**6. Toxic stress as an international health security threat**

No one is immune to the effects of COVID-19. In addition to millions of confirmed cases worldwide, COVID-19's effects on individuals and communities extend far beyond hospitalizations, morbidity, and mortality. Pandemics have deleterious consequences on the well-being of individuals and communities through direct effects of the illness and emotional isolation, economic loss, work and school closures, and maldistribution of resources [45]. Published data describe how various consequences of pandemic mitigation efforts (such as quarantine) affect stress, depression, fear, anger, boredom, stigma, and other negative states. Adults readily report worse psychological well-being now as compared to before the pandemic [46]. Because data suggest that children might less frequently transmit or become severely ill from the virus, the more unique consequences that COVID-19 has on children may easily be overlooked. Although data on child and family well-being during COVID-19 are not as robust, increasing reports of intimate partner and family violence around the globe continue to be of great concern [47–49]. Long-term impacts on broadly defined health security will likely be both significant and difficult to predict.

Within the international context, conflict-affected populations are particularly vulnerable to COVID-19. Overcrowding and inadequate water and sanitation systems in refugee camps and informal settlements, coupled with previously existing illnesses, may increase the spread of COVID-19 and further exacerbate the emotional trauma upon the most vulnerable segments of the population. Moreover, resource and health system constraints may restrict access to adequate and appropriate care. Control measures such as physical distancing may be difficult and may also increase economic precarity, intimate partner violence, and food insecurity in populations already vulnerable [3]. The incidence of posttraumatic stress will likely increase following the pandemic – another "invisible" aspect of this global event, reported following previous emerging infectious disease outbreaks [50].

Downstream, long-term consequences of toxic stress are more poorly understood, but the associated increase in behavioral health issues, combined with secondary implications inherent to these considerations, are bound to create a truly global urgency and crisis [4, 51]. This is especially true when looking at geographic areas with limited resources and a lack of robust mental health infrastructure. In terms of addressing some of the challenges related to halting any downstream escalations secondary to toxic stress, several truly international strategies can be considered. Among those, the most prominent is telehealth/telemedicine, as discussed in a subsequent section of this chapter [52, 53]. Other important components here include the provision of safe environments, education, as well as ongoing close support and reassurance.
