Unintended consequences of COVID-19

By William G. Hoy & Helen W. Harris
March 23, 2020
COVID 19 image HH story
What a difference a few weeks make in the way the world operates. Widespread limits on social interaction, closing of restaurants and other gathering places, and the moving of worship services to online-only experiences are just a few of the ways the world is a different place today. Political leaders insist the changes are both necessary and temporary. The importance of “flattening the curve” to reduce the rate of Coronavirus infection escalation is essential to protecting the most vulnerable among us. Limiting the size of crowds, elbow bumps instead of hugs, and three to six feet of space between us are some of the operationalizations of social distancing. Others include canceling sporting events and meeting for worship and education on-line.

The physical separations are intended to protect our physical health. However, the two of us and many of our colleagues in mental health think the unintended emotional and relational consequences of all of this “social distancing” will be much deeper and wider unless we recognize the risk and take action. It appears that the social, emotional, and spiritual toll this is taking on individuals and communities is largely unseen by the mainstream media and in many cases by public health professionals alike.

This is not good news. For at least 30 years, scientists have known that stress has a deleterious effect on human health and that experiences like depression, anxiety, isolation, and loneliness negatively impact the immune system, increasing vulnerability to illness and to disease. Azar (2001) articulately described the work done over the previous decade in what was then an emerging field, psychoneuroimmunology. Tsankova (2009) reported on the link between emotional interventions and the concentration of antibodies. Immune networks respond to significant changes in the emotional and social world. How significant is the impact of psychosocial stressors and social distancing on the immune capacity of persons? That powerful question is at play in these critical times. We believe caregiving professionals, volunteers, faith leaders, and the community at large can take some important steps now to limit the long-term unintended effects of this crisis; here are a few we think are important.

Connect and help others connect. Those who are technologically savvy will need to lead the way for those who are not. For example, we are piloting a project in Waco that purchased internet-enabled tablets for hospices to use with their patients in skilled nursing facilities who have limited visits. Some of these facilities have restricted all “non-essential personnel” which means not even social workers and chaplains are allowed to visit dying patients. While these seem to be short-sighted draconian measures, they are the reality of physical distancing.


Exchange the term “social distancing” for “physical distancing.” Studies suggest that social support has positive impact on immune and health responses to HIV/AIDS (Campbell, et al, 2013) and Epstein-Barr virus (McDade, 2001). The concept of social distancing suggests isolation. What we cannot afford under stress is to be socially isolated. When we cannot be physically present with one another, it is even more critical to be socially present and accessible to each other. One essential beginning would be to differentiate the terms. The term physical distancing acknowledges the need to minimize exposure to the virus without conflating the ideas of distance with isolation.

Further, it provides emotional space for social interaction that is not dependent exclusively on physical proximity. We are hearing reports in our own community and others of elders in skilled nursing facilities whose only contact with the outside world is through staff members, professionals who, while caring, are already stretched thin by health care budget-cutting initiatives and increasingly by their own vulnerability to this illness. Many of these elders do not have electronic connection through cell phones, tablets, and computers for connection with loved ones. In the absence of personal electronic devices and the skills to effectively use them, an issue that is clearly epidemic with many elders, these adults are “cut off” from virtually all contact with family, community volunteers, and others who provide needed socialization. A focus on social connection in the presence of physical distancing is one possible way forward. Join us in exchanging social distancing for #physicaldistancing.

Connect and help others connect. Those who are technologically savvy will need to lead the way for those who are not. For example, we are piloting a project in Waco that purchased internet-enabled tablets for hospices to use with their patients in skilled nursing facilities who have limited visits. Some of these facilities have restricted all “non-essential personnel” which means not even social workers and chaplains are allowed to visit dying patients. While these seem to be short-sighted draconian measures, they are the reality of physical distancing.

