‘Uncertainty is affecting all of us’

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Well known psychiatrist, Professor Patel talks to NT NETWORK about how the pandemic has affected people’s mental health, alongside highlighting aspects that need attention of the government, medical care experts, and stakeholders in society

Danuska Da Gama 

An expert in mental health, Vikram Patel is affirmative that despite the enormous uncertainties about the state of the pandemic at present, we should all be hopeful in the knowledge that it’s only a matter of time for it to subside and ultimately fade into our memories. At his Portuguese home in Britona, Patel sat down for an insightful chat with NT NETWORK before heading out of the country to USA after spending six long months in Goa.

The Pershing Square Professor of Global Health and Wellcome Trust principal research fellow at Department of Global Health and Social Medicine, Harvard Medical School- Patel, co-founded the prize winning NGO Sangath in Goa, that works in fields of child development and disability, adolescent health, addictions, and mental health.

Q. How has the pandemic hit the mental health of people?

I see the current situation dominated by uncertainties, for example the uncertainty of when this pandemic will finally go away. We have been told month after month it’s about to get better, but we now know that nobody really has any control over this pandemic. And this is a worry for citizens who would have thought that scientists and governments together would know how to get on top of the situation. Also, ordinary citizens can see that so many countries have moved on while India has become completely stuck in the worst epidemic in the world. It’s created uncertainty for all of us! Work from home, schools shut, few willing to go out, and no one really knows when things will go back to normal.

Q. And what is the biggest threat to mental health as you see it?

Uncertainty is affecting all of us. It is important to recognise that the distress we experience is a natural reaction of the human mind to an extraordinarily abnormal situation. However, as we go forward, we will see the emergence of mental health problems in a clinical sense, for example depression and alcohol abuse. In part, this is because of the prolonged uncertainty which acts as a chronic stressor. But also, the economic consequences of the pandemic have meant that a lot of people have suffered severely in economic terms. The World Bank estimates that tens of millions of people will slide into poverty which is a very important risk factor for mental health problems.

The pandemic has also seen a rise in gender-based violence because many women are trapped inside their homes with violent husbands – and of course, this leads to mental health problems. We may well witness an increase in suicide rates in the coming months. We also should pay particular attention to the needs of people with pre-existing mental health problems like psychosis, for their routine care has been disrupted. In many parts of the country with hospitals, OPDs and private practices shut down or diverted to COVID care, routine care has come to a standstill. In other areas of health-care there is now well documented dramatic reductions in help-seeking, for example, institutional childbirths and vaccination. I wouldn’t be surprised if there has also been a similar fall in continuing care for serious mental illness that will have adverse consequences.

Q. There is a lot of fear among people – fear of getting COVID, fear of death, etc.

This is, as I mentioned, an expected reaction to uncertainty and loss of control. Not knowing what is lying around the corner naturally evokes fear. Many people may experience sleepless nights, racing thoughts, and not being able to relax.  While many people are experiencing distress, this need not be equated with mental illness. One welcome aspect of the current widespread experience of mental health distress is that the entire population has begun to acknowledge the importance of their mental health.   People are now conscious that their mental health is like their physical health, a great personal asset which is highly sensitive to our social environment and that, when it is affected negatively, this interferes with their daily activities.

Q. What do you foresee in terms of challenges for mental health and mental illness with or without COVID 19?

Even before the pandemic, according to the government’s own National Mental Health Survey, the largest survey ever done in India, about 10 per cent of Indian population surveyed was suffering from a clinically significant mental health condition, which amounts to nearly 100 million adults in the country.  It also showed that up to 90 per cent of those affected did not seek any care and that the unmet needs for care in rural and low-income groups was even higher. In short, we have a very weak mental health care system and, in the face of rising need, there is a real crisis which is going to unfold unless we rapidly respond with making mental health care more affordable and accessible. This is, of course, exactly what Sangath has been pioneering for the past two decades and I am glad that our approaches are now being embraced and scaled up.

Q) When it comes to the pandemic we have been told to follow ‘social distancing’ norms, and it’s definitely not easy for us, being social beings at the core of our existence.

Social distancing is an inappropriate term to describe what we really want people to do, which is physical distancing.  Human beings are social creatures and the idea of social distancing goes against our fundamental needs. What we need to emphasise is how to ensure that social interactions are safe to minimise the risk of transmission of the virus.

The other aspect to remember is that the idea of physical distancing is a very upper-class one for India where most people live in very crowded homes and neighbourhoods. In Goa we are lucky that population density is low, but in cities like Delhi and Mumbai, it absurd to expect people to physical distance. This is the main reason why the virus has spread like wild fire in the crowded high density neighbourhoods and slums.

Q. In a positive way, this pandemic has kind of allowed us to prepare for something bigger in terms of uncertainty of whatever kind that may strike us in the future.

