Episode 3: Pandemic Stress (with Vikram Patel, Mary-Jo DelVecchio Good, and Giuseppe Raviola)

Whether or not you’ve been exposed to the virus, the COVID-19 pandemic impacts everyone’s sense of well-being. Three scholars in the field of global mental health look at the various ways loss, fear, anxiety—and on top of it, a massive global recession—weigh on the mental well-being of different groups. And they anticipate a surge in demand for mental health services as a result of the pandemic.

Three speakers of the podcast episode

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Although the contemporary world has never seen the likes of such economic contraction as we have now, the recession of 2008 might be an instructive case. Vikram Patel, professor of global health and population, explains what is known about the mental health impacts stemming from that recent recession. Mary-Jo DelVecchio Good, a sociologist and medical anthropologist, gets inside the mind and experiences of the doctors and healthcare workers who are taking care of us (and it’s not necessarily what you would expect). And psychiatrist Dr. Giuseppe Raviola gives an unflinching look at what American families and kids are struggling with during lockdown.

The scholars also discuss the fraught state of mental health service delivery in the US, and advocate for adopting an approach to mental health services very different from the US’s hierarchical system of licensed specialists.

Finally, our guests confront the great disparities in the hardships this pandemic creates: in short, wealthy people are doing just fine and have all the advantages, while for others, the pandemic has taken away so many of the resources they once had, causing enduring stress.

Disclaimer: This podcast was recorded on May 22, 2020 when the US had approximately 1.5 million positive COVID-19 cases.

Host
 

Kathleen Molony, Director, Weatherhead Scholars Program.

Guests
 

Vikram Patel, Faculty Associate. The Pershing Square Professor of Global Health and Wellcome Trust Principal Research Fellow, Department of Global Health and Social Medicine, Harvard Medical School. Professor, Department of Global Health and Population, Harvard T.H. Chan School of Public Health.

Mary-Jo DelVecchio Good, Faculty Associate. Professor of Global Health and Social Medicine, Department of Global Health and Social Medicine, Harvard Medical School, and Department of Sociology, Harvard University. For the past thirty years, she has cohosted the Friday Morning Seminar in Culture, Psychiatry, and Global Mental Health at the Weatherhead Center.  

Giuseppe (“Bepi”) Raviola, is a board-certified child, adolescent, and adult psychiatrist, and the Director of Mental Health for Partners in Health, a Boston-based humanitarian healthcare organization that serves ten countries. Bepi is actively involved in training contact tracers in Massachusetts through Partners in Health.

Related Links
 

Transcript
 

Kathy Molony:
Welcome to the Epicenter Podcast from the Weatherhead Center for International Affairs at Harvard University. I'm Kathleen Molony, Director of the Weatherhead Scholars Program. As we wait out the pandemic, we've been vigilant about keeping ourselves physically healthy and keeping others physically healthy to the extent possible, but we don't talk much about our mental health, fear, anxiety, grief. All levels and types of stress are in play. On some level, we are all affected.

Kathy Molony:
Today, we're speaking with experts in the field of global mental health delivery, to better understand the various dimensions of stress and its long-term impacts. We welcome our guests to our virtual studio. Vikram Patel is Professor in the Department of Global Health and Population at the Harvard T.H. Chan School of Public Health. He holds many distinguished roles at international health organizations and has been widely recognized for his work on the burden of mental health disorders and their connection to social disadvantage. Mary-Jo DelVecchio Good is a comparative sociologist, medical anthropologist, and Professor of Global Health and Social Medicine at Harvard Medical School.

Kathy Molony:
She and Byron Good have been hosting a weekly seminar in culture, psychiatry and global mental health for more than 30 years, and we welcome their colleague, Dr. Giuseppe Raviola, who goes by the name Bepi. He's a board-certified child/adolescent and adult psychiatrist, and the Director of Mental Health for Partners In Health, a Boston-based humanitarian healthcare organization that serves 10 countries. Bepi is actively involved in training contact tracers in Massachusetts through Partners In Health. The world is facing an unprecedented economic downturn in response to the pandemic. Depending on the country, anywhere from 3% to 70% of people have lost their jobs, and it's said that some jobs and businesses may not come back.

