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| EDITORIAL |
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| Year : 2020 | Volume
: 2
| Issue : 2 | Page : 51-56 |
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The Plague by Albert Camus, the COVID-19 Pandemic, and the Role of Social Psychiatry – Lessons Shared, Lessons Learned
Debasish Basu
Founding Editor, World Social Psychiatry
| Date of Submission | 18-Jul-2020 |
| Date of Acceptance | 19-Jul-2020 |
| Date of Web Publication | 14-Aug-2020 |
Correspondence Address:
Prof. Debasish Basu
Department of Psychiatry, Postgraduate Institute of Medical Education and Research, Chandigarh, India
 Source of Support: None, Conflict of Interest: None  | 1 |
DOI: 10.4103/WSP.WSP_67_20
How to cite this article:
Basu D. The Plague by Albert Camus, the COVID-19 Pandemic, and the Role of Social Psychiatry – Lessons Shared, Lessons Learned. World Soc Psychiatry 2020;2:51-6 |
“Indeed, we all were up against the wall that plague had built around us, and in its lethal shadow we must work out our salvation.”
–Albert Camus, The Plague[1]
Albert Camus, the Nobel prize-winning French philosopher–writer, published his book “La Peste” (The Plague) in 1947, describing a plague epidemic in the 1940s in the French Algerian town of Oran. He described, through his “absurdist” philosophical lens, the various reactions of the people afflicted with the plague. Complex psychosocial factors play a very major role in shaping the flow, the destiny, and the philosophy of this classic novel.
More than 70 years later, as we start writing this piece, on June 8, 2020, the numbers have just crossed seven millions. That's for the infected ones. For those who are dead: just crossed four hundred thousand. By the time this editorial would be completed, the numbers will have increased many more (see postscript).
And yet, these are just numbers. Statistics. The world is full of statistics and numbers.
Of course, we are talking about the coronavirus disease 2019 (COVID-19) pandemic – a term now familiar to most of the human inhabitants of our planet. Although pandemics are not new – and there have been more lethal ones in the past – this is the one the world is witnessing now.
| The Covid-19 Pandemic and Mental Health | |  |
That the COVID-19 pandemic is sending global shockwaves regarding health, mortality, morbidity, and disruption in the socio-cultural, economic, and political rhythms of life is almost an understatement now. It is now also getting rapidly established what a tremendous toll it has been taking on the mental health of people. Starting from the early quick surveys, there is already a sizable – and very rapidly expanding – database on the mental health issues of people afflicted with, or working with, COVID-19 (not necessarily rigorously defined mental disorders but usually screening–instrument-based psychological distress markers or symptoms). There are, in fact, now a number of surveys, reviews, and early meta-analyses available on the subject. The major strands of findings, so far, seem to be as follows:[2],[3],[4],[5],[6],[7],[8],[9],[10]
- There is a high level of psychological distress and morbidity in healthcare workers, especially those healthcare and other workers working in the frontline or first responders, related to apprehension and living difficulties
- There is not much evidence of neuropsychiatric morbidity other than delirium in the acute phase of those suffering from COVID-19, although later there may be risk of several mental disorders
- A third group of reviews have found substantive psychological issues in those living under quarantine as “suspects”
- The fourth group are about those whose near and dear ones have died due to the infection and often incomplete grieving due to barriers and restrictions even after death
- A fifth and often neglected group is those already with preexisting mental disorders, especially those with severe mental illnesses
- Finally, a last (and the largest) group are persons from the general population who belong to neither of the groups above but nonetheless have been living under the “shadow” of the pandemic, especially those experiencing the isolation of a stringent lockdown or its severe economic repercussions.
Of course, all these are early studies (and many of them just archived preprints at this stage, without peer review), but, together, they indeed emphasize the need of focusing on the mental health aspects of the pandemic as well.
