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 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?
In this panel, four distinguished medical experts discuss how we can keep up our energies for developing better resilience. What have they learnt anew in these past 15 months? What is the latest evidence on what works, and what doesn’t when it comes to emotional well-being? When is it imperative to seek professional help? How can we accept people’s emotional states as fully legitimate and real, and still help people transform hopelessness into more positive agency? As usual, the interactive discussion will leave enough time for audience questions.
0:00:10.7 Lekha: Namaskara. Good evening and welcome to today’s BIC streams session, Surmounting the Second Wave, Pandemic Lessons on Dealing with Grief, Loss and Fear. I think one speaks on behalf of several people when one speaks of fear and uncertainty, loss and grief. There is isolation, survivor’s guilt and often an inability to get some closure with rituals in case of death coupled with frustration and anger at the system. Normal ways of processing emotional tension seem to be less effective than usual. Today’s panel, we have four distinguished medical experts, Dr. Prabha Chandra, Professor Paulomi Sudhir, Dr. Soumitra Pathare and Dr. Ravindra Mehta in conversation with Rohini Nilekani, who has conceptualised and put this session together to discuss how we can keep up our energies for developing better resilience. What have we learned anew in these past 15 months? What is the latest evidence of what works and what doesn’t when it comes to emotional well-being? And I hand it over to Rohini to lead us into this journey of discovery.
0:01:29.4 Rohini Nilekani: Oh, Namaste everyone. It’s been a while since we’ve been together virtually like this at BIC, these are very tough times in which we find ourselves gathered here today. And thank you, as always, BIC for this stage, this virtual stage. Thank you so much to my panel, medical doctors, busy doctors. Thank you for your precious time to be with us all and dhanyawad as always to all of you listening in, now and later for tuning in thank you because it is for all of you that we try to do as good programming as we can here at BIC. So we are talking today about loss, grief and fear. These emotions have rarely been encountered together by so many people, all at once in this country.
0:02:16.4 RN: We’ve had many natural disasters earthquakes, cyclones, floods, droughts which come routinely in the country, and which shatter many, many lives. And we must never forget just how many millions of people still live because of such stressors with poverty, with injustice, with exclusion in this country. But this second wave of the pandemic seems to be different. It’s something else altogether. Few people have encountered a tragedy of this proportion in living memory, and the worst thing, as we all know is it’s hard to know when this will really end. The first wave we thought we had surfed. The second wave, we don’t know what to do. Normalcy, as we understood it, when will it return? We don’t know. When will these deaths cease? When will the virus become less virulent? It’s hard to also ignore the economic stress that awaits once it does.
0:03:10.9 RN: No wonder so many people are overcome with emotional stress, which they have not experienced before, and the data is really staggering. NIMHANS’s own helpline has seen a 40% spike in calls in April since it was started in March 2020 the institute has received about 4.5 lakh calls, mostly by people with no history of clinical mental illness, and that’s important to understand. People have anxiety, depression, fear, insomnia, loneliness. But these psychosocial issues of the first wave are now morphing as callers cope with hospitalisation, death of loved ones, not being able to perform the last rite, the fear of not finding hospital beds, oxygen, all that grief and uncertainty have led to severe psychosocial issues. Snehi, a Delhi based foundation running a COVID helpline reports the shocking news that after analysing the data since November, calls for help from those with suicidal tendencies have risen to 7% of the total from the norm of 1%. The NIMHANS’s own document suggests that several types of anxiety disorders are expected to increase with COVID. Cases of generalised anxiety disorder, cases of panic disorder, phobias and obsessive-compulsive disorder might become more common.
0:04:38.7 RN: They We have also seen cases of post-traumatic stress disorder, and they are expected to go up further. 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, and they run the helpline 080-4611-0007 and we are going to put out all the helplines later for you, you will be able to access those numbers even after this programme is over, believes that within about a year, the affected population will come down to about 30%, that is people suffering prolong grief over the severe trauma that they’ve suffered through this pandemic. And in another year there should hopefully be only about 10% who need long-term mental healthcare, that is the relatively good news, which we can discuss later with our very eminent panel. But the biggest problem is that even when people recognise that they have issues and that it is now really about mental health, and which goes beyond emotional well-being, it is not that easy in India to get professional help.
0:05:46.8 RN: The national mental health survey back in 2015-16 implemented by NIMHANS again, found a treatment gap for mental disorders ranging between 70% to 92% for different disorders and for common disorders 85%, for severe disorders 73%. That’s really not good news and all of us already know the people listening to this programme already know that we simply do not have enough mental help professionals in India for our population of 1.3 billion-plus people there are only 9000 certified psychiatrists in this country. We have two of them on this panel today. And add to this, we have about 700 psychiatry students graduating every year, and by this number, we have 0.75 psychiatrists for 100,000 people, and the desirable number is at least three.
0:06:41.4 RN: Knowing all this, it becomes very important for all of us to become as good as possible at helping ourselves and helping others around us and that’s what we’re going to ask our experienced panel, to help us understand how we can do that. And it’s good to know that we are all in this together, even though we feel very isolated and lonely at times, it’s good to know that we are not alone in feeling alone, and in the meantime, while all the stress is building up, India’s very resilient Samaj has stepped up, many helplines have come up in the past months run by NGOs, coalitions of mental health professionals and also government. We’ll be giving you a lot of helplines later, many are valid in Karnataka here as well. I’ve heard of people doing many creative things at a societal level to help vulnerable groups, especially the elderly and people watching this programme, I think, have likely experienced deep gratitude at the privileged position that we are all in, and also have tried to reach out in their own way to many other people.
0:07:50.2 RN: We have also felt extended empathy for people who are not so lucky as we have been, but if anything, this pandemic has reiterated that this is an era where the elite like us can no longer secede from the rest. That reaching out to others, doing whatever we can to build a society less segregated, less unjust actually is in our own enlightened self-interest, because viruses and other disasters, know no borders, know no gated communities, and this pandemic has reiterated the importance of creating better societal outcomes. So that next time around, there’ll be less devastation at a personal, social and economic level. Our panelists will share their experiences on these and other questions which we have ready for them. The format as usual will be as follows, I will ask each panelist to speak first briefly on their experience in these past 15 months, what have they learnt afresh and post that, I will ask them a few questions and then my dear audience, we will keep a lot of time for you to ask questions. I have only one request to you, we’ve always had very thoughtful questions from the BIC audiences and I’m sure the same will stay today but very humbly I request let’s not have very personal questions. Let’s use this marvelous panel to leave us with a little more knowledge and a little formed confidence about issues that commonly affect us all.
0:09:17.5 RN: So with that, I’m going to get right to it, and we have two psychologists, one psychiatrist, two psychiatrists, one psychologist and a cardiac pulmonologist, Dr. Ravi Mehta and Ravi, I’m going to go straight to you, the pulmonologist, he said, “I’m an outlier on this panel.” But throughout this pandemic, death and breath have been really at the top of our minds. Breath is life, and especially in the second wave the virus seems to go to the lungs very quickly and we hear of all this, to not be able to breathe is the worst nightmare of all. Ravi, I know you’ve been dealing with really in the ICUs, a lot of stress over the last 15 months, tell me in your long and distinguished career, what have these last 15 months, been like for you, if you can spend two or three minutes on that.
0:10:10.9 Ravindra Mehta: Right. Well, thank you Rohini for calling me here, and it’s lovely to see such eminent people and dwell onto aspects which we, I think, completely marginalise and ignore as we go on with our jobs, largely out of I think a sense of survival than anything else. So I think if I can summarize this billion dollar question, nothing is worth million dollars anymore. The last pandemic was bad, we could see it coming, it was swinging around the globe, coming to us, and it can be talked about, we accepted, not accepted, how prepared, ultimately it hit us, moving typically around Delhi, Bombay and then it comes to Bangalore, and then we went through quite a bit of problems, many problems understanding the disease. We have to understand that we ourselves as professionals did not know what this was. We’re using domain knowledge to understand a new entity as people around the world were scrambling.
0:11:00.0 RM: If you can see CDC, NIH, everyone was scrambling, and then we had to repurpose ourselves and then what to use and so on. So we thought the last pandemic was bad, and then came the interpandemic period, where a sense of relief, literally to use a crude word, chilling happened over here, which should have been a staggering field entity. And then came wave two and wave two has been like never seen before, I think it will leave memories, which are, just cannot be put into words at this point. Just when we thought the worst thing was settling, it came in and it’s come at a speed and intensity, which I think was completely, completely unexpected. The onslaught on healthcare if I’m to answer that specific question in a short span of time has been, in wave one, I think we saw fear, we actually saw fear, and to give a example, a 22 year nurse walks up to me in May last year and said, “Why do you want COVID to come, my parents don’t want me to work”. And we were thinking that if the Kerala borders open, all the nurses will disappear. So much as we were, you guys were trying to do, congratulate us and calling us warriors, there was not much of a warrior element left in the workforce at that point, anyway, something happened, we were repurposed and so on.
