My name is Maria Doria, I am a psychologist based currently in Uruguay. We are living a serious and sad moment, with a strong human, social and economic impact. Clearly, this global pandemic revealed that the world was not prepared on many levels for an event of this magnitude. It is a situation that shows our strengths and weaknesses as people and as societies. I would like to share with you some of my concerns regarding COVID-19 from a psychosocial perspective. I hope to be able to convey the vital importance of including psychosocial support in early phases of any infectious disease emergency, to effectively protect and support the mental health and the well-being of people, particularly the most vulnerable groups. The benefits of mandatory mass quarantine for mitigation of this pandemic are unquestionable today, but the direct and indirect psychosocial costs have to be considered by the Governance, and adequate alleviation strategies need to be put in place. The mere expression of “social distancing”, diffused worldwide as a protective recommendation, is rather misleading from a psychosocial perspective; it should rather be substituted by terminology such as “physical distancing” or “social-in-distance” highlighting the increased importance of being socially connected, even if by virtual means, in times of confinement.
The latest literature review on the impact of previous situations of mandatory quarantine due to infectious diseases (published recently in The Lancet), reports increased psychological distress, including anxiety and depression symptomatology, with long-lasting effects in some cases. In the latest outbreak of SARS in the city of Toronto in 2002, a Canadian study showed that depression and post-traumatic stress grew around 30% reaching increased prevalence with longer duration of quarantine and direct exposure to infected people. Other reported stressors are: inadequate information, inadequate supplies and protection, infection fears, boredom, frustration, financial loss, personal loss and stigma. Quarantine is often an unpleasant experience for all who experienced it, even healthy people, as it involves separation from loved ones, the loss of freedom and uncertainty about the future. However, the psychological impact can be dramatic to first-line exposed health workers (true heroes on this battle) and population groups with pre-existing conditions of vulnerability such as psychiatric history, substance-use dependency and familial intra-conflict or violence. The worst case scenarios might involve the combination of multiple psychosocial stressors, example: an infected nurse, affiliated to a low-protected health institution that has been put in layoff, with reduction of salary, after having infected a close one that ultimately dies alone of covid19 in the hospital. How long will be needed to recover from the magnitude of the trauma inflicted? And how can mental health and psychosocial support help, both in crisis and after-crisis management?
According to the latest WHO situation report dated 12th of April, we have today worldwide 1.7 million confirmed COVID-19 cases and around 100,000 deaths. In South America, a landscape of 58,000 confirmed cases and (1697 deaths) – equivalent only to 7% of the cases officially registered in Europe but more than triple of those registered in South-East Asian region. Brazil is in the lead (with almost 20,000 cases) followed by Chile and Ecuador. Across the region, social inequality emerged as an issue as COVID-19 cases were imported, affecting higher class citizens who could afford to travel abroad and pay for treatment in high-quality private hospitals. Very soon, the pattern reversed in many countries, being the poorest the worst affected, such as those living in Rio’s favelas, where there are now confirmed cases. Particularly horrific are the news from Ecuador, where corpses are abandoned in the streets of Guayaquil city due to the fear of contamination and exceeded capacity of the health system, funeral homes and cemeteries. As mentioned, aggravated complications of bereavement and trauma can be expected in such context, where the suffering of the loss of a loved one is exasperated by the lack of social support and the normal mourning rituals imposed by the emergency sanitary restrictions.
Uruguay is reported to have relatively few cases, 494 cases and 21 deaths. Although interpretation of the reported numbers for all countries should be conservative, due to multiple factors (including number of people tested), the decision of the Uruguayan government in declaring preventively the status of “health emergency”, after four confirmed imported cases from Milan, seems to have paid off in terms of public health. Other public health and economic efforts count in the equation, as well as collaboration from local scientific institutions, namely the Institute Pasteur in Montevideo, which helped significantly in diagnostic testing. At one hand, this sounds good news, but on the other hand, surprisingly, Uruguay is historically a country of great mental health vulnerability. It has the biggest official suicide mortality rate in the region (18 per 100,000 people, WHO 2017 – almost double of the average global rate), relatively high depression rates and very high divorce rates, with a critical problem with domestic violence. With only one week of quarantine, the cases of domestic violence in Uruguay have risen exponentially. Sadly, for many women and children, home is the place where they are most at risk, sometimes risk of life.
In conclusion, it is clear that the impact of this worldwide pandemic is systemic and needs a systemic response. It would be audacious trying to measure the real impact of the COVID-19 pandemic not only by the GDP, but also taking into consideration indicators such as the “Global Health Index” and the “Global Happiness Index”, which perhaps also need reviewing to integrate the specificities of this pandemic. What would be the cost-benefit value of having a psychosocial approach in the prevention and response to epidemic infectious threats? Overall, mental health remains a neglected part of global health services, one that is particularly relevant in emergency crisis affecting humanity. Today marks the historical launch of the first Uruguayan helpline service of psychological contention, established by common efforts between the Ministry of Health and Associations of mental health practitioners in Uruguay. The COVID-19 emergency, despite its tragic nature and adverse effects on mental health, is also an unprecedented opportunity to develop better mental health systems for all in need, which will be crucial to the overall well-being, functioning, and resilience of individuals and societies in recovering from this crisis.