Surmounting the Second Wave; Pandemic Lessons

Pandemic Lessons on Dealing with Grief, Loss and Fear with Dr. Prabha Chandra, Prof. Paulomi Sudhir, Dr. Soumitra Pathare and Dr. Ravindra Mehta in conversation with Rohini Nilekani.

The second wave of the pandemic has left ever more numbers of people dealing with stress and anxiety. There is fear and uncertainty, loss and grief. There is isolation, survivor’s guilt, and often an inability to get some closure with rituals in the case of death. There is frustration and anger at the system. Normal ways of processing emotional tension seem to be less effective than usual. There is a lot of alarming data on the emergence of widespread mental health issues in the pandemic. Yet there are some positive signs that there is less stigma about approaching professionals, and seeking help. People now recognize what we did not in 2020 – this will be a marathon, not a sprint. How can we hope to cope?

This is an edited version of BIC’s panel discussion on ‘Surmounting the Second Wave, Pandemic Lessons on Dealing with Grief, Loss and Fear’ with Dr. Prabha Chandra, Prof. Paulomi Sudhir, Dr. Soumitra Pathare and Dr. Ravindra Mehta, moderated by Rohini Nilekani. The four distinguished medical experts discuss what they have learnt over this past year, how to transform hopelessness into positive agency, and how we can keep up our energies for developing better resilience.

As a country, India has faced many natural disasters. Earthquakes, cyclones, floods, and droughts occur routinely and shatter many lives. Millions of people also live with stressors like poverty, injustice, and exclusion in this country. However, the second wave of the pandemic seems to be something else altogether. Few people have encountered a tragedy of this proportion in living memory, and we still don’t know when this will end and normalcy will return. When will these deaths cease? When will the virus become less virulent? And how will we deal with the economic stress that awaits once it does. It’s no wonder so many people are overcome with emotional stress that they have not experienced before.

The data is really staggering – NIMHANS’s own helpline has seen a 40% spike in calls in April and since it was started in March 2020, the institute has received about 4.5 lakh calls, mostly from people with no history of clinical mental illness. People are experiencing anxiety, depression, fear, insomnia, and loneliness. But these psychosocial issues of the first wave are now morphing as callers cope with the hospitalisation and deaths of loved ones, not being able to perform last rites, the fear of not finding hospital beds or oxygen, and all this grief and uncertainty has led to severe psychosocial issues. Snehi, a Delhi-based foundation running a COVID helpline reported that after analysing the data since November, calls for help from those with suicidal tendencies have risen from 1% to 7%. NIMHANS’s report suggests several kinds of anxiety disorders are expected to increase and cases of generalised anxiety disorder, panic disorder, phobias, and obsessive-compulsive disorders might become more common.

We have also seen cases of post-traumatic stress disorder (PTSD), which are expected to increase as well. The NIMHANS document cites a study that found a 7% to 9% prevalence of PTSD among those living in areas hit hard by COVID. Dr. Shekhar, who heads the Centre for Psychosocial Support in Disaster Management, believes that within a year, the affected population will come down to about 30% i.e. people suffering prolonged grief over the severe trauma that they’ve suffered through this pandemic. In another year, there should hopefully only be 10% who need long-term mental healthcare. The biggest hurdle will be access to professional help for people who are suffering. The national mental health survey in 2015-16 implemented by NIMHANS found a treatment gap for mental disorders ranging between 70% to 92% for different disorders, 85% for common disorders, and 73% for severe disorders. We simply do not have enough mental help professionals in India for our population of 1.3 billion plus people. We only have 9000 certified psychiatrists in this country, and 700 psychiatry students graduating every year. These numbers mean that 0.75 psychiatrists for 100,000 people, while the ideal number is at least three. We need to therefore learn how to equip ourselves and help others deal with these emotions.

Even though this pandemic has made us feel isolated and lonely at times, we are all in this together and India’s resilient Samaaj has stepped up with NGOs running helplines and coalitions of mental health professionals coming together. Many people have come up with creative solutions at the societal level to help vulnerable groups, especially the elderly. This pandemic has confirmed that this is an era where the elite can no longer secede from the rest. It’s in our own self-interest to reach out to others and do what we can to build a less segregated and unjust society because viruses and other disasters know no borders or gated communities. The pandemic has reiterated the importance of creating better societal outcomes so that the next time there is a crisis, we will see less personal, social, economic devastation.