0:12:11.8 RM: And then of course comes wave two and wave two was even more because it just, just came in at the stage where we could, had nothing with us, we felt that the amount of infrastructure, the medications, the preparation required was woefully lacking but there are good things. So in wave one if people were petrified, in wave two at least healthcare was willing to come to the job. People were used to it. They were used to wearing PPE, things had been figured out, at least they would come to the job, we would not have absenteeism, the healthcare people were vaccinated, so that was a big thing over there. But having said that, in wave two what I can lead as memories, has been the fact that we have this enormous number of young people, enormous number of shortage of beds, the fact that the phones were going on 24×7, you pick up a bed-call and in my life I had never imagined after doing all these studies and this profile which is being put up on the chat, I’ll be bed organiser, drug organiser, holding people’s hands and answering questions right from “What should I do at home?” to somebody who’s saying, “I can’t find a bed and my oxygen requirement is going high.”
0:13:16.8 RM: I hate to be gruesome, but reality is what we’re trying to project, calls used to come today, and two days later that phone would not ring because that person wasn’t around. So that was the status and in the midst of all this healthcare had to function and then we saw something which we never saw before, shortages, oxygen. It is not pleasant at 12 o’clock at night, that when you are getting a call that the low oxygen alarm is coming on your machine. So you first of all, those people who managed to get in are the lucky ones, those on top of that are now going to see that there’s gonna be a shortage, what do you do? Where do you scramble? Whom are you gonna call? So that was… There is so many such stories. In a nutshell if I’m to put this experience once in a lifetime, hopefully never seen again. Wave one dramatically we thought was bad, but literally a cakewalk compared to wave two. It has left in its, both its onslaught and its reflection, a lot of memories, I am glad it’s coming down now.
0:14:09.3 RM: And this breathing issue which you brought up, I mean it can not be put into words because it is something which they used to call us with and we’ve seen it happening, and there was something which we had to really figure out how to do this when we ourselves are strapped. So healthcare willing, healthcare are coming to the fray but at the same time, so limited that in the end we’re left with so many memories. One last thing was dealing with the familial situation. First it was the elderly, now it was dealing with people who are saying I have a three-year-old, five-year-old, 10-year-old at home, dealing with a 22-year-old whose father has passed away and she’s looking a bed for her mother and the mother needs admission. Dealing with talking to a 16-year-olds who we never conversed in our life, we don’t talk to these people to explain sadness, death and demise.
0:14:56.3 RM: So all in all, it was an experience which I think my guys have worked just by marginalising all these thoughts. I think there’s a whole pent up suppressed area which had no room to come out, otherwise they can’t come back to work the next day, which is now sitting as a boiling tempest, which ultimately will come out one day, I feel. All in all, many words, I am sorry, I may have exceeded my time, but it is a litany of both experiences, memories and the like, which I think will be there for a long time to come. Hopefully, hopefully a lot of these lessons will be learned, the good part, and we always have a good part. My god, healthcare has done well this time, I mean I didn’t have to talk to a single person. They came, they worked and they did their job, no donning, we used to talk of six hours, there was no six hours. Work as much as it takes, we used to talk of PPE time, nothing like that. Go, change, eat your food come back and continue to work.
0:15:47.5 RM: We talked of off time and doing test. No off time at all. Just come and do whatever you have to do. All in all, this was at least some saving grace, which we saw in the midst of the holocaust of our lifetime.
0:15:57.9 RN: Thank you Ravi. Of course I’ll be coming back to you later, thank you for that, and thank you to everyone who has worked through both all these 15 months to help so many people. Prabha I’m coming to you next. Similar question, 15 months, surely you must have had more people coming to you for help. Why is the second wave so much harder? Are there different kinds of people coming to you with different kinds of symptoms and just your experience? Is there something new you have learnt? Two or three minutes of that and then, of course, we’ll come back to you again.
0:16:29.0 Prabha Chandra: Sure Rohini, thanks. So I think, for me, the first wave was all about stigma, and that was huge, so a lot of people did not want to get tested, did not want to go into hospitals because there was so much stigma, there was labelling, there was putting things on your door and those tapes and all that. So it was a completely different kind of fear. It was not so much fear of the illness, but it was a fear of being stigmatised and marginalised, including health workers were beaten up, women were not allowed… Nurses were not allowed to come into apartment blocks because they thought that they would give them the illness. Strangely, in the second wave, nobody’s talking about stigma, so it’s like a complete change.
0:17:13.0 PC: So, in the first wave, I had to deal with a lot of all of that and sort of the economic loss, the migration, people struggling, none of that this time. This time Rohini, it’s all about grief, it’s all about loss. You know I had gone to the Rakai district in Uganda in the ’90s. I trained in HIV work over there, and I saw villages and villages with only grandmothers and children and no young people. I still remember that feeling of seeing no young people in a particular village and multiple deaths, and I thought even then, I hope to God this never happens again anywhere and that’s what’s happening now. So we are seeing multiple losses, like you have somebody whose parents have gone, and like somebody said, the generation which is the 20-30 generation, the young people who are in their 20s and 30s, suddenly they find both their parents have gone, this is not what they bargained for, this is not what they thought will happen to their life.
0:18:17.0 PC: Both parents in an ICU, two people in a family, three people in a family dying, multiple losses is something I think in my life I had not hoped to see, but I have seen and I’ve had to skill myself enormously, including training myself in newer methods of treating people and handling traumatic bereavement. And when we mean traumatic bereavement and maybe I’ll talk about that a little more later, but something where normally you have grief, people die, but this time it’s grief with trauma, and that is something which our training never equipped us with, I have never done it and so I think to me that was, that was a huge thing.
0:19:03.1 PC: And the second thing, which I’m sure the others will talk about, but it strikes me as being very important, is we pride ourselves as a society with a lot of social support. They say mental health parameters are better, outcomes are better in India compared to the West, because we have very good social support. And this time around, the socialised solution actually took away all of that social support, so things which were protective, which were buffering people from developing problems, we didn’t have those. And I think that affected particularly the elderly a whole lot, and I found that a lot of the elderly were coming with physical problems, with loneliness, with sheer anxiety, and just sense of utmost helplessness because they are not used to this social isolation at all. So I think these two things to me were totally different. I’ve not dealt with in my life, and I hope I don’t deal with it again.
0:20:03.0 RN: Thank you and of course Prabha we are going to come to you with many questions. Paulomi I’m gonna reach out to you. What have you seen that is different, more disturbing, or something that you learned in these 15 months as a professional?
0:20:20.5 Paulomi Sudhir: Yeah. Thanks for having me here, and I think I’d like to echo what Dr. Mehta and Dr. Prabha said, it’s been a whole new experience from the first lockdown, which we had in the March. And I’ve been associated with the helpline that you mentioned from the start, when it started in March 2020, and we had a lot of volunteers from the PhD scholars and clinical psychologists, psychiatrists, lots of people volunteering, but I think the helplessness of not being able to do anything for the calls that came in. So we had a flood of calls that you mentioned initially, at that point it was, they were all taken by surprise, and I think we were trying to help them with the resources, with rations, there were students stuck everywhere and when we were mentoring, we also found that there was a lot of anger about being stuck somewhere not knowing what to do. But I think over time that has changed and the emotions that we see now are more anxiety and more fear, and also much more uncertainty.
0:21:19.2 PS: We did a lot of work with managing uncertainty, but now we know that it’s something we have to deal with, lot of people have come to terms with that, but I think with the second wave, it’s also difficult for us to know what to say in terms of assuring clients when they call us about their own difficulties and their own helplessness. And I think one thing I’ve also noticed is that as people ourselves, we’re also experiencing similar anxiety, so what do we tell them, how do we actually assure them that things will be okay or things will get better? Because they’re things that I myself cannot help directly with. If there’s an oxygen need or a bed, it’s something I can refer them to somebody. But these are moments where you’re helpless as far as your skills are concerned, and I think I’d really like to echo what Dr. Prabha said about certain things that we are not very focused on in our training in terms of dealing with loss, what do you say to someone who’s going through this difficulty? Because it’s so sudden, it’s so unexpected, and it’s probably… In the department, people around us have also lost close one, it’s not just the clients.
0:22:26.7 PS: So I think, I would probably say that the last wave was something that, it was, in a way we are trying to look at how to deal with this, managing resources, managing anxiety. Like you mentioned, a lot of clients came with health anxiety, and we also on the positive side found that people whom we expected to not do well were actually doing well. But this time around, these are problems that probably we ourselves are likely to face, and there are not enough words or assurances that we can give as far skills and training, so we have to support them, and I think that’s what’s been a big difference from the two, last 15 months.
0:23:06.0 RN: Thank you. In the second round, of course, we’ll come to, so what should we all do? But Soumitra that it takes me to you and, really the same question, what have you learned, what are some of the new insights that have come to you practicing in these past 15 months?
0:23:25.8 Soumitra Pathare: Yeah, thanks. Thanks Rohini for this invitation, first of all, and to BIC for having me here, and I was very pleased to see that I didn’t know this, but that Ravindra is also an alumni of Seth G S Medical College, so it’s good to see somebody who’s from the same place on a panel like this. Some of the things, I’m gonna step back a little bit. I know that Prabha and Paulomi are focusing on the individual, and so I’m gonna step back a little bit and I’ll look at it from a more macro perspective. What could we be doing in a policy sense, and what should we be doing at a more social level rather than the individual? And that is not to say that the individual isn’t important, but there are many things we could be doing at a policy level which can make a difference.