These tablets, utilized by nurses and even left temporarily with patients, will enable family and psychosocial-spiritual caregivers to visit patients virtually in order to provide support. They are the vehicle for great grandchildren singing to a great grandparent. They are the method for adult children to be at the bedside of a dying parent in “lockdown” in a nursing facility. They provide the opportunity to “attend” worship in their church home. These provide one way to offer a social worker, minister, or chaplain visit. This does not come close to taking the place of human touch but it is certainly leagues better than no support at all. Further, we have the opportunity to evaluate this addition of tele-interaction to telehealth and telemedicine.

Unfortunately, many of the patients who are most vulnerable to loneliness, depression, and anxiety also have communication difficulties. Hearing-impaired individuals often have great difficulty with all manner of electronic communication, especially if they have become accustomed to non-verbal clues to contextualize a message. Clearly, electronic communication can help but it is certainly not a panacea in the current context. Perhaps a familiar face and familiar smile will communicate enough presence to make a difference.

Increase “talk time.” Human touch is vital and the human voice comes next in importance for our well-being. Relying on texting and social media is convenient because it is asynchronous, meaning both parties don’t have to be in the same time and/or space to communicate; we can respond to a text or a social media post when we “get around to it.” However, these media do not include the important hormonal responses we get from hearing a voice. Want to test this theory? Ask yourself how you respond differently hearing your boss’s voice rather than the voice of your beloved. Make it a point to stop mid-text and pick up the phone instead. Hearing another’s voice can be healing balm. In addition to talk time, we can include reading out loud time, singing time, and recitation time. A beloved granddaughter’s voice singing a favorite hymn can be balm for the soul and listening to a young person read a favorite book can be better than blood pressure medicine.

Introduce music and entertainment into your life and the lives of those you care for. One ancient mystic said, “Music is the language of the soul.” Even the U.S. National Institutes of Health agrees; through its special Sound Health Initiative, NIH is engaged in research that increasingly shows the benefit of performed music and experienced music on our mental, emotional, spiritual, and physical health. A number of music artists are providing concerts and performances on-line. Family members can schedule to watch the same concert at the same time and text or call one another to share the experience. The ancient wisdom of the Hebrew Bible tells us that “a merry heart does good like medicine” (Proverbs 17:22). Let us enjoy a joke or comedy together and not be afraid to belly laugh even in the middle of this painful time.

Understand that some withdrawal is natural but isolation is harmful. One of the findings of psychoneuroimmunology is that individuals often naturally withdraw when faced with infection or other sickness (Segerstrom, 2010). This adaptive response is shared between humans and their four-legged friends and likely having roots in our natural ecological need to conserve energy. But this is not the same phenomenon as prescriptive distancing in the absence of symptoms of illness. This lack of social interaction can increase the likelihood we will become ill—if not by the illness we are being isolated from then from some other ailment. We have the opportunity to find ways to connect socially and emotionally even as we reduce our physical exposure to the virus.

This might explain why the value of quarantine in public health emergencies is not the uncontested correct policy even though it seems intuitively correct. What we learned in the West African Ebola epidemic and in other quarantine events is that the long-term damage done to health-seeking behaviors, to growing mistrust in “the system,” and to individuals who potentially delay getting medical care because of fear of being isolated actually creates disease and makes it worse (Maglen, 2006; Pellecchia, et al, 2015). In other words, we might avoid Coronavirus and end up with some other illness which when left untreated, becomes even more lethal. This is a particular challenge as health care services are increasingly reserved for treating CoVID-19 while other health check-ups and services are postponed. That approach over time could prove to increase morbidity rather than reducing it.
Increase “talk time.” Human touch is vital and the human voice comes next in importance for our well-being. Relying on texting and social media is convenient because it is asynchronous, meaning both parties don’t have to be in the same time and/or space to communicate; we can respond to a text or a social media post when we “get around to it.” However, these media do not include the important hormonal responses we get from hearing a voice. Want to test this theory? Ask yourself how you respond differently hearing your boss’s voice rather than the voice of your beloved. Make it a point to stop mid-text and pick up the phone instead. Hearing another’s voice can be healing balm. In addition to talk time, we can include reading out loud time, singing time, and recitation time. A beloved granddaughter’s voice singing a favorite hymn can be balm for the soul and listening to a young person read a favorite book can be better than blood pressure medicine.