What Made the Second Wave Different 

Dr. Ravindra Mehta, a cardiac pulmonologist, describes the second wave of the pandemic in India as the holocaust of our lifetimes. The first wave was bad, but we could see it coming towards India, he says, although medical practitioners were still scrambling to understand the disease. Many in the workforce were uncertain and apprehensive about coming to work, and Dr. Mehta recalls fearing that all the nursing staff would disappear if Kerala’s borders were open. As much as medical practitioners were being lauded as warriors, there was not much of a warrior element in the workforce, he says. During the interpandemic period, there was a sense of relief, and then the second wave hit. This is when the lack of infrastructure, medications, and the preparation required came into stark view. On the other hand, Dr. Mehta says that the workforce was willing to step up now. People were used to wearing PPE suits, knew more about the virus, and were vaccinated, so there was less absenteeism. However this wave saw an enormous number of young people get sick, a shortage of beds and oxygen, and the chaos of grief. Calls came in everyday for medication or beds, and two days later when healthcare workers called back, the phone would not ring because that person wasn’t around anymore. Dr. Mehta recalls the devastation of low oxygen alarms for the patients who were lucky enough to get beds in the hospital. The first wave was a cakewalk compared to the second wave, he says. Healthcare workers had to deal with young people pleading because they had a three-year-old or five-year-old at home who couldn’t breathe, or a 22-year-old whose father passed away and who was begging for a bed for her mother. The only way for medical staff to keep going was to suppress their feelings in order to continue working long shifts and treating people, with no breaks or time off. 

Dr. Prabha Chandra believes that the challenge with the first wave was the stigma attached to the disease which meant that many people did not want to get tested or go to hospitals. The fear of being stigmatised and marginalised was greater than the fear of the disease itself. Healthcare workers were beaten up, nurses were not allowed in apartment blocks in case they were infectious. But in the second wave, those concerns along with the economic loss, migration, and struggling, has been eclipsed by the large-scale grief and loss. Dr. Chandra remembers a similar feeling when she was working in the Rakai district in Uganda during the ’90s. She trained in HIV work and saw villages that only consisted of grandmothers and children. She still remembers the feeling of seeing no young people in those villages after all the deaths. Now India is also seeing multiple losses – young people in their 20s and 30s suddenly have lost both their parents, families have two and three members in the ICU dying, multiple losses which no one ever thinks will happen in their life. Dr. Chandra says she’s had to skill herself enormously, training in new methods of treating people and handling traumatic bereavement. Normally when people die, you grieve, but with traumatic bereavement, the grief is coupled with trauma which her training had not equipped her to deal with until now.

We pride ourselves as a society with a lot of social support, says Dr. Chandra. Mental health parameters and outcomes are better in India than in the West because we have very good social support. However, the socialised solution we have was taken away during this time, so the things which were protective and were buffering people from developing problems were no longer possible. She believes that this has affected the elderly a lot, who were coming to her with loneliness, anxiety, and a sense of utmost helplessness because they are not used to social isolation at all. The support networks that they used to have through family or caretakers suddenly broke down.

With this in mind, Dr. Chandra mentions that there has been a heightened need for medication which concerns her because while she doesn’t want to medicalise some of these problems, it was the only alternative. It’s a dilemma as a psychiatrist, especially because for the elderly, those with medical issues, or people who are recovering from COVID, many of these medications cause their own side effects which is an issue at a time when medical care can’t be accessed easily. However, if a person’s functioning is impaired, their daily life is affected, and they’re not getting better using psychological methods, then medication under the supervision of a doctor does have a role to play, she says. Another issue though is that the majority of communication with doctors had to happen online and there is a large percentage of people who don’t know how to access Zoom or struggle with WhatsApp video calls. Dr. Chandra points out that we need to think through this issue on a policy level and as organisations, to enable better internet facilities and educate certain groups who don’t have access to the internet on how to use these systems and use telepsychiatry for their own benefit.

In March 2020, Prof. Paulomi Sudhir remembers many PhD scholars, clinical psychologists, and psychiatrists volunteering for the helpline that she has been associated with, however they experienced a lot of helplessness because they could not do anything for the people calling in. The flood of calls took them by surprise and they tried to help with the resources and rations, as well as people who were stuck where they were during the lockdown. Over time, this has changed and the emotions have turned from anger to anxiety, fear, and uncertainty, she says. During the first wave, they were looking at how to help people manage resources and anxieties, but the second wave left them at a loss in terms of being able to assure callers that things would be okay. It was difficult knowing what to say to clients who were calling when we were also experiencing the same kinds of anxieties and helplessness, says Prof. Sudhir. Training does not focus on how to deal with such traumatic and unexpected losses, not only with clients but also among people in the department, friends, and family.