0:24:10.9 SP: So the first thing that I think we’ve learned and we need to really improve on that, is that our public health messaging in the last 15 months has been pretty bad. It’s been confused, it’s not very clear, and in a sense, it did not prepare people for what might come ahead. We kind of told people that this was a 200-metre dash, when actually this is a marathon. And so suddenly after 200 metres everyone’s tired out because they would run at full speed and now they don’t know how to handle it, and then you tell them, “Oh, you have to run another 26 miles.” And that creates a problem. So I think our public health messaging has been very confused, [0:24:49.7] ____ and that’s very odd because we have had the HIV-related epidemic when our public health messaging was wonderful, NACO did a great job in getting even people like the truck drivers to start taking precautions. So we do have the expertise, so it’s a quite inexplicable, why we did not do that well. So that was one thing I think we need to learn going forward, that we need to get our public health messaging, it’s a specialist thing. It needs to be done properly.
0:25:19.0 SP: The second point is about grief that we were talking about, is that Indians while we talk and do counselling and all that’s fine, but for the large majority of Indians, a way to deal with grief is with actions. We do behaviours which help us deal with grief. Our rituals are important not because they’re religious, but because that’s our way of… We’re not a talkative community, you know what I mean, we like to work our way through by doing things rather than just talking things. And so that is creating a problem. So just yesterday, I in fact, wrote to the principal scientific advisor about the COVID Death Protocols.
0:25:56.4 SP: We’ve got this protocol, which makes no scientific sense anymore. Why are we not allowing family… The CDC in Atlanta is actually allowing families to do burials, prepare bodies for burials. So, why are we stopping that? And that would help with the grief, it helps if you’re able to carry out the last rites, do the funeral properly, and that will make a difference. So again, there public policy needs to keep up to date with science when it comes to dealing with matters which could help with grief. And the third and most important thing about grief, which we are not at all talking about is, along with the grief of the loss of people, there is also a grief of loss of material resources which is not being talked about. The loss of people is coming on the back of, a loss of other material issues. So, like loss of a job. Many people are in a situation where they have lost a job and now they’ve lost somebody very close to them. And so, issues like employment, issues like keeping people working, the practical issues about helping people have a livelihood, these are things that are equally important apart from providing just a psychological counselling service. So, if you were to step back a bit and take a more broader societal perspective on it. So, I’ll stop here and I’m happy to kind of discuss this further.
0:27:16.5 RN: Yeah, yeah, thank you. I’ll just ask a couple of follow on to you itself, before I go to Prabha and the others, Soumitra. I’m glad you pulled out to the social dimension, the public policy dimension. I think it’s important to keep in mind, we won’t discuss public policy further, but I’m glad you lodged that in our minds, that we must look to our government also, to set public policy in a way that is much more reassuring and less filled with doubt and uncertainty that has been experienced by all of us now. And hopefully learn some lessons from now for the next time. But to came back to your point about taking it from personal to social. This whole aspect that in India we need our communities to support us. And have communities in India been supporting their people in these 10-15 months? Could we have done better, could we have done something different, or were we all locked up in our own personal anxieties?
0:28:14.3 SP: No, I think, in fact, communities have done a brilliant job, and all kinds of communities. You go to rural spaces, because we have a large project across 500 villages. I… And Prabha knows about that project. And there there’s a lot of community support that happens. You look at urban societies, gated communities or large housing societies, there’s a lot of that social support that is coming through. Equally, on social media for example, Twitter and Facebook have created virtual communities of support. I think all of that is happening. But what happens is that that needs to be supported by a more supportive public policy situation. Where the… Very often, the confusing messages around, should you wear a mask, should you not wear a mask, which kind of mask, how are the police going to treat you, are you going to be stopped if you’re alone in a car or not alone in a car. Now, that kind of public policy stuff really, really needs to be…
0:29:16.3 RN: So, the fear of interfacing with the state in a unknown manner. But again, before I go to the others, Soumitra, how important it is for when we talk of our emotional well-being, to be able to plug into our social networks? How important is it for us to be able to come out of this with a better sense of coping because of our social networks? Can you reiterate as a professional, whether it is important or not, and how much we should seek that out?
0:29:49.1 SP: Absolutely. You look at any other plagues which has seen, and other times when we’ve seen these kind of catastrophes. Okay. If you don’t deal with grief, if you don’t resolve this grief, this is going to build up a problem for us as a society. And I’ll give you examples because you’ll say, “Can you illustrate that?” So, take partition, for example. We didn’t really deal with the grief of partition, we’re still living with the effects of that. Look across the world, look at the Gaza Strip and look at what happens in Israel. Unresolved grief, which then leads to a perpetuation of violence all along. Look in our own country, there have been episodes when such things have happened. So, I do think that as a society, if we really want to worry about the next couple of decades, we have to resolve this grief and we have to work out a way of getting through it. Now, South Africa did a brilliant job. If you remember, after the end of the apartheid. The Truth and Reconciliation…
0:30:45.9 RN: The Truth and Reconciliation…
0:30:46.0 SP: Yeah, which was a great thing, because it allowed a social process to have public grieving and get over what had happened and not let it then fester around for a long time. So there are things that we need to do as a society to actually deal with the grief. And individually, yes, but even as a society, we need to be doing some things.
0:31:06.8 RN: Thank you. Something for institutions of the Samaj to really start thinking about. How can we build social resistance, what kind of new forms of social capital need to be created in India post this pandemic, because it’s not a sprint, it’s a marathon. The effects are going to last for a very long time, and we all need to be in it together. Thank you for that Soumitra. Prabha I’m coming to you. This… We talked when we talked earlier about… Can you now talk to us about what have you been recommending to people who come to you with all the things that you talked about, grief, loss, anxiety, dismay, fear, uncertainty, even trauma? How much is it about medicines, how much is it about something else? When should we know that we have to come to a professional or try to solve it ourselves? Can you talk for three minutes or so, on all these kind of issues with especially with your new insights.
0:32:04.8 PC: Sure, Rohini. So, I think with any disaster or any, sort of, such a big event, what happens is that you have different trajectories. So, you have one trajectory where people actually are quite, doing really well. They’re coping. You have another group of people who are less than optimal who are kind of sub-optimal, but yet not collapsing, and there is another group which is really struggling to cope, and there’s yet another much smaller group who are probably doing even more than optimal. These are people who are trying to do many things for others and sort of reaching into all the inner resources they have, strengths they have, to help other people, and they’re actually doing even better than what they did earlier. So you have four different trajectories of mental health, and I think it’s very important for us to understand that, that not everybody is going to collapse. We must also remember that all of this does not happen on a blank slate, people already have vulnerabilities, they may have pre-existing mental health problems, they may have difficulties at home, they may have other disabilities, there maybe somebody on the house with dementia.
0:33:19.0 PC: So you’re dealing with people who already have some vulnerabilities and then you have COVID and all its complexities thrown in so probably these are people who actually need that real extra support. And I think we should have planned better for these people, we should have actually had services available for these people much beforehand, even before the second wave came in, because we knew that they’re more vulnerable.
0:33:45.9 RN: Can you describe how, because given the limited number of professionals in this country, how do you suddenly ramp up support for so many people coming into the… Though I see what you’re saying, that everybody didn’t need so much extra help, but still what is your suggestion for ramping it up quickly?
0:34:03.6 PC: I think it’s a great question, and I’ve been pondering about it quite a bit because like you rightly said, everybody doesn’t need specialist mental health help, and mental health is too important to be left alone only to professionals. Because it’s everybody’s business honestly, and that’s WHO’s slogan, mental health is everybody’s business. So I think that we need, it’s a very favourite concept of mine, even before the pandemic came and it became much more, and Soumitra knows about this, is the concept of social scaffolding, that when… It’s like a building, when there are weak parts in the building, you actually provide scaffolding till the time that the thing gets more strengthened, the building gets strengthened, and then you kind of gradually remove that scaffolding. And I think social scaffolding is something which is such an important aspect of providing social support and you can provide social scaffolding in so many ways, so trying to identify these groups of people who really needed more help, so having systems in place. There are NGOs who could have done it, there are families who could have got together, who could have made sure that people who are vulnerable get extra support at that time. Let me give you an example.
0:35:20.5 RN: Is there any single resource… Prabha, sorry to interrupt you, but is there any single resource today, say a website or something, where you can go and say, here are the kind of symptoms that if you begin to feel… Perhaps you need to go into the next level of help, is there some single resource and should there be more public resources like that?
0:35:40.3 PC: I think that the WHO actually very early on in the pandemic brought out a lot of resources including guidelines for psychological first aid, and that’s something I think psychological first aid is very simple. It’s providing safety, providing calmness, improving people’s self-efficacy, promoting social connectedness and providing optimism and hope. They’re very, very simple guidance, and there’s actually courses available free of cost for people to do training in psychological first aid, and this is something that can be done by all of us, where we can actually provide support to everybody around us. So I think if people wanna go, there are several websites including the NHS in the UK brought out a lot of material, there is WHO which brought out a lot of material. So I think there’s lots available out there, I think it’s for people to be able to access that and to support themselves.
0:36:34.7 RN: Okay, but when do medicines kick in. And when… I think earlier, we had a lot of stigma about people not wanting to take medicines, has that changed Prabha in these last few months? Have you seen a shift of people actually saying, “Whatever it is, I can’t deal with this anymore, my old coping mechanisms are not working, I need something stronger, maybe medicine this time.” Have you seen that shift?
