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| PERSPECTIVE/VIEWPOINT - COUNTRY/REGIONAL |
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| Year : 2020 | Volume
: 2
| Issue : 2 | Page : 94-96 |
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Coronavirus Disease 2019 Pandemic in Low- and Middle-Income Countries: The Pivotal Place of Social Psychiatry
Oye Gureje
WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, University of Ibadan, Ibadan, Nigeria; Department of Psychiatry, Stellenbosch University, Stellenbosch, South Africa
| Date of Submission | 01-Jun-2020 |
| Date of Acceptance | 02-Jun-2020 |
| Date of Web Publication | 14-Aug-2020 |
Correspondence Address:
Prof. Oye Gureje
WHO Collaborating Centre for Research and Training in Mental Health, Neurosciences and Substance Abuse, University College Hospital, Ibadan, Nigeria
 Source of Support: None, Conflict of Interest: None
DOI: 10.4103/WSP.WSP_54_20
Coronavirus disease 2019 (COVID-19) is wreaking havoc across the world, upending every known facet of the human activity. Although a viral disease, it has nevertheless brought home to the world the huge importance of social factors as determinants of health and, of course, of ill health. These social determinants, though universal, are generally more inequitably skewed in low- and middle-income countries (LMICs). Since social factors are important in the acquisition and dissemination of the infection, it is no surprise that a number of the containment and mitigation activities are also essentially social. Yet, those mitigation efforts such as a stringent lockdown and social distancing create their own problems, more so in LMIC. The situation is precarious for LMIC in both ways. The consequences of both the disease and the mitigation strategies on mental health of the population are multifactorial and likely to be huge. Further, it is plausible to expect the effects of COVID-19 to include a widening of the treatment gap for mental disorders in LMIC. Social psychiatry provides an important platform to grasp the contextual demands of community response to COVID-19. A good understanding of the social contexts in which the mental health consequence of COVID-19 is being experienced will be vital to provide appropriate care to persons affected. These are not strategies and approaches to be seen as only for short-term use. Clinicians will require the necessary skills of social psychiatry as approaches to care for the long-term, as the mental health consequences of COVID-19, including associated stigma of those infected by the virus, may linger much longer in the LMIC.
Keywords: Coronavirus disease 2019, low- and middle-income countries, mental health, social
How to cite this article:
Gureje O. Coronavirus Disease 2019 Pandemic in Low- and Middle-Income Countries: The Pivotal Place of Social Psychiatry. World Soc Psychiatry 2020;2:94-6 |
| The Ravage of the Pandemic | |  |
Coronavirus disease 2019 (COVID-19) is wreaking havoc across the world, upending every known facet of the human activity. As, at the time of this piece, 213 countries and territories around the globe have been affected, almost 6,000,000 persons have been infected by the virus causing the disease and over 367,000 have died.[1] Millions of people have lost their livelihood or at the brink of doing so. Families have been torn apart, unable to provide succor and comfort to one another and to mourn and share grief in ways that may lighten the burden of trauma and make quick and full recovery from adversity likely. Even though the pandemic has its origin in China and a few other low- and middle-income countries (LMICs) such as Brazil and India are now among the ten most impacted countries in the world, the disease has caused more human loss and misery in high-income countries (HICs).[1] Still, it is clear that the rampaging effect of the pandemic is just beginning to take its toll on LMIC, in general, and those in Sub-Saharan Africa, in particular. In the latter, countries such as Nigeria and South Africa seem to be in an unwinnable battle to stem the drip–drip onslaught of the pandemic.
Caused by a microbe, COVID-19 has nevertheless brought home to the world the huge importance of social factors as determinants of health and, of course, of ill health.[2] The transmission of the virus is heavily dependent on social interactions. As the pandemic has gripped the world, many types of physical engagement have become a source of dread and practices to be avoided. As is now very clear, its spread is influenced by social and economic factors. Thus, in many countries, those at the lowest socioeconomic strata of societies are at higher likelihood of becoming infected. Such persons may be made more vulnerable because they are more likely to harbor preexisting physical health conditions that compromise their immunity or because they are engaged in economic sectors with greater risk of exposure to the virus. Even with the knowledge that such occupations may constitute a risk to acquiring the infection, many do not have the luxury of choice as they have to earn a living for survival. This heightened vulnerability of sections of the community that are characterized by low social and economic indices has been more clearly highlighted in HICs.[3] However, they are most likely to become evident in LMICs as the infection takes firmer root in those countries. Indeed, that patterning is already evident in Brazil where the greatest risk of disease transmission is among the poorest communities in the country.
