful consequences of protective policies and offer immediate solutions and resources, such as creating or expanding options for people who lose their jobs to retain health insurance, expanding telehealth infrastructure, proactive mental health outreach, and community-based operations that allow people to give aid and support to those in their own neighborhoods.

A second key takeaway is the need to address the ways in which the consequences of the pandemic are stratified across existing racial, socioeconomic, and gender inequalities. Privilege—including the ability to retain employment, health insurance, and healthcare access—can protect some Americans from negative consequences. On the other hand, historically marginalized groups are more likely to experience harm. BIPOC are not only more likely to have adverse outcomes from Covid itself, but are also disproportionately impacted by pandemic-related economic distress.9 Women and femme-presenting individuals also face harsher economic consequences of the Covid-19 pandemic, demonstrating that women’s labor is often undervalued, underpaid, and ignored.10 BIPOC, women, and femme-presenting respondents may be experiencing unique (mental) health distress because they live with the intersectional consequences of racist and heterosexist histories in the United States. For policymakers to address these inequities, they must focus on changing the social structural conditions that create health inequality in the first place, and ensure that changes are accessible for historically marginalized Americans. More specifically, policies targeting racial, socioeconomic, and gender inequality will also work to resolve some negative consequences of Covid-19.

Together, these two takeaways underscore the need for a comprehensive yet targeted response to the health challenges brought by the coronavirus pandemic, one which takes into account potentially unanticipated consequences of public health policies as well as the acute needs of the most vulnerable populations.

Jeremy Freese is a professor of sociology at Stanford University. Amy L. Johnson is a graduate student in sociology at Stanford University. Macario Garcia is a research manager at the Stanford Center on Poverty and Inequality.

Notes

1. National Academies of Sciences, Engineering, and Medicine. 2017. Communities in Action: Pathways to Health Equity. Washington, DC: The National Academies Press; Weinick, Robin M., Sepheen C. Byron, and Arlene S. Bierman. 2005. “Who Can’t Pay for Health Care?Journal of General Internal Medicine 20(6), 504–509; Sainato, Michael. 2020. “The Americans Dying Because They Can’t Afford Medical Care.” The Guardian; Carney, Megan A. 2015. “Eating and Feeding at the Margins of the State: Barriers to Health Care for Undocumented Migrant Women and the ‘Clinical’ Aspects of Food Assistance.” Medical Anthropology Quarterly 29(2), 196–215; Quesada, James, Laurie Kain Hart, and Philippe Bourgois. 2011. “Structural Vulnerability and Health: Latino Migrant Laborers in the United States.” Medical Anthropology 30(4), 339–362; Kattari, Shanna K., N. Eugene Walls, Darren L. Whitfield, and Lisa Langenderfer-Magruder. 2015. “Racial and Ethnic Differences in Experiences of Discrimination in Accessing Health Services Among Transgender People in the United States.” International Journal of Transgenderism 16(2), 68–79.

2. Green, Monica H. 2008. “Gendering the History of Women’s Healthcare.” Gender & History 20(3), 487–518.

3. Keisler-Starkey, Katherine and Lisa N. Bunch. 2020. “Health Insurance Coverage in the United States: 2019.” United States Census Bureau. Report Number P60-271; Banthin, Jessica, Michael Simpson, Matthew Buettgens, Linda J. Blumberg, and Robin Wang. 2020. “Changes in Health Insurance Coverage Due to the Covid-19 Recession: Preliminary Estimates Using Microsimulation.” Urban Institute.

4. Raifman, Matthew A. and Julia R. Raifman. 2020. “Disparities in the Population at Risk of Severe Illness From Covid-19 by Race/Ethnicity and Income.” American Journal of Preventive Medicine 59(1), 137–139.

5. CDC Covid-19 Response Team. “Geographic Differences in Covid-19 Cases, Deaths, and Incidence—United States, February 12–April 7, 2020.” MMWR. Morbidity and Mortality Weekly Report 69(15), 465–471.

6.  See the CDC Covid-19 data center for more information: https://www.cdc.gov/coronavirus/2019-ncov/cases-updates/index.html and https://www.cdc.gov/ coronavirus/2019-ncov/covid-data/investigations-discovery/hospitalization-death-by-race-ethnicity.html.

7. Washington, Harriet A. 2006. Medical Apartheid: The Dark History of Medical Experimentation on Black Americans from Colonial Times to the Present. New York: Random House; Dudley, Rachel. 2012. “Toward an Understanding of the ’Medical Plantation’ as a Cultural Location of Disability.” Disability Studies Quarterly 32(4), 2159-8371; Davis, Angela. 1983. Women, Race, & Class. New York: Random House.

8. See https://www.ipsos.com/en-us/news-polls/axios-ipsos-coronavirus-index for summary of tracking poll information on Covid-19, including the time series and wording for questions about personally knowing someone who had the disease or died from Covid-19.

9.  Thakur, Neeta, Stephanie Lovinsky-Desir, Christian Bime, Juan P. Wisnivesky, and Juan C. Celedón. 2020. “The Structural and Social Determinants of the Racial/Ethnic Disparities in the U.S. Covid-19 Pandemic. What’s Our Role?” American Journal of Respiratory and Critical Care Medicine 202(7), 943–949; Collins, Caitlyn, Liana Christin Landivar, Leah Ruppanner, and William J. Scarborough. n.d. “Covid-19 and the Gender Gap in Work Hours.” Gender, Work & Organization n/a(n/a).

10. Landivar, Liana Christin, Leah Ruppanner, William J. Scarborough, and Caitlyn Collins. 2020. “Early Signs Indicate That Covid-19 Is Exacerbating Gender Inequality in the Labor Force.” Socius: Sociological Research for a Dynamic World 6, 1–3.

The American Voices Project gratefully acknowledges support from the Annie E. Casey Foundation; the Bill & Melinda Gates Foundation; the Center for Research on Child Wellbeing at Princeton University; the Chan Zuckerberg Initiative; the David and Lucile Packard Foundation; the Federal Reserve Banks of Atlanta, Boston, Cleveland, Dallas, New York, Philadelphia, Richmond, and San Francisco; the Ford Foundation; The James Irvine Foundation; the JPB Foundation; the National Science Foundation; the Pritzker Family Foundation; and the Russell Sage Foundation. The Stanford Center on Poverty and Inequality is a program of the Institute for Research in the Social Sciences.

The authors thank Prabal Chakrabarti, Tiffany Hollin-Wright, David Huete, Karla Jimenez-Magdaleno, Bina Shrimali, and Julie Siwicki for their helpful comments. The views expressed here are the authors’ and not necessarily those of the Federal Reserve Bank of Atlanta, Federal Reserve Bank of Boston, Federal Reserve System, Stanford Center on Poverty and Inequality, or the organizations that supported this research. Any remaining errors are the authors’ responsibility. The American Voices Project extends our sincere gratitude to everyone who shared their story with us. We would also like to thank our researchers and staff.