0:37:00.1 PC: I think so I’ve seen that. I have seen that and I think… And that, I think, is because people don’t have the other kind of network. Support networks that were available to them, so if an elderly woman is not able to sleep at night and gets these thoughts, is what’s gonna happen to my kid or my husband. Earlier, there was somebody around who could kind of say, no kuch nahi hoga, please sleep, sleep, but now you don’t have anybody, you don’t have your caretakers who can’t come in because they are… They’re not allowed by apartment blocks to come in. You don’t have that kind of support system. So I think I have experienced there’s a heightened need for medication, which I worry about because you don’t want to medicalise some of these problems, but sometimes in helplessness, I have prescribed. And I particularly worry when I prescribe it for the elderly or for those with medical problems, those who have recovered from COVID, because many of these medications have their own problems and their side effects, and when you can’t access medical care very easily, then that becomes a problem, so it’s a dilemma as a psychiatrist about prescribing more or less honestly.
0:38:03.8 RN: Right, but sometimes you just… You know about so many decades ago I went through panic disorder, Prabha, and it was very hard. I tried all the… What you’re calling social scaffolding, what we are talking about social networks, but eventually, I found that I needed to get out of it with medicine. So we should not also demonise the notion of having to take the real help you need, for the short time that you need to take it, till you’re able to, be able to walk on your own again. Is it fair to say that?
0:38:40.2 PC: Yeah. Yeah.
0:38:40.3 RN: Because there are many people in the audience who feel very guilty about reaching the stage where they have to take pills.
0:38:48.2 PC: Yes.
0:38:48.5 RN: So in a society like ours, would you again reinforce the right message about taking medicines and not taking medicines, how we are able to distinguish?
0:38:57.5 PC: Yeah, I think that if your functioning is impaired, if you’re using all the psychological methods that have been told to you and you’re not getting better, if it’s affecting your daily life, I think medication has a major role to play, and under the supervision of a doctor. So that’s the other thing, Rohini, that when Soumitra was mentioning, and you said, we’ll not really go into policy very much, but I think one of the things that I have found is that the all the communication with doctors is happening online, and there is a large percentage of people who cannot manage online communication, who don’t know how to access Zoom, who struggle with WhatsApp videos.
0:39:42.0 PC: And so, what do you do for these people? And these are the people probably who need it the most, people with cognitive disturbances, elderly, and other kinds of disabilities. So I think we really need to think through what we need to do as a policy, and as organisations to enable better internet facilities and educating certain groups who don’t have access on how do you use these systems and how do you use telepsychiatry, which I mean telepsychiatry became such a big thing, but how many people are able to use it.
0:40:15.8 RN: Access it. Yes.
0:40:16.8 PC: That’s my worry. Yeah.
0:40:18.2 RN: Yeah. So no, I agree, a total shift, we need to take mental health much more seriously as a national priority, that’s pretty obvious. This is certainly not the last pandemic or the last disaster coming our way, couldn’t agree more. And we’re going to have to do more such programmes with all of you to delve deeper into those issues, but Paulomi if you can pick up from where Prabha left off on, you as a psychologist, people are not coming to you to get medicines prescribed. They’re coming for other kinds of help. What have you seen has worked? I know earlier when you opened your remarks, you said, It’s been very difficult because there’s no, there’s no… I mean there’s no pill you pop and just… As somebody said you have painkillers, but not sorrow killers. So, how have you found it? What are the best advice you have been able to give?
0:41:11.6 PS: So I work predominantly with anxiety disorders and depression. So, I mean I found that falling back on these strategies and psychological methods that we’ve been using before has actually been helpful. It’s just that practice was becoming very difficult with the modality of therapy that we were doing because we’re used to seeing people face-to-face, doing relaxation methods and a lot of that which was just not possible.
0:41:37.3 PS: So we’ve had to be quite innovative, reach out to people like Dr. Prabha said, you can’t do something on the phone, so it has to be a video-based. So we did have our limitations, but I have found that using simple psychological methods did help in those who were mild to moderately anxious, and if we could identify that the anxiety was something we could provide these interventions for. Of course there were some practical concerns like people being alone, there were calls where there was nobody. I have a client now who’s all by himself and his family is abroad. So, I was one of the resources he had. Even when he contracted COVID he would call me and tell me how he’s doing.
0:42:18.2 PS: So I’ve had to do things beyond just the usual CBT or usual psychological interventions to provide support as well. The other thing, of course is sometimes we found that healthcare professionals themselves have come to us, so that becomes a little challenging because we’ve done a lot of training programmes and working with healthcare professionals, providing them resources, talking about self-care that Dr. Prabha talked about because we find that during this time, routine has got upset. A lot of them have not been going to work regularly. So, depressive symptoms have increased because we can’t advise them some of the usual routine activities that we would do for behavioural activation. So a lot of these have had to undergo changes from the way we’ve been discussing methods, as well.
0:43:08.1 RN: What has been the most successful? I know, it’s been tough but what has been the most successful approach you have found, when you have had to work in remote conditions, when your people can’t, patients can’t even come to you. What has worked the best in these few months, something that you can tell us to take away?
0:43:28.6 PS: So I think being persistent with them also because we’ve been following up clients. In fact, we did a lot of… When we suddenly moved online, I remember we had our team call everybody back and tell them that we are available online, so get in touch with us. So people were quite ready to even have those phone calls and reach out to us. So we didn’t wait for clients to come in and speak to us because we’re in a small unit which offers clinical services. So we got all our trainees to actually call people and get in touch and make sure that they were back.
0:44:01.8 RN: Making them feel that you are there to support them…
0:44:04.5 PS: Yes. Yes.
0:44:04.8 RN: Throughout. Okay.
0:44:05.4 PS: We did a lot of that in the beginning and so now referrals are also coming in, people are calling and they are, they’ve sort of got used to the fact that we’re there and we’re available for those services as well.
0:44:14.9 RN: Wonderful. I want to talk about the elephant in the room. I want all of you to quickly react in your own way, the fear of death. I mean death is certain for us all, but the proximity of death, which is really all around right now is something that we don’t always experience. We know we’ll die sometime if you’re ill or something but having death around us so much, in the news, in our lives. How in your experience, do people face, cope with, live with the fear of death and what is your advice? Because at the end of it, even when I had my panic disorder, when I unpacked, unpacked, unpacked it, I found actually I was, it was the fear of death that was causing me that anxiety at that particular time. And then I had to learn and do lots of things to help myself overcome this fear, fear of death. All of you very quickly, Ravi I’ll just start with you because I’m sure people who come to you, who can’t breathe, whose lungs are not functioning, it must be top of mind. What is your experience, what would you tell people about this absolute biggest nightmare of our lives that, philosophically we know we can’t have much of life without death, but what would you say to our viewers on this?
0:45:33.0 RM: Would you want a confession and would you want the bravado, which we were trying to show?
0:45:36.8 RN: No, I really want something. I want to leave my audience feeling like they’ve met all of you, they’ve heard you speak from your heart and so just feel a little more equipped at the end of this one and a half hours.
0:45:48.8 RM: Well let’s look at from both sides. If you look at the fact that you’re trying to reassure somebody, very, very confessionally, putting all the cards on the table, absolutely, shamelessly, you have to be first confident that you are not afraid of death yourself. How can you communicate, where can there be conviction, where can there be content, where can there be transmission and where can there be assuring somebody, when you yourself are petrified that this is not something you can go through and that was the first thing. So very, very confessional and I was thinking that it is the first time in one and a half years, I have actually been called on such a forum and we are also now figuring out how to answer Rohini’s questions and how much to actually put on the plate because these are not things, which sometimes… Some things are better unsaid than said, much against where Prabha or Paulomi or Soumitra may not be doing or may agree. But let’s face it, first healthcare professionals had to get very, very comfortable and that has taken a long time, and I don’t think people have gotten comfortable. First of all, the high-risk people clearly decided they cannot come forward.
0:46:50.9 RM: They switched to other useful roles such as online, which has been excellent because there was so much more to be done, as long as we agreed that the tool of online can be implemented in whatever fashion possible. Then the next part was to get the people who could come in, they themselves had two generational issues, my generation behind, what’s gonna happen to me? My generation ahead, what’s gonna happen to them? So this was another big thing out there. Thirdly if at all, some guy got a little practical, they would say where’s my insurance, my nurse says if I’m not gonna make it, where’s my insurance, so if the government is not giving, are the hospitals gonna give it? Hospital administrators themselves don’t understand that they’re crisis administrators, they are regular guys who run shows as per operational issues, to suddenly repurpose them and put them as crisis administrators, most of them have never entered the inside of a hospital, a COVID ward or an ICU. They’re not gonna come in, so they have no idea until a look, the value of a look inside a COVID ward or ICU is irreplaceable for the conviction it takes to have action. When you go inside, you can either be petrified or you will come out thinking, “Okay, now I know what it is.” You have reached the next stage of saying, “I can do something, and then you can actually spring into action.”