Kathy Molony:
Vikram Patel, can you help us fathom the types of mental health issues that we should anticipate if we are facing an extended global recession, as many have predicted.

Vikram Patel:
To be quite honest, I can't recall in my two and a half decades of working in Global Health that the world has ever witnessed something as terrifying as what we're seeing right now. Never before have so many countries been united in terms of facing a cataclysmic economic recession. People don't even really have historical precedence for this because perhaps the closest precedent is, in terms of time was in 2008 with the banking crisis, which triggered, of course a recession, but that recession was largely focused only on those countries where banks were very poorly regulated, and the U.S., of course was the exemplar country that was worst affected, but you didn't see much recession, for example, anywhere in Asia or Sub-Saharan Africa, where banks were much better regulated. I think that was a very localized recession in many ways, but I think that's a very instructive recession for us to address the question you've just asked. Following the recession of 2008, the U.S. became the only OECD country, that is to say the only wealthy country in the world, where life expectancy gains did not only stall, but actually reduced.

Vikram Patel:
This reduction was predominantly in working age Americans. That is to say people between the ages of around 18 and 45, and much of those losses were seen in the Rust Belt of America, the Heartland of America, and obviously, people have done a lot of soul-searching on this. Much of those deaths were driven by what was essentially a different epidemic, the epidemic of opiate use. In fact, if you look at the terrific book by Angus Deaton and Anne Case, that was published a few months ago, called the Deaths of Despair, a term that has been more and more commonly used in the context of the economic recession that is unfolding in front of our eyes right now, it was interesting to ... The choice of words are very interesting actually, because they weren't talking about the deaths due to, for example, hunger, which is a real and immediate threat in many parts of the world, such as the one that I'm currently locked down in India, but they were because, of course Americans didn't go hungry even during the economic recession.

Vikram Patel:
Not in the same kind of way that people are going hungry in India and in Africa right now, but it was despair that killed them. Obviously not directly. It was despair that was born out of a sense of purposelessness, of sense that the way of life that people had known, that their forefathers have known had basically evaporated, and that there was no chance that that way of life would come back. It was a sense of being essentially uprooted, losing anchor from the rock of certainty, the rock of history. That despair also was combined with rising inequality.

Vikram Patel:
I think it's a sense that I didn't have a place any longer in this world that I knew so well, and while I don't have a place, I can still see lots of people making a lot of money and doing extremely well. It's that despair that drove, of course, the actual deaths were primarily due to suicide and substance use related mortality. I think we have that historical precedent. It was only about 12 years ago. It seems eons ago, but it was not that long ago.

Kathy Molony:
It seems like we're just starting to hear about mental health concerns related to the pandemic. How widespread is the awareness that mental health issues are going to increase?

Vikram Patel:
A couple of days ago, the UN Secretary General published a brief from his office on the oncoming mental health crisis. In fact, he's just released a video, a testimony, as well as an op-ed in Time Magazine on this. This is an important issue really, because the UN Secretary General historically doesn't talk about mental health. Very rarely have you ever heard someone from that particular position talking about mental health, but incredibly so, too, President Trump. I would find it very hard to agree with President Trump on most things, but I have to agree with him on his most recent statement.

Vikram Patel:
He uses the argument, of course, the mental health for the wrong reasons, but the argument that he makes is absolutely right. That is we need to prepare ourselves for a surge of depression, suicide, and substance use in America. Of course, the solution isn't rapidly lifting the lockdown in a wanton way, but on the other hand, it's about strengthening the mental health system with a significant investment in resources, also ensuring that those resources are used in a way that are consistent with our understanding, a modern understanding of what a mental healthcare system should look like. I think he's absolutely right in terms of getting us thinking about mental health as the UN Secretary General is. I want to end just simply by remarking on what kinds of mental health problems we're going to see.