Make room for multiple memorials. One of the saddest parts of this crisis for the two of us is seeing the number of funerals and memorial services being cancelled and/or postponed until later. Worden (2018) posited that frequently we arrange funerals too quickly after a death while “immediate family members are in a dazed or numb condition and the service does not have the positive psychological impact that it might have” (p. 121). However, in a recent conversation between the first author and Dr. Worden, the two discussed the inevitable complications that arise in bereaved families and communities when memorialization is delayed or postponed indefinitely (J.W. Worden, 19 March 2020, personal communication). The news media has already begun addressing these difficulties in traditional communities around the world. Reflecting on the lack of traditional ritual when her grandfather died a few days ago near Cremona, Italy, Marta Manfredi lamented, “They buried him like that, without a funeral, without his loved ones, with just a blessing from the priest.” Then she continued, “When this is all over…we will give him a real funeral” Echoing a similar sentiment, Spanish Prime Minister Pedro Sanchez has called the virus a “cruel” disease because of its ability to rob humans from their innate need to socialize in the face of death (Amante et al, 2020, n.p.).

Funeral homes have already brought services online at no additional charge to families and communities, expanding on an option long-available for distant family and friends unable to travel the geographical distance to attend a funeral. In this way, where permitted, a few family members can gather together in the presence of the deceased knowing they are “virtually” surrounded by watching family and friends whose attendance would exceed mandated maximums of persons in one location. In other cases, entire funerals are delayed for what will hopefully be a period not exceeding a few weeks.

One additional option, however, is to think about multiple ceremonies. In this case, one simple ceremony can be held now accompanied by a few family members or, when necessary, attended only by funeral home personnel but livestreamed to family and friends in their own homes. Through options such as Zoom, these individuals can watch from multiple locations, a priest or minister can officiate from their own location, and a funeral director can use a smart phone to web-cast the burial or placement of the body in the crematory.

But no one dictates that funerals must be “once-and-done” ceremonies, and in fact, many religious traditions dictate that they not be. Hoy (2013) wrote, “adherents of Vajrayana Buddhism embrace a concept that rebirth to a new existence can last up to 49 days, a period known as bardö. This intermediate state culminates with a family meal on the forty-ninth day after the loved one’s death, celebrating that the spirit has been reborn into a new existence. Other services can follow on the hundredth day and on anniversaries of the death as well (Hoy, 2013, p. 99). Traditional Jewish rituals honor the deceased on the anniversary of the death with the unveiling of the gravestone the first year and the lighting of the Yahrzeit candle annually. Some couples are already making this change with wedding ceremonies, opting to have small private gatherings now followed by a rescheduled public reception at a later date. While these changes are certainly viewed as less than ideal by brides and bereaved families, alike, the presence of Coronavirus does not prohibit the eventual gathering of people together, an “anchor” of funerals and other life transition rituals (Hoy, 2013).



Prepare now for the emotional health cleanup. Long after the physiological aspects of Coronavirus have faded from the headlines, those of us who care for the psycho-social-spiritual aspects of humans could be sweeping up the mess. Suspicions about institutions like government and health care linger long after the headlines fade; some in Iran, for example, have concluded that the lack of funerals is more about covering up the real number of dead than preventing the spread of disease (Amante, et.al, 2020). Steps we take now and in coming weeks will undoubtedly help mitigate some of the distrust that ensues in the months and years ahead.

Let us use our incredible creativity and capacity for care to consider and implement methods for social connection. It is our opportunity and challenge to be there for our neighbors and friends and family in ways that minimize illness and maximize resilience. We have the problem-solving capability, the technology vehicle, and the ingenuity and commitment to develop social connections, to enhance our immune responses, and to turn isolation in to insulation/protection.

The challenges of Coronavirus and this pandemic include both threats and opportunities. The interfaces between physical health and mental health must not be lost in either arena. Social distancing contributes to social isolation which we know can contribute to poorer immune response and health outcomes. While physical distancing and proactive health measures are essential to prevent the spread of disease, proactive social connection is protective of mental health and of immune function.