In fact, although relatively ignored earlier, this need has been adequately flagged up now by several agencies, including the United Nations (UN), the World Health Organization (WHO), and the World Psychiatric Association (WPA). The UN, in its recently released “Policy Brief – COVID-19 and the Need for Action on Mental Health,” sums it up quite succinctly: “Although the COVID-19 crisis is, in the first instance, a physical health crisis, it has the seeds of a major mental health crisis as well, if action is not taken.” Good mental health is critical to the functioning of society at the best of times. It must be front and center of every country's response to and recovery from the COVID-19 pandemic. The mental health and well-being of whole societies have been severely impacted by this crisis and are a priority to be addressed urgently.”[11] The WHO Director-General similarly emphasized the need for “Addressing mental health needs: An integral part of COVID-19 response” in the latest editorial of World Psychiatry.[12] Finally, the WPA has issued a Position Statement that underlines the specific role of a psychiatrist.[13] Many have feared that the mental health consequences and concerns of the pandemic will themselves constitute a “pandemic within a pandemic,” or a “tsunami.”[14],[15] The figures have varied widely depending upon the study populations, mental health issues studied, methods of detection, and several other parameters; however, overall, they are impressive and scary. A number of articles, advisories, and guidelines have already been published on how to minimize or mitigate these adverse mental health consequences.[9],[15],[16]
| The Obvious Question: How Is Social Psychiatry Relevant? | | |
Therefore, the obvious question for those of us interested in social psychiatry: What is the role of social psychiatry here? And, more importantly, what can social psychiatry offer?
To answer these questions, let us try to understand the genesis of the total rubric of the problems. If mental health issues represent the “outcome variable,” what all are the “independent variables?” Well, the obvious fact is that there would be no COVID-19 without that SARS-CoV-2 virus and its physical sequelae on various body systems (including the central nervous system). That may explain a small part of the mental health issues faced by those infected by the virus, along with the obvious psychological threats, anxieties and difficulties faced by the isolation, and treatment and complications of the treatment. It may also partly explain the significant mental health issues faced by those who have recovered from the clinically symptomatic infection, as an aftermath. However, as mentioned above, the huge shadow of mental health aspects of the pandemic are not faced by those infected but by those who are, as of now, not infected though living with the proverbial Damocles' sword hanging over their head, or those who are more concerned with their survival from financial hardship at the moment than from the viral infection!
The word “social” appears in two very distinct contexts in this perspective: “social” distancing (which is a misnomer – physical distancing should be the correct phrase – but, it does capture the social element inherent in this distancing) and social determinants of health (including mental health, of course). Both these are directly concerned with social psychiatry because both have mental health consequences, but one goes downstream and the other comes from upstream. A third context that we wish to introduce here is the phrase “social concomitant” or “social infection,” which works at a parallel level. Let us explain, with the help of a tentative diagram [Figure 1]. | Figure 1: COVID-19 and mental health outcomes: The role of social psychiatry
Click here to view |
| Social Distancing and Mental Health Issues | | |
“Thus, the first thing that plague brought to our town was exile. And then we realized that the separation was destined to continue, we had no choice but to come to terms with the days ahead……….“
“What do they do with themselves all day?” Tarrou asked Rambert.
“Nothing.”
Almost all, indeed, had empty hands and idly dangling arms. Another curious thing about this multitude of derelicts was its silence.
“When they first came there was such a din you couldn't hear yourself speak,” Rambert said. “But as the days went by they grew quieter and quieter.”
Everyone Tarrou set eyes on had that vacant gaze and was visibly suffering from the complete break with all that life had meant to him. And since they could not be thinking of their death all the time, they thought of nothing. They were on vacation.