Vikram Patel:
I think, of course, mental health is a very heterogeneous group of health conditions. The ones that are most prominently associated with economic recession essentially fall into two buckets. You have the mood and anxiety conditions, and the second is substance use conditions. Of course, these often coexist, and they drive mortality primarily through suicide and the kind of medical morbidities that are associated both with mood disorders, as well as substance use disorders, but I think it's important for me also to point out that people with serious mental illnesses, the enduring mental health conditions, such as intellectual disabilities, chronic schizophrenia, these are conditions that can be significantly worse than an economic recession indirectly because of ... Obviously, directly as well because of stress, but more indirectly because the affordability of mental health services becomes reduced, but also currently, my bigger concern is that mental health services have been interrupted because all our attention has diverted to the care of people with COVID-19, but unfortunately, that has also meant that the care of people with other preexisting chronic conditions has often been neglected, and I think we really do need to make sure that we don't take, as it were, resources from one pot, and apply it to another because there are people in that pot who continue to need our attention and care.

Kathy Molony:
I'm going to switch now to talk about American families and the unique situation they're in. Kids and parents have been spending more time together than maybe they ever have, as kids have been out of school, and it can't all be bad. Bepi, in reference to your clinical practice, what are some of the challenges that come up for families and children?

Bepi Raviola:
We are dealing with the global catastrophe, and health systems are upended and family structures are upended as well. There's a lot of mixed messages that families are receiving, so there's this feeling people have that they're on their own, and so clearly, there's increased stress and friction within households. There's normal reactions, irritability, anger, insomnia, anxiety, grief. There's a diversity of families and households, and certain families are more vulnerable, migrants, refugees, immigrant families, families in which there is an active substance user, and there's this concern also that aggression and violence between family members may worsen. The data seems to show that while there's been a 20% reduction of crime in urban centers, there's been at least a 5% increase in interpersonal violence at home. There are single parents...

Bepi Raviola:
I think things are particularly difficult for them. There are people without children or other family members who are alone, but with regard to children, of course, we have to think about child development, and starting with the issue of schooling, children are not being homeschooled because homeschooling is an accepted, organized practice, and we're in an emergency situation. Families are not on an extended vacation. This is not a trip. It's not a family trip, and parents aren't able to have rests, and there's a big question for parents on how they manage their own anxiety, how they contain their anxiety to provide children with a feeling of safety and comfort, and information.

Bepi Raviola:
Not all families have the resources to do that, and so some of the inequities around access to services and various resources plays into that, because some families are in a better or easier position to "Buffer their kids" from anxiety. Kids also, with executive functioning challenges, are more vulnerable. There are lifelong benefits of healthy executive functioning and self-regulation and social interaction, and school is not there to bind them, and teachers themselves are also frontline workers who are under duress, and there's a risk of burnout of teachers as well. With regards to school, it's really quite profound and interesting.

Kathy Molony:
Are there any silver linings for kids? Maybe they don't see their peer group as much, and that has its own challenges, but they do get more family time.

Bepi Raviola:
Some kids are reading faster actually. I mean, this is from the experience of practice, but not necessarily scientifically shown, but kids are getting a lot of attention, so whether it's reading or math, there are some areas where kids may actually benefit because they're getting so much attention from parents, and kids are resilient, and so we need to factor that in. Kids will become more patient. They will learn to handle and make sacrifices. They will develop more self-control. They can become more flexible.

Bepi Raviola:
They can appreciate their peer relationships that they've lost and commit in a different way when they return to school, and kids will learn how to make do if they haven't already. There's also a lot that can be done by families, giving kids meaningful jobs, cleaning, washing their laundry, helping parents, and then there's another silver lining, which is that people are helping each other, that one can instill within a family a sense that people are intrinsically good and seeking to help each other, and there's a spirit of altruism that also can come out of this.

Kathy Molony:
Another group experiencing a tremendous level of stress is doctors, nurses, and frontline workers. Mary-Jo, you're an anthropologist in the study of the medical profession and Global Mental Health. You meet with healthcare professionals from around the world in your weekly seminars. What have you been hearing from them?

Mary-Jo DelVecchio Good:
Thank you, Kathy. I've been hearing stories that are extraordinarily emotional. I would like to read a short comment that one of my colleagues here, who also works in South America, wrote about his feelings and his sense of what it was like to be encountering COVID-19 patients. He calls it “Fear and Beauty.” I had asked him a number of questions, and it led to this response.