| Responding to the Challenge | | |
Inevitably, since social factors are important in the acquisition and dissemination of the infection, it is no surprise that a number of the containment and mitigation activities are also essentially social. Yet, those mitigation efforts create their own problems, more so in the LMIC.[2] Lockdowns are difficult to enforce in settings where the majority of those employed eke out a living on a daily basis and where not working for a few days is likely to deepen their poverty and lead to hunger.[4] No wonder that in places such as South Africa and Nigeria protests has been sparked off by prolonged lockdowns. Social distancing, another mitigation strategy, is extremely difficult to enforce in the congested cities of LMIC, whether it is in the slums of New Delhi, Lagos, or Sao Paulo. Understandably, and for precisely because of the negative effects of these measures on large sections of the community, some have wondered about their appropriateness as strategies to respond to COVID-19 in LMIC.[5] Perhaps, the early disproportionate impact of the pandemic on HIC and relatively lower numbers of cases in LMIC might have strengthened such argument. However, rather than seeing them as unreflective adoption of approaches being utilized in HIC, it is important to consider the dilemma faced by LMIC in responding to the pandemic. It is, for example, clearly the case that even in settings with preexisting social and economic disadvantages as well as high burden of other health conditions, governments would be keen to avoid the likelihood of the pandemic adding to those disease burdens as well as of posing a long-term risk for deepening national economic difficulties.[2] In any case, the burgeoning of cases in a number of LMIC is a pointer to the fact that several of the approaches used to confront the pandemic in HIC are going to be needed to achieve the same goal elsewhere, with the appropriate contextualization. Moreover, irrespective of the location, it is still the case that human-to-human community transmission is the most potent route for the virus to wreak both human and economic havoc, and in the absence of a vaccine, that fiery route will require any measure that is likely to effectively staunch it.[6]
| The Mental Health Consequences | | |
We can expect that communities in LMIC are going to experience the usual psychological sequelae of traumatic events as well as of situations that create uncertainties and fear. Thus, disorders such as depression, anxiety, substance use, stress reactions, including posttraumatic stress disorder, and suicidal behaviors may increase in their occurrence as a direct effect of the pandemic. Conditions such as bodily distress disorders, health anxiety disorders, and dissociative disorders are likely to increase. Persons who have had to undergo isolation and quarantines are likely to be at an even elevated risk for these conditions. Loss of livelihood will deepen poverty levels and social disadvantage. Persons with preexisting mental health conditions will be impacted by the generally heightened levels of stress, social distancing, or physical distancing that pries away emotional and instrumental support provided by caregivers. As a result of the negative effects of the pandemic on household incomes, many of such persons may become unable to afford usual medications, especially in settings where out-of-pocket payment of health services is the norm. A large section of these persons receive care at traditional and faith healing homes in many LMICs, especially those in Sub-Saharan Africa.[7] Such persons may harbor undetected infections and, even with COVID-19 symptoms, may not avail themselves of any medical treatment as healers espouse causes other than medical for the condition. Refugee camps, scattered around LMICs, present peculiar problems of control.[8] In essence, it is plausible to expect the effects of COVID-19 to include a widening of the treatment gap for mental disorders in LMIC.
| The Relevance of Social Psychiatry | | |
Social psychiatry provides an important platform to grasp the contextual demands of community response to COVID-19.[9] A good understanding of the social contexts in which the mental health consequence of COVID-19 is being experienced will be vital to providing appropriate care to persons affected. While poverty may be an overarching issue of concern, a clinician will also need to be sensitive to other important social factors. Among these are cultural norms and practices of social interactions and how the containment and mitigation strategies against the pandemic affect these norms and practices, constitute risks for mental ill health, and how best to reactivate social networks to aid recovery. How might social re-connection be initiated? What, for example, are the social factors limiting the use of mobile technology for the individual in procuring needed social support and what is the appropriateness in the context. Furthermore, how may lay views of illness, in particular, and of the symptoms of COVID-19, in particular, be understood and used in expanding the adoption of mitigation strategies? What engagement strategies are required to bring healers on board in expanding control measures?
These are not strategies and approaches to be seen as only for short-term use. Clinicians will require the necessary skills of social psychiatry as approaches to care for the long term. The race to develop a vaccine is currently intense. However, even when a vaccine is developed, it is unclear how soon it may become available to populations in the LMIC. Even when it does, community acceptance and wide adoption are not a given. Experience with other vaccines, including that for polio, shows that communities in some LMIC may harbor notions about perceived deleterious effects of vaccines and be reluctant to avail themselves of their protection. The mental health consequences of COVID-19, including associated stigma of those infected by the virus, may linger much longer than in HIC. Arming ourselves with those skills now is essential.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
| References | | |
| 1. | World Health Organization. Coronavirus Disease 2019 (COVID-19) Situation Report – 132; 31 May, 2020.  |
| 2. | World Health Organization. World Health Organization and Calouste Gulbenkian Foundation. Social Determinants of Mental Health. Geneva: World Health Organization; 2014. |
| 3. | Hooper MW, Napoles AM, Pérez-Stable EJ. COVID-19 and racial/ethnic disparities. JAMA 2020;323:2466-7. [Doi: 10.1001/jama.2020.8598]. |
| 4. | International Labor Office. Women and Men in the Informal Economy: A Statistical Picture; 2018. |
| 5. | Cash R, Patel V. Has COVID-19 subverted global health? Lancet 2020;395:1687-8. |
| 6. | Kucharski AJ, Russell TW, Diamond C, Liu Y, Edmunds J, Funk S, et al. Early dynamics of transmission and control of COVID-19: A mathematical modelling study. Lancet Infect Dis 2020;20:553-8. |
| 7. | Gureje O, Nortje G, Makanjuola V, Oladeji BD, Seedat S, Jenkins R. The role of global traditional and complementary systems of medicine in the treatment of mental health disorders. Lancet Psychiatry 2015;2:168-77. |
| 8. | Raju E, Ayeb-Karlsson S. COVID-19: How do you self-isolate in a refugee camp? Int J Public Health 2020;8:1-3. |
| 9. | Di Nicola V. A person is a person through other persons: A social psychiatry manifesto for the 21 st century. World Soc Psychiatry 2019;1:8-21. |
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