“But worst of all,” Tarrou writes, “is that they're forgotten, and they know it.”[1]
Social distancing, in its broadest sense, comprises all those measures taken to minimize transmission of the infection in the society. It encompasses such simple measures as the “6-feet/2 m rule,” to more restrictive solutions, such as isolation (for those already infected) or quarantine (for those not yet infected but at a tangible risk), to more drastic measures adopted during a total lockdown, such as complete closure of almost all shopping, travel, and social, recreational, and religious gatherings. These are understandably, to a varying degree, associated with a sense of social isolation and alienation, which can further exacerbate the mental health issues of those especially with preexisting mental illnesses or those living alone, separated from family due to job and now unable to return, just to give a few examples. Some “remedies” include constant social messaging or use of social and electronic media, which, though beneficial in general, might have adverse consequences if carried out to an extreme. The obvious and common fallouts of such broadly defined social-defined measures include depression/demoralization, anxiety (of various sorts), sleep disorders, substance misuse or exacerbation of disorder, and also, delirium during acute infection or posttraumatic stress disorder after physical recovery. In rare cases, suicides or suicidal attempts have been reported.[17] These are the obvious repercussions of the social distancing and hence constitute the “downstream” effects. Domestic or other interpersonal abuse or violence is another documented serious fallout of these measures.[18]
| Eco-Social and Structural Determinants | | |
“The result was that poor families were in great straits, while the rich went short of practically nothing. Thus, whereas plague by its impartial ministrations should have promoted equality among our townsfolk, it now had the opposite effect and, thanks to the habitual conflict of cupidities, exacerbated the sense of injustice rankling in men's hearts.”[1]
In contrast to the downstream effects of social distancing on mental health, the “upstream” factors are the social determinants of (mental) health, famously defined as “circumstances in which people are born, grow, live, work, and age. These conditions are influenced by the distribution of money, power, and resources operating at global, national, and local levels.”[19]
This is where social psychiatry comes to the forefront. Human beings have always been divided, on the basis of umpteen numbers of real or, more commonly, artificial boundaries: world region, country, regions within countries, economy, class, color, race, ethnicity, gender, age, language, history, culture, caste, work, healthcare systems, and access, among others. These divisions determine many aspects of health, including mental health. These divisions may operate at different levels: global, regional, macro, medium, small, and micro. Whereas divisions are not necessarily bad (some of them are unavoidable, pragmatic, or even useful), it is when discrimination and inequity (unjustness, unfairness) are implied or created by these divisions they become undesirable, unethical, or maladaptive. Social psychiatry has since long studied the role of explanatory theories, such as “social causation” and “social drift,” in explaining excess mental illnesses in the lower socio-economic strata, for example.
These divisions, with their consequent discrimination and inequity, have been a part of human history, and it is safe to presume that they will always remain in different and evolving shapes and sizes. What every disaster, natural or artificial, does is to re-ignite the lamp of recognition in the darkness of oblivion. Every disaster unmasks the obvious by bringing in sharper focus these discriminatory divisions and by amplifying them. The larger the scale of the disaster, the larger is its unmasking and amplifying effect. Moreover, the COVID-19 pandemic, by every conceivable means, is one of the largest disasters in at least a hundred years!
There is an apparent paradox that needs to be clarified first. As asked in a recent editorial, the question arises: is the virus responsible for the COVID-19 pandemic racist?[20] The obvious answer is, of course, no! Nor is it anti-poor, anti-black, or anti-ethnic minorities. So far, it has not shown any specific predilection – nor any specific resistance – to infect anyone based on any of these divisions alluded to above. Then, how or why should these social–environmental factors be important or indeed relevant for health-related (including mental health) issues during this pandemic?
The answer to this apparent paradox is simple, yet profound. When a member of any disadvantaged group is excessively posted for direct high-risk exposure-related work, when a poor person lacks the money or the insurance to pay for the treatment access or costs, when a migrant laborer working in the unsecured informal sector starts “reverse migration” walking thousands of miles after losing the day-paid job, when a person belonging to a particular country is jeered at or abused simply because of one's country-of-origin, when a person is mocked or scoffed at simply because she/he looks likeone from a particular country, when a person of a particular background or income level is more harshly treated by the police for violating lockdown than another from a different background or income level, when the police is warned by an influential political leader because he/she happened to warn him/her for violating social distancing, when an opioid-dependent person cannot obtain his buprenorphine tablet because of lack of access imposed by lockdown and inability to buy it from the private sector (with resultant relapse)……. and in many, many such circumstances which could easily fill up this entire editorial, the “social determinants” of health including mental health can be clearly seen to operate, as the mediating or modulating variables, between the pandemic and the resultant mental health issues.