0:48:00.2 RM: So again to answer your question with this background was first healthcare had to convince itself and I’m sure most are still not convinced. We’ve had enough and more people who have come and said that, I don’t know this in my lifetime, I don’t see demise, I chose a healthcare profession of a nature that I don’t have to see demise and now you’re showing me demise on a regular issue. Then demise is one issue, then communicating demise, then talking to one person, you’re fine today and three days later, communicating you’re not well, then taking the hit home, holding somebody’s hand and saying you’re gonna be fine, but then three days later the situation’s reverse. So we had to deal with a lot of this stuff. Then came the ability that once a good deal of them got comfortable, then communicating this was a little easier at least. I feel, two statements out there, if you are mentally prepared before a pandemic because of the nature of work you do, the sort of person you are and your ability to quickly go from crisis to resolution, you made it in the pandemic. Those are the people we banked on, those are the people we held on to, and those are the people who have been the anchors, the pillars of the pandemic. Repurposing people was scrambling, they’ve been useful in some way, but not in the acute care element.
0:49:06.7 RM: The second thing, getting an outcome, you send somebody home and giving that message back to healthcare was the biggest feeder we could ever find from a positive nature because as long as they feel, they’re doing good, they can continue that work otherwise, it’s very, very difficult to come back to work. So again, communicating has been a challenge. I’ll tell you one thing very truthfully, we have no modules for this, and to add to what the others said. There is nothing who can tell anybody that you’re gonna be talking to, say 35 intensive care people in a day, once a day, once a day, because there is no way to sit and communicate beyond that, and then tell them about what is going on, and then at the same time communicate back only with sort of online consents and so on. So very repurposed communication, healthcare providers have at various degrees of familiarity and comfort…
0:49:54.5 RM: They have transmitted to people. I don’t think I can speak for the whole healthcare community because it’s been so different and so variable but I think as a whole, people have at least gone the extra length to try and tell others, “Let’s do what we can, we’re here with you and let’s try and push everything in the right direction.” The second thing is video calls. I’ll just spend 30 seconds on this. Video calls were a huge challenge because they wanna see them, and can you imagine that if somebody enters a ICU, it’s like an Abhimanyu.
0:50:20.2 RM: They’ve entered, they may never exit the ICU, and you never planned for it, you never thought. You and your naive mind thought this is never going to come to your door. So video calls, we had to arrange people to do video calls where they patiently stand and after five-seven minutes you have to tell them, he has to go on to the next person, we can’t have 25 people to do video calls. So what I’m trying to tell you is trailers out there, many challenges. To put it in perspective, two angles healthcare getting comfortable to whatever extent it could and I’m sure it can be better, but that’s humanity, and after all everybody is human, and then using them to communicate to people and then hiding your own emotions that you have to still be the voice because it’s all tone. There is no visual, it’s tone, it’s measured language, it is using the right words, and it’s still giving them hope when you know in your heart that you’re fighting against a wall all the time.
0:51:07.4 RN: Thank you so much Ravi for reminding us that healthcare professionals, their fear of death, their fear of their patient’s death is something normally we don’t think about, thank you for bringing that into perspective. Soumitra, what about you, just giving our viewers a sense that fear of death is something, what is your advice?
0:51:27.5 SP: Oh, wait a minute. I’m gonna talk about personally how I have dealt with it. I think some of the things that I always end up doing is being practical about it. And what I mean by being practical about it is now my entire family knows all of my passwords, they know where the money is hidden, they know where all the documents are, they know what to do if I die, how I want to be disposed of. They’re very practical, real life things. I just, in a sense, settled my affairs, if you know what I mean. I have a sense that I’ve settled my affairs so that if I end up going to the ICU tomorrow out of the blue, I don’t feel, “Oh my God, I didn’t deal with that stuff, and I left that out.” So, I’ve done all of that, and that’s probably my only way to say that, tell myself that I have control. I have some control. I’ve done everything that I could do, and now we shall see what happens.
0:52:23.1 SP: That does not mean I go off and start taking undue risks. I have probably been the most cautious person around, but also you have to be cautious and ready. I think it’s a odd combination, you might say, that if you’re cautious but you’re still ready, but I think that’s the only way to do it. Sar Pe kafan bandhke nikle hai so that doesn’t mean you go out and put your head over the parapet and get shot off. You want to kind of also be careful of what you’re doing.
0:52:50.5 RN: Abundant precaution and preparedness, Prabha, fear of death, overcoming it, living with it, coping with it, especially in a pandemic like situation.
0:53:00.6 PC: Somebody said like the Amitabh Bachchan dialogue na, Jo Dar Gaya, Woh Mar Gaya. Instead of that it is Jo Dar Gaya Woh Bach Gaya, because in the context of COVID, people who were a little bit more, had a little bit more fear, actually took more precautions like Soumitra said, and the people who didn’t were probably very lackadaisical about it. Having said that, personally, I’ve had major losses, and very, very early on during the pandemic, the second wave, I lost a very dear friend literally, as he was with me on WhatsApp “I’m not getting oxygen. My oxygen is dropping, dropping, dropping, I’m not getting ICU” and then there was silence. So, and this was a 3:00 AM friend who I would talk to very often. So another very dear friend of mine is right now in ICU battling her life.
0:53:54.0 PC: So this has touched all of us, and I think because it has touched all of us, like Soumitra said, many of us, and I find that happening to many of the people I talk to including my patients, developing a very practical attitude about death, about mortality, something which we never thought about earlier. And but the ones who are struggling are the children, because I saw a 16-year-old the other day whose dad was having breathlessness and he had COVID. She was so anxious. “What will happen to Papa? Will he die? Will he die?” And that is heart-rending.
0:54:34.8 PC: The older people, I think have come to some sort of understanding, and they’re planning and thinking about it, but it’s the younger people who are… What do you say to somebody whose father is gasping and she’s simply not prepared. So I think to me, that has been heart-rending and I don’t think I have any answers. And I just had to kind of reassure her and tell her, “He’ll be okay. We’re doing this. This is the practical thing that we can do. Can you look after him in this way?” And you won’t believe it, the number of children who become parentified recently. When parents are falling ill, children are actually taking charge, ordering the ambulance, checking the oxygen levels, things that you don’t want your children to do.
0:55:23.2 RN: They have to grow up very fast.
0:55:25.6 PC: Yeah, they have to grow up very fast, and it’s not fair, and I think to me, that was very heart-rending, that it’s not fair, that kid should not be going through this, and I don’t have any answers. I tried reading Victor Frankl because that is my go-to Bible every time I struggle with death and mortality, what people did in concentration camps when everybody was dying. But maybe we need another Victor Frankl to write another book about the COVID pandemic, which will tell us what philosophy we should use. Don’t have any answers.
0:56:01.1 RN: Right. In some sense, being mortal shifted the whole conversation on being able to accept death, and so those of you who have not already read Atul Gawande, of course it has a western perspective, but that’s one good place to start. Paulomi your thoughts on this subject. Our audience is asking many questions, and I don’t know where the time is going, but please Paulomi. Fear of death, getting past it, some coping mechanisms, knowing that it’s a long-term thing that we have to worry about.
0:56:34.6 PS: Yeah, so both I think, both the practical aspects, that it’s something that we can’t deny and all fears have some purpose, because the fear now of death is perhaps going to make us more cautious, but I’m also thinking the fear of someone close to us dying is also very important. So we’ve had people actually becoming more cautious about other people’s behaviour, watching what they do, so it’s not just the fear of our death, and it’s often the process of death than the death itself. So how I’m going to die, what is gonna happen, how difficult or painful will it be? Will it be painful for the other person? So I think those questions about the process of death are very essential, and what we do about those fears.
0:57:15.6 PS: So we found people either reading too much of news to find our what is going to happen and that actually can accentuate the fear, or there is complete avoidance, not dealing with it at all or getting into a lot of behaviours that might not be helpful. And so if you look at a lot of mental health conditions, with or without COVID, I think the fear of death or death anxiety is quite common. I mean, like you said, it could finally come down to that.
0:57:42.5 PS: And so it’s important for us to address, we don’t often get to it in talking to clients, but I think the meaning about death what it means, so it’s a sort of an exposure, but in a very gentle way to look at and understand what the meanings are. And also that certain behaviours which are, at this point, we can’t call it irrational, but there are certain behaviours at other times that may not be very helpful in processing this fear as well. So there are behaviours that might sort of abort or not allow the processing to happen in helpful ways, by avoiding reading…
0:58:14.7 RN: Can you give an example?
0:58:16.5 PS: So not… Avoiding reading about things which are actually helpful for the person, I’m not just about COVID, but otherwise also. So I think it’s important to get the right information to understand whether one is at risk or not, whether one is being overly anxious about something that is not. And here we can’t give probability estimates, we can’t say this is not gonna happen to you, so I think that’s where the situation here about assuring people about the fear of death or not having fear is not something that’s… What we’ve read about in other conditions. We have to understand that the same technique, same strategies will not work here, and we have to be careful when we use them as well. Having said that, I think some of the relaxation or other techniques that might help them, and we find that persons are extremely dysfunctional because of the fear, either they’re house bound when they need not be, and they’re not allowing others to go out because they’re restricting other family members, because I think that sometimes happens, that they’re so afraid that something would happen that they’re not allowing others to go out. I think those can be addressed with the psychological methods or even the restructuring of some of the beliefs they have about what these fears are.
0:59:27.2 PS: So I think you could look at both the practical and the acceptance part as well. And I think, as Dr. Mehta said, a lot of healthcare professionals have come to us, it’s difficult for us to assure them that this is what they have to do because we haven’t been there and they’ve been there and they’re experiencing it. So I think it’s difficult for us to speak from not knowing what they’re experiencing.