Prof. Sudhir agrees that falling back on regular strategies and psychological methods for people with anxiety disorders or depression was difficult given the modality of therapy that they were able to provide. The relaxation methods that were possible face-to-face were no longer an option now, and so she says that had to get innovative in how to reach out to people. With these limitations, interventions were still possible for mild to moderate cases where the anxiety was identifiable and simple psychological methods made a difference. However with the collapse of other support systems, Prof. Sudhir notes that often she was the only resource for many of her clients who were isolated at home or not around family. She says her work has now gone beyond the usual CBT or psychological interventions that she used to provide. She has also had to put together training programmes and resources for self-care for the many healthcare professionals. But for those who were suffering from depressive symptoms during this time, it was inadvisable for them to go back to their routine activities which would otherwise help with behavioural activation. So there were many ways in which usual psychological methods had to be adapted to the situation. With the move to online consultations, she soon realised the importance of being persistent and following up with clients rather than waiting for clients to call, assuring people that their services were available.

Coping With a New Reality

In terms of how people cope, as with any disaster of this magnitude there are different trajectories, says Dr. Chandra. One trajectory could be that people are actually doing quite well and coping with the situation; another where people are sub-optimal but not collapsing; a third where people are struggling to cope; and a much smaller group who may be doing better than optimal i.e. those who reach into their inner resources to help people and are doing even better than they did earlier. These are the four different trajectories of mental health, Dr. Chandra says, and it’s very important for us to understand that not everybody is going to collapse. We must also remember that all of this does not happen on a blank slate because people already have vulnerabilities, pre-existing mental health problems, difficulties at home, or other disabilities. For people who may already have certain vulnerabilities in addition to a COVID diagnosis, they would need extra support. She believes that we should have planned better for these people and had services available for them beforehand, even before the second wave began, because we knew that they’re more vulnerable.

When it comes to mental health, even the WHO agrees that it’s everybody’s business, Dr. Chandra points out. Mental health is too important to be left alone only to professionals. If certain parts of a building are weaker, we provide scaffolding until that area can be strengthened. Similarly, she describes the need for social scaffolding i.e. providing social support to vulnerable groups while they wait for access to professional help. NGOs, families, and communities can make sure there are systems in place to identify and support vulnerable people. Early on in the pandemic, the WHO put out a lot of resources including guidelines for psychological first aid. It focuses on providing safety, calmness, improving people’s self-efficacy, promoting social connectedness, and providing optimism and hope. There are also courses available free of cost for people to train in psychological first aid, notes Dr. Chandra, which is a way for any of us to provide support to others. 

We’re also having to grapple with a kind of proximity to death that most of us have never experienced before. I realised that the root of my panic disorder was about my fear of death, and at this time so many of us have come face to face with death on a very large scale. As someone who faces a lot of death, Dr. Mehta says that usually one has to be unafraid themselves if they are to reassure others. However, the pandemic has changed things in different ways. Those who were high-risk stepped back to provide other roles and consult online and for healthcare workers who were coming in, there were several fears about death as well as what would happen to their families and loved ones afterwards. Nurses and doctors were concerned about whether the government or hospitals would provide their insurance. Hospital administrators who were usually just dealing with operational issues suddenly became crisis administrators. He explains that in order to deal with others, first healthcare professionals had to come to terms with the situation themselves, which some are still struggling to do. 

Dr. Mehta describes many medical professionals having difficulties with the scale of death and how quickly each patient’s situation could change for the worse, especially when they chose the profession in order to save lives. He says that it has taken some time for healthcare workers to get used to this. Ideally, they would have been mentally prepared before the pandemic, so that they could quickly move from crisis to resolution. There were also issues of communication – to provide medical professionals with a positive feedback loop so that they could continue to do work and for patients to be able to speak with their families. Arranging video calls for people in the ICU was a challenge, when people have a limited amount of time on a device before it has to be given to the next patient. Slowly, healthcare workers have gotten comfortable with the challenges of this pandemic and have been able to learn to cope with it and give their patients hope.