We are uniquely positioned in this day of technology and of intergenerational responsibility to maximize meaningful social contact in the midst of physical distancing. We are not called upon to stay home and do nothing. Instead, we are called upon to stay home and do those things that keep us connected, that speak to one another’s hearts, that reach out to vulnerable elders with all the tools at our disposal. Let us resource and support those who are physically present in hospitals and nursing homes with the tools they need to protect themselves and to connect older adults with their social workers, ministers, families, children, and with fun. Let there be more singing and music, and more FaceTime, and shared memories. And watch our immune systems respond with vigor.




References.

Amante, A., Hafezi, P., & Choi, H. (2020 March 19). ‘There are no funerals:’ Death in quarantine leaves nowhere to grieve. Reuters World News, Retrieved from https://www.reuters.com/article/us-health-coronavirus-rites-insight/there-are-no-funerals-death-in-quarantine-leaves-nowhere-to-grieve-idUSKBN2161ZM

Azar, B. (2001). A new take on psychoneuroimmunology. Monitor on Psychology, 32(11), 34-36. http://www.apa.org/monitor/dec01/anewtake

Campbell, Catherine; Scott, Kerry; Nhamo, Mercy; Nyamukapa, Constance; Madanhire, Claudius; Skovdal, Morten, Sherr, Loraine, Gregson, Simon. (2013). Social capital and HIV Competent communities: The role of community groups in managing HIV/AIDS in rural Zimbabwe, AIDS Care, 25, S 114-122. https://doi.org/10.1080/09540121.2012.748170

Hoy, W.G. (2013). Do funerals matter? The purposes and practices of death rituals in global perspective. New York, NY: Routledge.

McDade, Thomas W. (2001). Lifestyle incongruity, social integration, and immune function in Samoan adolescents. Social Science & Medicine, 53, 1351-1362. https://doi.org/10.1016/s0277-9536(00)00414-7

Maglen, K. (2006). “In this miserable spot called quarantine:” The healthy and unhealthy in Nineteenth century Australian and Pacific quarantine stations.” Science in Context, 19(3), 317-336. https://doi.org/10.1017/S0269889706000950

Pellecchia, U., Crestani, R., Decroo, T., Van den Bergh, R., & Al-Kourdi, Y. (2015). Social consequences of Ebola containment measures in Liberia. PLOS One, EPub ahead of print 9 December 2015. https://doi:org/10.1371/journal.pone.0143036

Segerstrom, S.C. (2010). Resources, stress, and immunity: An ecological perspective on human psychoneuroimmunology. Annals of Behavioral Medicine, 40, 114-125. https://doi.org/10.1007/s12160-010-9195-3

Tsankova, D. (2009). Emotional intervention on an action selection mechanism based on artificial immune networks for
navigation of autonomous agents. Adaptive Behavior, 17(2), 135-152. https://doi.org/10.1177/1059712309103433

Worden, J.W. (2018). Grief counseling and grief therapy: A handbook for the mental health practitioner (5th ed.). New York, NY: Springer.

The Authors: For more than three decades, William G. Hoy has been counseling with the bereaved, supporting the dying and their families, and teaching colleagues how to provide effective care. After a career in congregation, hospice, and educational resource practice, he now holds a full-time teaching appointment as Clinical Professor of Medical Humanities at Baylor University in Waco, Texas. His research examines the role of poverty in end-of-life and funeral decision-making, especially among African American patients and families. Helen W. Harris is an associate professor in the Diana Garland School of Social Work at Baylor University. A licensed clinical social worker and supervisor with extensive experience in health care and hospice social work, Dr. Harris’ areas of research interest include children’s grief and congregational support of person with physical and mental health challenges.

Copyright © 2020 by William G. Hoy and Helen W. Harris. All rights reserved.

Citation: Hoy, W.G. & Harris, H.W. (2020). Unintended consequences of CoVID-19. GriefPerspectives, 19(3), 1-4. http://www.baylor.edu/medical_humanities/
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