0:59:49.5 RN: Right, no, yes, it’s a terrible burden all around and all of you must be very over-stressed in dealing with things that you are, as you said, not even fully trained for, for having such a barrage of things happening to you at the same time, both in the ICU and in your counselling practices. Before I turn to the audience, we hear a lot about post-traumatic stress disorder, but in my research, I came across this concept of post-traumatic growth, and while I’m very sensitive to what Soumitra and I also discussed, that we don’t want to put the full burden of emotional recovery on the individual, because you need a lot of support around you. So you should not say, “Oh, if you stay positive, you will get well.” That’s really not fair to an individual who’s suffering, but I did read a lot about post-traumatic growth, and many studies, which even looked at COVID-19 recently, and they’re saying, and this I find hopeful for all of us, that you can actually, after trauma, experience not necessarily disorder, but a kind of personal growth. And they say that some beliefs associated about the world, such as a primal belief about a good world, or some sense of acceptance of death or a different positive orientation, more of looking forward rather than backward, seems to be associated with the ability to move towards growth rather than disorder. I’m a layperson, I don’t want to overdo this.
1:01:33.8 RN: It just made me feel a little as though if some of us were able to understand that a bit more for ourselves and others, without guilting people into being positive, is that something to look forward to? Because this is going to be such a long haul. Your quick comments, each one, just two or three sentences on the idea of growth versus disorder, and then I’ll really open to my audience. Ravi first, very quickly, all four of you, Ravi. So I’m trying to find the optimism, I’m trying to find the positive way forward, how can we think of this in some way as an opportunity also, at a personal and social level?
1:02:14.9 RM: I’ll put a very crude statement followed by your answer, we’ve reached a stage where we internally we would think that if you’re alive, you can deal with all these issues, that was recorded some months ago, it was very clear, only alive people have problems, depression, anxiety, mental health issues, if I’m not alive nothing is gonna work. So being in the wrong end of a machine, versus this was the crudest way we tried to pull ourselves through.
1:02:37.1 RN: Yes, yes.
1:02:37.6 RM: Secondly, I would leave an add-on statement to your concept, it is the strength born out of crisis, ultimately, if you’ve gone through something of this nature, and you remember some positive thought, some organised action, some commitment to the larger cause, for example, we had to really think of outcomes, in the midst all these issues, we’ve got to be… We had to send people home. Ultimately, at the end of the day, forget resources, no oxygen, this, that, manpower, we gotta send people home. So if we remember that, we held on to it, and as I told everybody, “Don’t worry about who’s going, worry about sending people home.” Whatever you send home is a percentage improvement from everybody not going home, which is what we’re seeing if you look at the scene four weeks ago. So just to add to your point, the strength which can be ingrained, encouraged and collected out of crisis is a form which we are left with because I feel that this wave was better than the last wave for that single reason, that we had some memories, some organisation, some strength which we were able to repurpose very fast. Because in this wave, if you were not prepared, as I said, there was no way to move that fast, so this may be two lines to add to the concept you’re bringing up, and I believe in that strongly when it comes to healthcare.
1:03:50.9 RN: Thank you. Prabha.
1:03:57.0 PC: I work a lot with obstetricians and with pregnant women and postpartum women. And to me, one strength was that many, many, many obstetricians came to us to get trained in mental health because they found that women who are pregnant, who had little babies were really struggling with anxiety and fear of death and a lot of things. And earlier they would never really bother about these things, but a lot… So like obstetricians a lot of other medical professionals actually wanted training in mental health. Which I think was a big plus for me. And so while I’m not addressing post-traumatic growth as such. I’m saying that systems were changing to become slightly stronger, more resilient…
1:04:44.9 RN: More responsive…
1:04:45.6 PC: Yeah, more holistic, and to me, that also is post-traumatic growth or post-crisis growth kind of a thing. And I would be sort of… Think a bit like Soumitra, and say that what we want is a post-traumatic growth of systems, not just the individual. So there is a domino effect. One thing leads to another. If you have a school which is doing a lot of proactive things and thinking beyond just online classes and addressing art, culture, discussing pandemics, discussing emotions, that effect is going to happen with the children and those children are going to then help parents to be more resilient and the system to be more resilient. Let’s talk about resilient systems and post-traumatic growth among systems rather than putting all the onus on the individual.
1:05:40.2 RN: I agree. Thank you. Beautiful. Paulomi to continue on that.
1:05:44.1 PS: Yeah. Two things, one is that for post-traumatic growth to occur, one has to have gone through adversities. And I’m reading now about post-traumatic growth for organisations, not just individuals also. When we’ve been through a lot of difficulties, we’ve learned that a lot of systems have to be in place and how to actually become better at the end of it. So a lot of change in our beliefs would result in this growth. And I’ve also found that people have been resilient, in that they’ve been adaptive, they’ve been able to cope, they’ve been able to be flexible. That’s a lot of positive thing that I have learned in these last 15 months, particularly in the second wave.
1:06:22.1 RN: In fact, you were saying that patients who had already had some experience and learned about coping were doing better than those who were coming in…
1:06:29.4 PS: Yes. And they wrote to me saying that “I’m thanking you because I’ve been able to cope with this even though the whole family has tested positive and I’m doing well.” Because I was expecting them not to do well in this time, but when they came back and told me “I’m reassuring my in-laws, I’m doing better.” I thought it was a very good bit of news for me.
1:06:47.7 RN: So we can train ourselves to be able to deal with stress better differently than before. And your example of some of your patients being able to deal with it better than people who are not already had been trained or had not previously experienced emotional issues before, and had not taken, help before, actually they did better, so that’s very good to know. Soumitra, throwing post-traumatic growth at you, again not to put the burden on individuals, but just to be able to think differently about the future.
1:07:22.7 SP: Let me frame that slightly differently. What can we as a society and in public policy do to promote post-traumatic growth? Maybe that’s the way to ask ourselves.
1:07:35.1 RN: Yes.
1:07:35.4 SP: What can we do as society so that more people get growth rather than disorder?
1:07:39.0 RN: Yes.
1:07:39.3 SP: And I think that that’s where some amount of joined-up public policy thinking is required. We tend to think in silos. Our health system thinks in its own silo. Our employment system will think in its own silo and our social justice system thinks in its own silo. Whereas probably what is required is a much more joined-up thinking that is required. Let me give you an example, what I mean by that so that it makes some sense. Very early in the pandemic, at the first wave, Canada said that they would pay employers 80% of salaries to keep people in a job, even if there was no work to do. And you’d say, “Why would you do that? Why don’t you just pay the unemployment money to the people, and that’s the end of it.” But that is not acknowledging the fact that employment and work has a psychological meaning, has a psychological value. And so keeping people in a job so that they feel they have work to do is more important than just giving money. And I think this joined-up thinking that is required when governments are coming up with public policy for growth is what we really need and we’ve really not seen that.
1:08:47.9 SP: We tend to take very, very narrow attitudes towards dealing… It’s a health sector problem so health sector deal with it. Very often, the health sector is picking up the pieces of problems which are created in other sectors, if not the health sector creating the problem. The health sector is at the end of a long chain and the dumping ground of everybody’s problems.
1:09:09.2 RN: So many determinants, there are many other determinants, yeah.
1:09:12.9 SP: Exactly, So I think we need to be looking at how are we gonna do that differently so that we can get growth.
1:09:19.4 RN: Right. Thank you very much. I’m turning now to my audience who has many, many questions. Ravi, because these are questions that are slightly different from the ones to the other doctors, I’ll ask yours first. And you’ll have to be short because we have only 20 minutes left. How long is this pandemic going to last? And you have to give us the definite answer and is it true in this third wave that kids will be affected?
1:09:49.6 RM: I lost my crystal ball Rohini, so I don’t think I can answer the first question easily. The prediction is, till we have a way out. The way out is either some sort of solution like vaccination, which I don’t think is a total solution, it’s the initial solution, or the virus comes to what’s called a epidemic endemic level like influenza and we learn to live with it. To put it into perspective, if we can just figure out who’s gonna get sicker, I think the problem is sort, that’s all. Otherwise, we’ll be on this usual flu-like illness and we can get rid of it. So short way of answering, what is a very profound question. The second is third wave. Third wave is logical, we’ve been following the other parts of the world, they all are going through some sort of 2.5 or third wave, and so on. It’s understandable that in some way the virus will take a three-four month break and then it will come back either in its own form or mutant form, whether our measures will work, not work, whom will it affect and we’re seeing various populations. So a very realistic consideration, if we plan seminars like this in a comprehensive way it’s easier…
1:10:47.0 RM: It’s unlogical to think about it. Will it affect children? Well that’s because at the end of the chain, that’s what’s left, we saw it moving towards the younger population who were not vaccinated, and that’s why children is being brought up, largely a question of concern, not definitely a matter of certainty but something to plan for. So I don’t think it’s a panic situation more to think that, “Okay, it’s possible, let’s go and put our resources into it and figure it out.” More for planning I think, because interpandemic before this, we, I think, were basically sitting just pretty much doing nothing, if you look at the audit, critical audit we do of ourselves.