Yes, I guess you could say that, but I wish we didn’t need such a devastating pandemic to teach us such a basic lesson of life. In any case, thanks to the pandemic, there is huge awareness about mental health and on the ways in which one can promote and protect it. That most people are coping with the situation in innovative ways is reassuring. But, at the same time, we need to acknowledge that not everyone is managing well and it is important for the government and civil society to give support to those who are struggling with overwhelming stressors and do not have the necessary resources to cope.

Q. These last few months has been like a litmus test for professionals and experts like you in conducting research and to discover a lot more in the sphere of mental health that was not dealt with previously.

Yes, the pandemic has forced us to start thinking in novel ways about the work we do. For example, historically all our work has been done in person. Now there has been a dramatic shift in trying to see how we can train people, deliver care and conduct research remotely. Today, the use of telemedicine has become a routine but only months ago it was only done exceptionally. Personally, I would like to see this become a norm going forward and giving people a choice on how they can access training, care or take part in research. A lot can be done remotely and this has to be encouraged. Digitally enabled remote training, health care and research offers an opportunity to dramatically improve access across the country.

Q. What’s more lethal: COVID or mental illness?

I think our immediate focus should lie in making sure the number of deaths is kept as low as possible. I do worry that people come to hospitals quite late. Part of this is because people are hopeful that their initial symptoms will be, as it is for the vast majority of patients, mild and transient. Additionally, people are scared that they and their families will be stigmatised and so they keep their illness hidden. It is very important to de-stigmatise COVID. Twenty years ago, I recall a similar situation with HIV. People would not go seek care because of fear and stigma and by the time they would come to the hospital they would have full blown AIDS, when the chances of survival was lesser. I see a similar thing happening with COVID. Thankfully, at least people are being encouraged to get tested so that they can take the necessary steps to avoid infecting others, for example by quarantining at home. If they start developing symptoms, particularly experiencing difficulties with their breathing, they should not wait till they are gasping for breath before seeking health care.

Q. Whether we like it or not, consciously or in a casual approach we tend to stigmatise.

I feel sad about the misinformation and poor communication which has been a problem with this pandemic since the very beginning. The way the lockdown was announced was the single most fear inspiring moment and set the tone for what was to follow. To shut down a country in four hours sent out a loud and clear message that this is a terrifying and deadly virus. Why else would you shut down a whole country with just four hours notice?

Since then, we have witnessed a series of poorly communicated policies. The constantly changing SOPs, some being announced an hour before they were due to be implemented. Ordinary people are scared as they cannot trust the government, scientists, health care workers and, ultimately, even one another. Much of this fear is the direct result of high-handed, poorly communicated policies and converting a public health emergency into a law-and-order problem. Finally, the communication has achieved some degree of common sense, for example, that we should not fear the virus but at the same time we should protect ourselves and others around us.

Q. Those who get tested positive are more worried about guilt than the virus. What would you say to them?

Never ever blame yourself for getting an infection that has already affected tens of millions in India alone. The infection has been spreading in our community for months. It is a mystery why the government seems to deny that there has been community transmission for quite some time. It’s not   a defeat to accept that there has been community transmission and recognising this will only make people realise the importance of protecting themselves and others at all times and places. The infection is either mild or non-existent for most people but you might pass it on to others who may become seriously ill. Thus, we all have to be sensible and follow the well-known steps to keep all of us safe. Only then will we all emerge, together as one community, from this difficult situation.

Q. How are children the worst affected at this stage of the pandemic?

We treat our children as unaffected bystanders and forget that they are watching and hearing everything. Parents and teachers need to be aware of their children’s needs. Children have been locked out of their schools. Schools are much more than learning environments, they are also social environments. I am hoping that schools will reopen soon. Most stakeholders want to reopen schools, and that is exactly what should be done.  Of course, teachers and adults at home will need to be protected but we cannot sacrifice children’s development, learning needs and their mental health on account of that. We have to figure out as a society how we can allow children to re-engage in the school environment while minimising the risks to adults that they interact with. The other group whose voices and needs are completely missing is that of people with disabilities, in particular children with disabilities. In the coming days I hope we focus on their

needs too.

Q. There’s so many do’s and don’ts that are driving people crazy. But, I am sure you have something interesting to say about taking care of ourselves.

My hope is that we may see normality, whatever that might ultimately look like, return by the end of the year, at least in Goa.  You can think of our current situation as a pause to our regular life, and we have to adjust to this situation without losing hope. We have all made these adjustments. My advice to your readers is not to think about what lies ahead. Instead, focus on the present, find as much pleasure and satisfaction as you can from the situation you are in right now, as I have done with spending the past six months renewing my connections with my neighbours, appreciating the beauty of my village in the monsoon, bonding with our dog whom we adopted from the Assagao shelter, enjoying my afternoon siesta and socialising with a small group of friends keeping physical distance. At the same time, I have found fresh satisfaction from working with my colleagues in Sangath to pivot our mental health and child development work to reach out to the wider community, for example by building a digital training platform to support front-line workers to deliver mental health care in partnership with grass-root organisations and government health care systems.