In a way, the people who acted cautiously and were fearful and practical about the risks we were facing are the ones who may have been better prepared during the second wave, says Dr. Pathare. He mentions his own practicality, in terms of making sure his family knew where documents and money was kept in the house and his preferences for his funeral, in case he was to die. By settling his affairs, he says that he was able to feel prepared in case the worst happened. However, even though she was cautious, Dr. Chandra notes that she still lost many loved ones in both waves as have so many others, so this crisis has touched all of us. She has found that her patients now have also developed a practical attitude towards death, similar to Dr. Pathare’s, where they are coming to terms with their own mortality. However, this is easier for older generations than young people who are simply not prepared to lose parents or family members so soon. Many children have had to mature very quickly and look after their parents, taking charge, ordering ambulances, checking oxygen levels, etc. They’ve had to grow up very fast, says Dr. Chandra. 

Prof. Sudhir notes that, more than the fear of death itself, many people are anxious about how they will die, how difficult or painful it will be, and how it will affect their families. What we do to cope with these questions and fears is essential. For example, people focusing on the news to try and understand what is going to happen can actually accentuate this fear, she says. On the other hand, complete avoidance and a reliance on behaviours to distract ourselves from dealing with reality might not be helpful either. For many people, it comes down to a fear of death which needs to be addressed. Although it’s not an irrational fear, there are certain behaviours that may not be helpful in processing this fear, says Prof. Sudhir. It’s important to get the right information about whether one is at risk or not, but being overly anxious to a point where people become extremely dysfunctional is an issue. For example, being house-bound when they need not be and restricting other family members and not allowing others to go out because of that fear. These kinds of anxieties need to be addressed with psychological methods or even the restructuring of the beliefs that they have about these fears. 

Strength Born Out of Crisis 

These past few months have been difficult on many, but especially on overstressed healthcare professionals who have had to deal with things they may not have trained for at a scale that they’ve never encountered before. We hear a lot about post-traumatic stress disorder, however I’ve also come across the concept of post-traumatic growth. This isn’t to say that we should place the burden of emotional recovery on the individual, expecting them to stay positive in order to get well. But there are many studies, some of which have looked at COVID-19 as well, which have found that after trauma you may be able to experience a kind of personal growth. This is rooted in the idea that a primal belief in a good world, an acceptance of death, or a different positive orientation where one looks forward rather than backward, is associated with the ability to move towards growth rather than disorder. The idea that maybe some of us will be able to understand a bit more of ourselves and others feels like something to look forward to, while knowing that we are all in this for the long haul.

Adding to this, Dr. Mehta mentions that many have also gained the strength born out of crisis. When you go through something of this nature, you remember some positive thought, organised action, or commitment to the larger cause that gets you through it. For him, it was to think of outcomes and concentrate on the people they could help and send back home to their families. For many medical professionals coming out of the second wave, they are left with this strength which they can repurpose and help them to be more prepared in the future. Dr. Chandra also notes that more healthcare workers became cognizant about mental health issues and were seeking training now. She works with obstetricians and with pregnant and postpartum women, and found that many pregnant women and new mothers were struggling with anxiety and fear of death. Obstetricians began approaching Dr. Chandra to understand how to help these patients, which was not the norm earlier.

Perhaps systems will change now, to become slightly stronger, more resilient, and more holistic, she says. We need post-traumatic growth of systems, not just the individual. For example, if a school begins doing a lot of proactive things and thinking beyond online classes to address art and culture, discuss the effect of the pandemic, and open conversations around emotions, that is going to make a difference to children, who will then help their parents to be more resilient and thus the system is more resilient. So Dr. Chandra advises talking about resilient systems and post-traumatic growth in that context, rather than putting all the onus on the individual.

When we’ve been through adversities, we realise that we do become better because of it, says Prof. Sudhir. People evolve to be more flexible and adaptive, they learn how to cope with difficulties, and they become more resilient. She noticed that some of her patients who had already had experiences with trauma were able to handle the pandemic better than others. One of her patients wrote to her to thank her for the ability to cope even though their whole family had tested positive. So we can train ourselves to be able to deal with stress better or differently than before. 