1:11:21.8 RN: But very quickly, and it’s really not fair to dump this question on you, but yes, preparing… Suppose it comes to the children, we have 600 million people below the age of 18, that’s two Americas. What does it mean in terms of children, how do you keep children safe at all. Is there any one suggestion? .
1:11:42.0 RM: So yeah, again, naively when you ask a question, we tend to answer it as if we know. The answer is we probably don’t know enough. What I do understand is first of all, very comforting facts, it’s never shown bad outcomes in children. Very, very small chance of significant affliction come what may. So let’s not confuse…
1:12:00.1 RN: Don’t overdo the anxiety, number one.
1:12:02.4 RM: Let’s not confuse these numbers, see we look at numbers because we are stock exchange, how much wealth do I have, the ATM which comes to, RTGS which comes to me, this is not about numbers, single question, how many people are gonna reach hospitals? That’s all we need to understand now, let’s treat what we have, otherwise malaria, TB, dengue if we start thinking, we’ll to hold five such meetings and still we’ll not have closure. Secondly, we will have solutions, there’s so much a vaccination, which won’t leave many targets for the virus, it’s not gonna be something which is gonna be profound. Thirdly, the preparation of the healthcare system, the government, I don’t think we’re going to be naively doing what we did so far, so there’s many many hopeful things out there, which are there. People are also much more aware. I think we have a rational way of handling this rather than a irrational fear of third wave, children gone, let’s prepare for calamity and doomsday, and let’s prepare Noah’s ark or something. It doesn’t work that way.
1:12:57.4 RN: Thank you. And in case I can’t come back you in the short time we have, I wanted to ask all of you, but you have to answer very briefly Ravi. How do you, people, cope? If you give us a secret on how you cope, maybe we can learn a little bit to cope, you face a hundred times what I had to face. Tell us two or three things that you do very seriously for yourself to cope.
1:13:19.6 RM: It sounds very cliched, but focus, compartmentalise what you cannot help and focus what change you can make, marginalise all that, which is going to take you down and reserve all this introspection and assessment for later when the task is done. If I put it very crudely, when you’re standing out there in front of a patient who’s very sick, he’s on the other side of the machine, you are not. So if you can keep that realisation and then get all your reserves in, it works miracles, and then of course, all the other stuff, peer systems encouraging each other and so on, but these three, four things at a individual level, I think work very well for most of us.
1:13:58.7 RN: Thank you so much. Thank you so much, Ravi and thank you for all that you do. Some questions from the audience. What is a good way… And if you want to take that, any of the other three doctors, what is a really good way to support people who are grieving? And what are really bad ways to do so?
1:14:19.8 PC: So I’ll take that.
1:14:21.0 RN: Yes.
1:14:22.0 PC: So I think we need to understand that everybody has their unique pathway about grief, there’s no right one way to grieve. There are some people who will talk about it endlessly, to call up relatives and talk about what had happened to the person, there’ll be people will not talk about it and want to process it themselves. So I think one must recognise that grief will take its own path, and I think what you can do is to simply say, be available to listen to the people, be witness to the grief. Grief needs to be witnessed. Grief needs to be validated. You don’t have to say anything, all you need to do is to listen and to be available, so I think to me, that is something that even as a therapist, that is what people who are grieving need. They need someone whom they can talk to about their loss, not just the lost person, but the identity they have lost, so I’m no longer so and so’s mother, I’m no longer so and so’s daughter. So there are many losses along with somebody dying, so I think grief needs to be witnessed is what I would say.
1:15:24.3 RN: Thank you, Paulomi, is there some bad way to do this ? When you’re trying to help and you’re making saying doing the exact opposite of what you should be doing.
1:15:33.4 PS: I think we all jump to giving practical solutions of what to do, and I think what Dr. Prabha said in terms of each one having their own way of processing, not to interrupt that, but just to understand and be there, so if you are prematurely offering suggestions or saying, this is the way to do it, or why don’t you do this to forget things? So I think that would not help the person, so I know it’s difficult to just be there and not offer solutions because we’re all trained to do something, so I don’t know if it’s a bad way, but it may not be very helpful for the person.
1:16:03.4 RN: Thank you. There’s a question about numbness, that there’s a dangerous numbness around in this wave. Like somebody said, okay, somebody… Something happened to my and the reaction on the other side is not what you expect, can any of you Soumitra, anyone… What do we do with this strange numbness that sometimes has enveloped us?
1:16:26.2 SP: I think that this is also, it also depends on your own personal backgrounds as well as personal experience, so I suspect that this numbness probably affects certain people in a certain situation. I think talking to people and keeping yourself busy with some activity is probably your best way to try and get out of that numbness stuff. That numbness thing is what then isolates you, and if you’re gonna get isolated, you’re just gonna make that worse, so the way to fight it is to not kind of withdraw into a shell where you’re allowing the numbness to become a cloak around you, which then stops you from doing things. So I mean that’s a… I’m trying to give a very, very broad general answer, it’s very difficult to generalise answers to these kind of questions because they tend to be so specific to the individual at that point.
1:17:22.1 RN: Right.
1:17:23.0 SP: And Paulomi has got her hand up so I’m very happy to let her add to this.
1:17:25.9 PS: Oh no, I’m not, I have not put my hand up.
1:17:30.0 RN: Paulomi, anything you want to add to this ? And also… If you, any of you want to talk about, people are also feeling great anger and frustration, hopelessness at the system. That somebody should have been doing more for us. How does one deal with that?
1:17:48.0 PC: I think that anger needs to be acknowledged, I think it’s very important in any situation.
1:17:54.1 RN: By whom, by who?
1:17:55.4 PC: By whoever… By anybody. So supposing somebody is very… Getting very angry, so instead of saying “No, no.” Let me give you an example, So I had somebody I know, lost her mother, and she was very angry. And she’s not a doctor, she was very angry with the medical system because the doctors did not speak properly to her, they did not tell her what was happening in the ICU. And she was told by some people, “You know what, doctors are also so tired and they are frustrated, they are upset, so they can’t talk to you… So you shouldn’t be saying that.” And she was even more angry, so I think what she wanted at that point was, “Yes, your anger is justified. Yes, you deserved to know more about your mother when she was in ICU. Yes, you deserved more empathy.” I think anger needs to be validated and acknowledged.
1:18:42.0 RN: And some people have asked that teenagers especially, are showing great signs of anger. Any advice to teenagers or parents?
1:18:53.8 SP: I have a teenager at home, a 19-year-old, and one of the things that I’ve learned now is to actually let them be. Look, it’s very difficult. Just think about it Rohini, imagine the best years of your life. When we were 19, these are the best years of your life. You’re never gonna be 19 again. And what do you do, you spend 14 months of those best years of your life locked up at home, you can’t go out, you can’t do the kind of things that 19-year-olds do. It’s easily understandable, Why 19-year-olds and 20-year-olds are feeling the way they are feeling. And to just say to them, “Well, but you need to be safe, and… ” They know they need to be safe. And one of the things I’ve noticed in this entire 14 months is actually the maturity shown by our young people. The young have shown far more maturity than I would say our middle-aged and older folk. They’ve been very sensible, they’ve actually… You look about and look around, how many times have you had stories in the newspapers about a bunch of youngsters hanging about somewhere and creating a problem.
1:19:57.3 SP: This hasn’t happened. It’s the elderly and the older people who’ve done that. Hanging around in crowds, congregating in groups and creating a mess. The young haven’t done that. I think the young have… We need to give them a little credit for having done a pretty good job, despite a really difficult odds.
1:20:17.0 RN: Yeah. There’s a question about how can we help them better to cope. Anybody wants to answer that? Young people especially… They are looking at their future plans suddenly derailed. What can we do? Any of you, as a professional what can you say? I know there’s no one single answer.
1:20:35.6 SP: Give them the space, let them be, I think, that’s probably one of the best things parents can do, give them that particular space… I hear these stories like, “You know, he goes to bed at 3:00 AM and gets up only at midday.” What difference does it make to you if he goes to bed at 3:00 AM and gets up at 12:00. Why should he get up at 7:00 for example? These kind of stuff, I think parents need to really lay off this stuff, they don’t need to be…
1:21:01.8 RN: Keep a much more open mind about routines, old disciplines. Give space and freedom. Alright, thank you. Paulomi to you a question that we’ve been talking about loneliness and stuff, and isolation. But actually the opposite is also a problem when you are surrounded by too many people in small spaces and you don’t have privacy, you can’t even reach out to a psychologist or counsellor on your own. Both the problems have been happening in this pandemic. Isolation and too much crowding. Any advice from any of you on how to deal with well, your family sometimes.
1:21:42.3 PS: I don’t know. I thought too much crowding now would make us anxious also because we don’t want crowds, but I don’t know if the question is about whether there is no privacy and people have no access to…
1:21:53.6 RN: And also domestic violence, the lack of privacy, lack of space. There are people who are all alone and are desperate for company, but there are people who’d love a little space. So for those who need space, who literally don’t have physical space for themselves, who may be victims of domestic violence or anger or frustration, what is the advice for them, any of y’all.
1:22:20.3 PS: I think Dr. Prabha would answer that.