The HIV pandemic was dubbed as the “Pandemic of the poor.”[21] Perhaps, this is true for the current pandemic as well. At least, it clearly hits the poorer the harder, economically, socially, physically, and mentally. Many of these issues have been highlighted, but many remain to be further searched for, documented, highlighted, and mitigated. If social psychiatry does not do this, who will?
As Mr. Barack Obama, former President of the USA said in his recent Commencement Speech:
“This pandemic has shaken up the status quo and laid bare a lot of our country's deep-seated problems – from massive economic inequality to ongoing racial disparities to a lack of basic health care for people who need it. It's woken a lot of young people up to the fact that the old ways of doing things just don't work; that it doesn't matter how much money you make if everyone around you is hungry and sick; and that our society and our democracy only work when we think not just about ourselves, but about each other.”[22]
This is also important for management. As a blog in Nature lamented:
“….when I look closer, I'm struck with a familiar disappointment. Once again, recommendations forget half of the equation: our need to address the social and economic conditions that contribute to poor mental health. A woman who has lost her job and cannot feed her family will find little relief from a meditation app. Advice such as “stay off social media” will do little to ease the anxiety of a young black man in constant fear of being kicked out of shops by security guards for wearing a face covering, or abused or even killed by law-enforcement officers who have been given new powers to police social behaviour.”[23]
| Social Media | | |
“The newspapers, needless to say, complied with the instructions given them: optimism at all costs. If one was to believe what one read in them, our populace was giving “a fine example of courage and composure.” But in a town thrown back upon itself, in which nothing could be kept secret, no one had illusions about the “example” given by the public. To form a correct idea about the courage and composure talked about by our journalists you had only to visit one of the quarantine depots or isolation camps established by our authorities.”[1]
A slightly different, but related, component of the social determinants could be the role of social media. Social media is a double-edged sword: while it can be a tremendous boon in quick and wide spread of useful and factual information, it can also be the bane by equally rapidly, efficiently, and widely disseminating half-facts, nonfacts, and plain lies and loads of them (“infodemic,” misinformation, miracle treatments, or doomsday prophecies). As exemplified above in Camus' description of the role of predigital social media of his times, the messages peddled in social media often serve masters other than pure science and data. More worryingly, these can also increase anxiety[24] and even disseminate racial hatred.[25] That is what constitutes the “social concomitants” of the pandemic, with palpable effect on mental health.
| Social Concomitants (Or “social Infection”) | | |
“For it's common knowledge that you can't trust your neighbor; he may pass the disease to you without your knowing it, and take advantage of a moment of inadvertence on your part to infect you…… people who are haunted by the idea that when they least expect it plague may lay its cold hand on their shoulders, and is, perhaps, about to do so at the very moment when one is congratulating oneself on being safe and sound.”[1]
This pervasive sense of paranoia is a hallmark of every pandemic, which is generated by the infectiousness and its consequences, which are biological factors. However, it is fed, flourished, and nurtured by social psychological factors.
Thus, the third and, we feel, the most important, context in which social psychiatry becomes relevant for the pandemic, is the related group of factors we choose to call the “social concomitants” or “social infection.” As was aptly said – AIDS was a social pandemic.[26]
If social/structural determinants laid the groundwork as predisposing factors, and social distancing provided the platform to act as precipitating factors, then the social concomitants may be thought of as the mediating factors. These social concomitants take many forms: not letting in the nurse in her own apartment after her 12-h duty in the COVID hospital (“social media said she may infect all of us”); ostracizing the doctor or the frontline care workers for similar reasons; not letting the family bury their dead; keeping a distance away from your gardener because he comes from a particular class; hating, or being scared, of others simply because they are not like “us.” Discrimination, xenophobia, stigma (against multiple agencies, persons, or classes) - you name it. The basic formula: “Us vs. them” operates at all levels, places, cultures, indeed, at all power distribution scenarios. COVID-19 anxiety only feeds on this multilevel discrimination (or xenophobia in a broader sense – the fear of the “others”) and produces more hatred, more discrimination, and more stigma.[27],[28] There is a clear “infectious” quality in the spread of this stigma, facilitated often by the unprecedented powers of the social media.