Dr. Pathare believes that we need to now reframe how we look at resilience and ask ourselves what we can do as a society and in public policy to promote post-traumatic growth. What can we do as society so that more people get growth rather than disorder? He says that this is where some amount of joined-up public policy thinking is required. We tend to think in silos – our healthcare, employment, and social justice systems think in their own silos but we need collaboration now. He gives the example of the Canadian government during the first wave, who promised to pay employers 80% of salaries to keep people in a job, even if there was no work to do. They could have just paid unemployment money to people instead, but that ignores the fact that employment and work has a psychological meaning and value. Keeping people employed so that they feel that they have work to do is more important than just giving money. This is why joined-up thinking is required when governments are coming up with public policy for growth. Instead, what we’re seeing are very narrow attitudes towards dealing with the issue. The pandemic is seen as a health sector problem so they should deal with it, whereas the health sector is often only picking up the pieces of problems created in other sectors. The health sector is actually at the end of a long chain and the dumping ground of everybody’s problems. So we must look at what we’re going to do differently so that we can grow from this crisis, Dr. Pathare advises. 

The Way Forward 

Dr. Chandra reminds us that there’s no one right way to grieve, everybody has their unique pathway to deal with grief. Some might want to talk about it with relatives and friends while others may prefer to silently process it themselves. We must recognise that grief will take its own path and all we can do is listen to people and be witness to the grief, she says. Grief needs to be witnessed and validated. People should be able to process their loss, not just of the person they have lost but the identities they have lost as well, as daughters, mothers, brothers, etc.  Prof. Paulomi agrees, mentioning that one of the things we are trained to do when someone around us is grieving is to suggest practical solutions for what they can do to distract themselves or feel better. But instead, we must learn to understand, be there for them, and let them process their pain on their own terms. Anger is another emotion that needs to be acknowledged and validated, of bereaved families but also of the frustration of young people. Teenagers are having a difficult time right now, says Dr. Pathare, because they’ve lost the freedom that they’re used to. Parents need to give them some space during this time and keep an open mind about routines and discipline, she suggests. 

While some people are experiencing a lot of loneliness and isolation, we also have the opposite problem where families are now crowded into small spaces and there is a lack of privacy. This has been dangerous especially for women in abusive households, where they are not able to access psychologists or counsellors because there is no privacy or space to do so. Dr. Chandra mentions a study she has recently concluded on women experiencing domestic violence, in which counsellors one-stop centres reported that many women are not able to avail of their services because of privacy issues. They have had to think of different code words to use to indicate violence, so that women can speak without fear in their homes. Counsellors also said that they need more training with telephone support and access to transport to help women who otherwise cannot leave their house during a lockdown. Going forward, we need to look at how to improve these systems for families and children, she says.

In terms of a macro perspective, there are many things that we could be doing at a policy level that would make a difference, argues Dr. Soumitra Pathare. The first thing we need to improve on is our public health messaging. The information given to the public was not clear over the past 15 months and did not prepare people for what might come. Indians believed that this was a 200-metre dash, when actually it is a marathon. The problem arises when suddenly, after 200 metres when everyone is tired out because they ran at full speed, they’re told that they have to run another 26 miles. Our public health messaging, which we have otherwise fared successfully like with HIV-related messaging, was quite inexplicably confusing and inadequate. Going forward, we need to get this right, says Dr. Pathare. 

The second public policy issue that needs to be updated is the regulations around last rites and funerals, according to Dr. Pathare. While counselling is important, many Indians work through their grief through actions, and the rituals and behaviours are not just important from a religious perspective, but as a way of dealing with those difficult emotions. The current COVID death protocols don’t make scientific sense anymore, when the CDC in Atlanta is allowing families to prepare bodies for burials. It would help with grief if families here are able to carry out the last rites and hold funerals properly. When we talk about grief, Dr. Pathare reminds us that this also includes the loss of material resources, which is not being talked about. The loss of people is happening in addition to other material losses like losing employment and livelihoods. These are also important to address, apart from providing a psychological counselling service.

If we look at other large-scale catastrophes, we can see the consequences of not dealing with grief adequately, Dr. Pathare notes. We didn’t deal with the grief of the partition, and we’re still living with the effects of that. If we look at the Gaza Strip and Israel, we can see how unresolved grief then leads to a perpetuation of violence as well. South Africa on the other hand did a brilliant job with the Truth and Reconciliation Commission after the apartheid, which allowed a social process to have public grieving and heal rather than let it fester for a long time. These are the things that we can do as a society to collectively heal from this. It’s something for institutions of the Samaaj to think about as well – how can we build social resistance and what new forms of social capital are needed in India after this pandemic. 

The pandemic has brought mental health issues to the forefront and perhaps we now have the opportunity to change our vocabulary and how we talk about these issues in the future. Dr. Pathare points out that conversations around mental health were equated with the stigma of mental illness, but that is starting to change now as these issues are normalised.