Mary-Jo DelVecchio Good:
"Lately, I have been experiencing many emotions and feelings in respect to the practice of medicine, flowing out from some internal center that was very well-known and dear to me, but which I had lost track somewhere in the road. I never thought I could relate to the life of a soldier, but now, I cannot stop thinking about young soldiers, battles and war, and the feelings are an inseparable mix of pain, fear, sadness, discomfort, pride, and hard to say why or how satisfaction and beauty." The term, satisfaction comes up frequently in the conversations that we've had with people in Indonesia, and fear and pain as well. The Indonesian clinicians, who spoke with us most recently spoke about being terrified of bringing home the virus to their families, and yet they also speak about satisfaction and pride, and being able to do a good job to be successful in treating. It is tied to the change in time and what has been able to be done, so initially, people who were telling us about what Iranian physicians were suffering from the early onset of COVID there, over 100 doctors died, there was great fear, and there was inability to control what was happening.

Mary-Jo DelVecchio Good:
What you see in the United States and you see also now in Indonesia, additional PPE and ability to kind of control the situation, to control the virus, to control what they're treating, so we see a lot of stories in the newspapers, which are very, very moving, about burnout, but we also have this sense of the sort of adrenaline that comes up when people are going to war, and this is the war against COVID, and their ability to actually be flexible and creative, and taking control of their professional decision-making, so it is a very interesting kind of thing that has happened. The ability to have enough, you have to have enough protection for yourself, you need to be able to figure out ways to protect your family, but then you can attend to the patients in need in a different way. This sense of fear, and beauty, and pride, and satisfaction, I think runs through conversations of many physicians. From what you've said, it seems like doctors are really feeling their purpose in the world and truly fulfilling their calling. There's a really interesting article in The New England Journal that just came out.

Mary-Jo DelVecchio Good:
Here it is, “Physician Burnout, Interrupted” by Pamela Hartzband and Jerome Groopman. It looks at how the COVID virus may have actually broken apart the burnout that physicians have been experiencing with the increasing control of the electronic health records and the problem of electronic health records, and intervening in their professional autonomy, in destroying the sense of competence that they have, and really bringing the profession of medicine and its cultural authority and power under attack, where there's a great deal of discussion of that. Now, today, in the U.S., dealing with COVID, physicians are able to be innovative, creative, and make decisions at the moment on the fly. There's a kind of heightened sense of being able to take pride and control over what you're doing. It actually raises very, very interesting questions about whether or not the electronic medical record or the electronic health record shouldn't be revised and control, broken open, and the way people record what's happening to their patients have space for the relationship and also how that relationship is to be structured.

Kathy Molony:
Perhaps, that's another silver lining in this crisis, being forced to step back and reevaluate the systems we have in place. For example, how we deliver healthcare in the United States. One issue you all have in common is your work on progressive and diverse methods of healthcare delivery, especially in the field of mental health. Your research points to community-based models that reach far more people than the tightly-regulated mental health systems we have in the U.S. Mary-Jo, you studied healthcare in Indonesia, where they have what is called healthcare cadres or kaders in Indonesian, a system used in the developing world where groups of community workers are trained to provide a variety of basic healthcare services, and also mental health support. Can you tell us about Indonesia's response to the pandemic?

Mary-Jo DelVecchio Good:
At the community level, again, if we look at places like Indonesia, there are health kaders in every community. The health kader has been in place since early Suharto days, so for decades, there have been health kaders. Those health kaders not only provide data about what's happening, they also control the community, so in places like Bali, people are not allowed to leave their village and no one is allowed to come in. People who are in need are provided food and support. In Bali, there have been virtually no cases identified. Their primary problem is an economic one, and there's great grief around that.

Mary-Jo DelVecchio Good:
On the other hand, the Banjar system and the kader system is still working very well, and my colleagues and friends are on the frontlines there. In Yogyakarta, the neighborhoods or small kampoongs, they call them, the neighborhoods also have the same thing, with health kaders. Kaders provide support and also referral. There is a very positive mental health program going on, both in the villages and in the city in Yogyakarta, in which there is reaching out into the puskesmas, which are the health centers and to the kaders, to teach them to recognize and refer and support patients who have mental illness. We've seen a great deal of popular voice around promoting mental healthcare, and actually sensitivity to it.

Mary-Jo DelVecchio Good:
I think that one thing that is happening though, is that the mental health of doctors are under stress because every day, the pictures of doctors and nurses, the health professionals in the hospitals are put out, those who acquire the disease and are diagnosed with a disease and those who die, and it does scare people.