1:22:23.4 PC: Rohini, I have just finished this study called, the dial and see study, where we actually spoke to counsellors in one-stop centres and about women coming with domestic violence. And one of the things they mentioned to us was that only the women who have extreme violence are coming to them. Earlier, even women with sort of milder forms of violence would come and seek help, now they are not able to come. And the counsellors in the one-stop centres are not able to talk to these women on the phone because of the very things that you said, because of privacy issues. We are now trying to train the one-stop centre counsellors, “how do you talk to a woman when she’s within the household, so can you… Can we use words which indicate violence, but the woman does not have to use the word violence. So code words like, aaj baingan banaya hai ki bhendi banaya hai kind of a thing. And the woman actually says…
1:23:27.4 PC: Means kaafi pitaai hui hai types. So training counsellors… Counsellors are also saying that we would like methods by which we would be better trained to handle telephone support, and also if there are any ways in which we can do sort of more… They can go there, if they have transport they can go and help women in their own locations because women cannot travel during lockdowns. So I think we really need to think of some of these… Like I said before systemic ways of trying to improve systems for families and children. Another big issue, not to sound very negative or pessimistic, but it’s a problem, is child marriage, which is happening quite a bit, because governance systems are not in place, the teachers are not looking… Normally, teachers look out for kids, young girls and that’s another problem. These are some of those unique things which are happening because of all the problems that you have said and we need to find innovative solutions for these.
1:24:30.3 RN: Somebody said in the questions that, this might be a great time to change the vocabulary of how we talk about mental health issues and bring some of these to the forefront, that, it’s not just something esoteric or out there. Any thoughts on how we can use the pandemic and the fact that, so many more of us have stresses that we didn’t call out before, we just dealt with them. How can we make emotional well-being, more centre of life’s lives conversations?
1:25:02.4 SP: I think it is… Rohini, I think it is already happening, if you see…
1:25:06.1 RN: Okay.
1:25:06.5 SP: There is a lot more conversation… I think what is important and this is what I worry about is, to not talk about mental health as an equivalent of mental illness. Mental health is not some kind of a code for saying, mental illness. When we talk about health, we are actually talking about much more than illness. And I sometimes find that it gets reduced down to illness. And not everybody who might have a mental health problem has a mental illness, not everybody who has a mental health problem needs a professional like Prabha or Paulomi.
1:25:38.7 RN: Right.
1:25:39.0 SP: In fact, I think what… If you want to normalise mental health, I think what we need to do is, if I can use this example of, cough and cold. Every time you have a cough and cold, you don’t end up with Ravindra and tell him to say, “Oh, my God, have I got pneumonia?” You probably do some household remedies, you might talk to somebody. If that doesn’t work, you might see your GP. If that doesn’t work, you might go into an MD, physician and if worse worst case scenario, you might end up with a Ravindra. And the same thing, holds true for mental health. I don’t think anyone who has or everyone who has a mental health problem needs to see me, Prabha or Paulomi, for that matter. And I think we need to build these informal systems of support, informal care, which can provide a lot to people and normalise the conversation, so that it’s not a whole thing, that is done by going to psychiatrists.
1:26:28.4 RN: Right, right. Thank you. And before, we are almost… Yes, please, Ravi.
1:26:34.4 RM: I think learning is, commenting and learning more than actually being an expert for this aspect of it. I think, it’s all a, that what’s called, a tier tiered approach in life. Where do you stand in terms of your mental health, that you’re able to tackle this. I mean, if you’re a Jew in the concentration camps, 14 months of your life is nothing, you’ll pretty be happy to be out. And you’re gonna go out and you’ll look at it that way. On the other end, if you’re very vulnerable and you’ve been in a horrible… You’ve been in a life which has been challenging you, you can’t take it. So, I think the tier approach, where we are and what can we build up? That if this is where we are, and healthcare had to go through it, we have a tier… You have so many reserves, you need to build those reserves for this amount of time. If that could be applied across the board to every one of us, then I think we’ll at least pull in some reserve, before we contact all these august people and to at least bail out… Understanding that everything will come to an end, there is no way this goes on indefinitely, there is light at the end of the tunnel, there are solutions. And, for the first time in our lives, it is not only your problem, it is a global problem, we’ve never seen this before. So, it’s not that you’re being persecuted, singled-out, you just have to go with the flow, figure out your means and methods, reach out for reserves and one day this will be history.
1:27:46.6 RN: Yes, before we go, Ravi, told us what he does. Please, all three of you. How do you cope when you have to deal with everybody else’s grief and loss, every single day? Paulomi.
1:28:02.5 PS: I mean, to some extent, we’re trained to distance ourselves, not get into personal distresses, but for me, I, my routine work is very essential, I actually don’t have time, once I get home. I think, so, it’s in a way a good that I have to do a lot of my work, on my own. Plus, there’s, of course a lot of students to talk to, find out how they’re doing, so I think that keeps me busy and keeps me distracted from things that are going on as well. And I feel quite satisfied at the end of the day.
1:28:32.3 RN: Thank you. Soumitra.
1:28:34.3 SP: Oh, fine, this is going to be an unusual answer, I’m sure. I spend a lot time on Twitter, as everyone who knows, by now… [laughter] And…
1:28:42.7 RN: It’s what people, tell other people, not to do, and you’re saying that what’s you do.
1:28:47.1 SP: I mean, it relaxes me. It relaxes me, I enjoy it, I have lots of wonderful conversations, I put out some interesting tweets. I enjoy it, if it was gonna trigger me, I wouldn’t be there at all, I would get out of it. And I use it as a way of having… Making lots of new friends, that sounds very unusual, I’m sure.
1:29:06.2 RN: And you don’t have fights on Twitter, clearly.
1:29:08.7 SP: I don’t get into the fights, I just walk away from fights as…
1:29:12.6 PC: He blocks people. He blocks people.
1:29:15.6 SP: Yeah, exactly, I don’t get into fights.
1:29:17.6 RN: Walk away from a fight.
1:29:18.9 SP: I just block people or mute them, I don’t wanna get into fights.
1:29:24.1 RN: Okay, but do you get enough sleep? Because, sleep is supposed to be a big indicator of health?
1:29:29.1 SP: Well, actually, I told you, I’m a freak, because even before the pandemic, I used to only sleep about four hours or four and a half hours…
1:29:38.5 RN: Wow, one of those super people.
1:29:42.0 SP: So, I mean, for me, it’s like, nothing has changed. I still sleep four and a half hours, a day and that’s completely fine. But, so, I’m not… I’m two standard deviations from the normal…
1:29:50.3 RN: [chuckle] Okay, good. So, Twitter and no sleep. This is not a prescription, guys. Prabha.
1:29:58.7 PC: So one thing, like Paulomi said that, we’re trained to manage our stress pretty well, so, that training is helping. But what I do is, when I’m doing a certain kind of work. Let’s say I’m talking to patients and I’m doing a lot of grief work right now, so if I’m… I’ve seen three families, who are grieving. What I do is, I try to do something else, within my work, which is in a slightly different compartment. So, for example, I’ll write something or analyse some data or plan some intervention. So, trying to do something which is similar, but using my time more effectively, upskilling myself. I’m doing a lot of that, I’m learning more about… Let’s say, traumatic bereavement, doing a course, that helps me. And of course, I have a wonderful dog, Juno. And she amuses me no end and we have these very interesting conversations, I think she’s a very good listener. And that is probably one of my major stress-busters.
1:30:56.7 RN: Yes, I was reading that, just petting a pet, an animal, gives tremendous… Listening to music, there seem to be many pathways. Thank you for sharing. Before we come to a close, I can’t resist reading out a short part of a poem by Rebecca Elson, “Sometimes, as an antidote to fear of death, I eat the stars. Those nights, lying on my back, I suck them from the quenching dark, till they are all, all, inside me, pepper hot and sharp”. So, to all those who have listened, to all those who have been here, I thank you so much for having attended this session. I know there are a lot of topics we did not cover, I, myself, had so many more questions for our marvelous panel. I want to thank the doctors, very much, for having come here. Thank you so much for taking your time, I know how busy you are. Especially Ravi, who can get called any time. Thank you for being here. Thank you to everybody, we’ve listed some resources there. Thank you, BIC. And stay safe, stay well. There are pathways, out of this. That end of the tunnel will come, this too shall pass. Thank you, stay safe. Thank you for being with us. Namaste. All the… Especially to our doctors.
1:32:23.4 PC: Thank you. Thanks a lot.
1:32:25.0 SP: Thank you.
1:32:28.0 RN: Lekha, over to you.
1:32:29.4 Lekha: Well, I thought, Rohini summed that up and ended the session, quite beautifully. Thank you. Thank you, Doctor… Dr. Chandra, Dr. Pathare, Professor Sudhir and Dr. Mehta, it has… The outpouring, in the Q&A box itself, is a testament to how much we needed this session and how much I personally also needed to hear this and this lovely gathering. I hope we have many more of these, over time and I hope that this conversation keeps going.
1:33:04.1 RN: In fact, Lekha, if I may request listeners. If they want specific topics, very happy to put together more panels, so that we can keep this conversation going. I think public dialogues are very important now, because we need to have a whole new societal understanding of what the pandemic is still to have in store for us. Happy to do that. If people can keep writing into BIC about what more panels they would like to see.
1:33:33.0 Lekha: Yes.
1:33:33.3 RN: We don’t usually end a panel like that. [chuckle]
1:33:38.0 Lekha: Thank you all and hopefully see you on a brighter, lighter note, next time. Good night.