They are rapidly, efficiently, and dangerously transmissive and contagious – a product of the social determinants distally and of social distancing proximally, often utilizing the power of social media for the tremendous transmissibility and capturing the vulnerable, naive, gullible people. Hence, we coin the term “social infection”as a massive fallout of the pandemic that often results in mental health issues by those affected by it. Recent studies have started documenting the increasing discrimination, mental health issues, and, very importantly, the links between the two.[29]
This is one of the many examples of social psychiatry in action.
| So What to Do? | | |
If social psychiatry is integral to understanding the intersectional links among social–ecological factors, COVID-19 pandemic, and mental health issues, and if it appears to have implications for both understanding and action, then the obvious next question arises: what can an academic scientific journal on social psychiatry do about it? More specifically, what can WORLD SOCIAL PSYCHIATRY do about it?
The answer is simple: we do what we are supposed to do. We build up a movement. A movement backed by knowledge, attitude, and practice. We try to gather the scenarios from all over the world, understand and document the links alluded to above, and advocate for the cause and application of social psychiatric principles to COVID-related mental health issues and what can be done about it. In short: amalgamation, assessment, advocacy, and action.
And this is exactly what this SPECIAL ISSUE purports to achieve.
This issue is truly a global collection of articles from all the continents (barring Antarctica) of the world, from many countries of the world, focusing on their COVID-related problems, social psychiatric aspects, and potential solutions.
There are several sections in this issue of the Journal. Following this editorial, there is the World Association of Social Psychiatry (WASP) Position Statement on COVID-19 pandemic, highlighting and pledging the role of WASP in the areas highlighted above.[30] Also in this “Special Communications” is an important article by Mezzich et al. focusing on the intersection between person-centered psychiatry, social psychiatry, and COVID-19. Five invited commentaries from very eminent persons in the world psychiatric scenario, on the WASP Position Statement, comprise the next section.
The following sections of perspectives/viewpoints make up the real value of this issue. The “Global” section consists of important cross-cutting issues globally. The “Country-regional” section focuses more specifically on countries or regions. The “Special Population” section concerns with the children and the elderly.
The ensuing debate, though more generic in nature, does touch upon the conflicts that COVID-19 has brought upon us. This is followed by a case series on child and adolescent aspects, first-person account of organizing mental healthcare services during COVID times, a Brief report on a successful program to contain the epidemic, and two relevant Letters to Editor, one on need for more research and another on digital burnout. These are finally followed by the “In Memoriam” respects paid to two of our past WASP Presidents who sadly passed away during this time.
All in all, we have tried to gather together what is known, and, more importantly, what is learned through this steep unflattening curve, about this pandemic and the role of social psychiatry: Lessons shared, Lessons learned. We hope that this special theme issue will provide the much needed impetus in this area.
However, in the end, let's again return to Albert Camus. Eventually, just like the plague in his novel, every pandemic is ultimately also a pandemic of the mind and of the society, where the social–structural–ecological seeds of multilayered inequities, when in the right conditions provided by the contagious and difficult-to-treat infectious agent and watered by the social concomitants of various kinds of discrimination and stigma, grow rapidly into the forest of chaos, with massive economic, social, physical, and mental adverse effects. This is what the protagonist says at the end of the novel: “The plague bacillus never dies or disappears for good.” The rats carrying them are roused when the conditions are right. The virus, in this sense, is a necessary but not the sufficient cause of the pandemic and its mental health fallouts. We need social psychiatry now like we have never needed it before.
“…… the plague bacillus never dies or disappears for good; that it can lie dormant for years and years in furniture and linen-chests; that it bides its time in bedrooms, cellars, trunks, and bookshelves; and that perhaps the day would come when, for the bane and the enlightening of men, it would rouse up its rats again and send them forth to die in a happy city.”[1]
Postscript: today, the day of sending the final proofs of this editorial to press (July 30, 2020), the figures cited at the beginning of this article stand revised to MORE THAN 17 MILLION, and nearly SEVEN HUNDRED THOUSAND, respectively. And, yes, watch this space!
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