Kathy Molony:
Going back to the idea of training community members to deliver healthcare services, Bepi, you work directly with contact tracers to train them to provide mental health support to patients. How does this work?

Bepi Raviola:
The contact tracers come from a wide variety of backgrounds. Some have backgrounds in mental health services, and some do not. They have a set list of tasks that they need to accomplish in terms of their functional contact tracing responsibility, in terms of flattening the curve and reducing transmission of COVID, but at the same time, of course, they're coming into contact who are under great duress and profoundly stressed, and all kinds of issues are going to come up, and so we do have a responsibility to support them in delivering empathic, open-ended support, and also problem-based support to solve issues that are very individual, and so what we've done is we've added in a mental health and psychosocial training component to the program. The fundamental premise is that no matter what people's background, you don't need to have a clinical background to provide basic, evidence-based support that really takes a do-no-harm approach that is human rights-oriented, and that is really oriented towards the hierarchy of needs. In terms of starting with social considerations and basic services, and strengthening community and family supports before you go in a clinical direction, these are not clinical interventions.

Bepi Raviola:
These are basic ... It's a basic toolbox of support that everybody should know. We've been emphasizing the fact that these are skills that anybody can learn, and it really puts everybody at a common baseline.

Kathy Molony:
Vikram, we Americans know how expensive it is to get mental health services. Nowadays, it's difficult to find an experienced therapist or counselor that accepts health insurance, so that leaves quite a lot of people without the support that could really help them, especially during a time of crisis. Is it time for our mental health system to be revamped?

Vikram Patel:
The single most important recommendation for the United States is to learn on how mental healthcare can be delivered in low-resource settings. I think one of the great ills of America's healthcare system is so much money is spent, and yet so many people do not receive quality care. I think the idea of simply spending more money on the same is the wrong solution. More money is needed, but it needs to be spent on cost-effective strategies to improve access to quality mental healthcare. What is that one thing about all others that need to be done?

Vikram Patel:
The use of task-sharing, a strategy that has been used widely in global health and over the last decade and a half, increasingly in the area of mental health. That is to say to skill up community health workers and other frontline providers, community-based nurses, midwives, for mothers who are depressed, a whole range of paraprofessionals and peer support workers. We now know, through literally hundreds of randomized control trials from the developing world, many of those that I have been directly involved with conducting, that appropriately designed training programs, followed by continuing supervision can lead to community health workers delivering a range of psychological and social interventions for a very wide range of mental health conditions. That is the approach we need. We don't need a duplication of hospital-based, purely specialist service-driven, and often almost medication-focused services.

Vikram Patel:
Medication isn't the only intervention we have for mental healthcare. Psychological therapies are amongst the most potent of all mental healthcare intervention, and I think the real crisis in America's mental healthcare system today is that most people can't afford it. In part, that cost barrier is because the number of providers skilled or licensed to provide psychological therapies and heavily controlled. There are very few providers who are licensed, and as a result, of course, when anything is so heavily regulated, it becomes very expensive. On the other hand, in the developing world, community health workers are delivering psychological treatments for mood, anxiety, and substance use conditions very safely and very effectively.

Vikram Patel:
Now, the good news is that many American healthcare systems are actually beginning to adopt this approach. Through our Global Mental Health at Harvard Initiative, we have launched an institute called EMPOWER, which is to use digital tools to build a workforce, to use digital platforms through which carefully designed training programs can be used for training community health workers and paraprofessionals to learn evidence-based brief psychological treatments, then to use the same platform, to give them an opportunity to master that treatment, because obviously, just learning a treatment and doing a competency exam isn't sufficient. You have to actually ... Doing is actually the single most important adult learning opportunity to become good at a particular skill, and so using the same digital platform for supervision and quality assurance, and in this way, building a workforce. We're in conversation right now with a number of different healthcare systems in the U.S., and this would be a remarkable example of reverse engineering.

Vikram Patel:
That is to say to take an innovation, a frugal innovation, that has come from the least resource parts of the world, and to transplant it to the most resource healthcare system in the world, the one that has historically underperformed particularly poor is disadvantaged populations.

Kathy Molony:
I'm going to end with a general question for the group. There are plenty of people who are faring well during the pandemic. They have not lost their jobs because they can work remotely, and they have a stable home and are keeping their family safe. Yet, they feel that just staying at home is not quite enough. What can we, that is the people with resources, do to help others in a meaningful way? Vikram?

Vikram Patel:
I'm currently locked down in a country which has amongst the worst inequalities in the world. Actually, the U.S. is very similar. It also has terrible inequalities. The difference between the U.S. and India is that the proportion of people who are absolutely poor is also huge, and so it's a toxic mix of not only inequality, but also absolute poverty. That's something luckily the U.S. doesn't see to the same scale that you see in India, or in Indonesia, where Mary-Jo works.

Vikram Patel:
What do we do? I'm locked down, where obviously I'm a Harvard faculty. I'm extremely privileged. I have a wonderful home, a second home here in India. Although I'm locked down, I'm continuing to work on Zoom like many of us are and my colleagues are. I'm still earning a monthly paycheck, but in the last eight weeks, about 70% of India's 1.3 billion people have seen their salaries hit or evaporate.

Vikram Patel:
70% of 1.3 billion people have actually had a direct economic hit. What do I do as a wealthy person? First of all, directly contribute. Yeah, directly make financial contributions to charities, to organizations that I trust that can actually directly provide relief. Secondly, directly contribute to independent media organizations.

Vikram Patel:
I think it's very important for us to recognize, the U.S. has, got a very free media, and I don't think the same applies in the U.S., but in many developing countries, the lockdown has given an opportunity for increasing the authoritarian positions by governments. They're using the lockdown. They're using the need to control the epidemic to actually suppress many fundamental freedoms, and so we also need to contribute to the brave journalists, who are collecting on the ground information about what is happening around the country. The third, on a very local level, check out on your neighbors. There are always people around you in the next house, and I live in a village.

Vikram Patel:
Visit them, with the due precaution, wearing your mask and all the rest of it, and just find out, do they need any help with their groceries, small little acts of goodness and kindness. I want to say this is unfinished. Oftentimes, we see this as charity for others. Actually, I completely disagree. I think it's charity for yourself. I can't think of a more fulfilling act for oneself than actually being useful to someone else, and so I would certainly not consider this charity for anybody else.

Kathy Molony:
Mary-Jo?

Mary-Jo DelVecchio Good:
I think, like Vikram, we too are sitting in our comfortable house. Because we have this interesting neighborhood pod, so there are a number of them and around Cambridge, people are organizing, and we also have ways to financially support food banks, et cetera, so that it's not enough. No. We raised lots of money and also delivered food to Chelsea, and that's not enough. People are also checking in on each other, so it is a neighborhood of that sort, even though most of us don't know each other.

Mary-Jo DelVecchio Good:
I feel also, like you, "Okay, we will soon be done with these Zooms. What can we do? What are we able to do that will be meaningful?" It needs to be political and economic, I think.

Kathy Molony:
Bepi?

Bepi Raviola:
I think that there's really an incredible opportunity here to do things in a creative, new way using technology. Hopefully that service to others really is one of the silver linings of the situation. The other thing is with regards to mental health, for people who haven't taken mental health seriously, to really take it seriously and to really think about the role of stigma and fear around mental health, and both infectious diseases such as COVID and mental health conditions are both independently highly stigmatized, so you have a double stigma. There's all the fear around the COVID, but there's also fear around mental health, and it would be really important for people to take that seriously and to understand that this is going to be a marathon in terms of the chronicity of uncertainty, and so really reinforcing the importance of public health and science, and clear information is essential to help people stay grounded, and people should understand that and commit to helping with that as well.

Kathy Molony:
May we all stay grounded and healthy as we manage these trying times. A warm thank you to our guests, Vikram Patel, Mary-Jo DelVecchio Good, and Bepi Raviola. Thank you so much for listening. If you've enjoyed our podcast, please subscribe to Epicenter on Apple, Spotify, Google, or other popular listening platforms. I'm Kathleen Molony, signing off from the Weatherhead Center for International Affairs, a research center at Harvard University that promotes interdisciplinary conversations, just like this. See you next time.