COVID-19 Webinar 7: People in vulnerable situations
The Lancet Psychiatry, Mental Health Innovation Network, MHPSS.net and United for Global Mental Health have launched a series of weekly webinars designed to provide policy makers and the wider health community with the latest evidence on the impact of COVID-19 on mental health and how to address it.
Chair: Julian Eaton, CBM Global, London School of Hygiene and Tropical Medicine
Panellists:
Dr Katrin Seeher, Technical Officer (Brain Health Unit), Department of Mental Health and Substance Use (MSD), World Health Organization
Sudipto Chatterjee: National Institute of Advanced Studies, Bangalore and Parivartan Trust, India
Martin Prince: Professor of Epidemiological Psychiatry and co-Director of the Centre for Global Mental Health, King’s College London, Global Health Research Unit on Health System Strengthening in Sub-Saharan Africa (ASSET)
Víctor Lizama: Coordinator of the Team of Justice Facilitators of the Disability and Justice Program of the Mexican NGO Documenta
Katrin Seeher. WHO
In the context of COVID-19, there are three particular areas of concern regarding older people – older adults are particularly vulnerable (the UN Secretary General recognised them as a key vulnerable group at the World Health Assembly in his speech this week) yet they are traditionally neglected in emergency responses; measures that are currently used to contain COVID-19 have an affect on access, treatment and care for older adults; and there are long term implications of the pandemic on older adults. The increased mortality risk is because older people are more likely to have underlying health conditions and the immune system tends to weaken with age. Outbreaks in long term care facilities are also a concern.
What have countries done so far? Suspension of routine and emergency health services e.g. surgery and treatment. Older people fear infection so are no longer accessing services for example in Italy there has been a 50% reduction in hospital admissions for stroke while in Argentina visits to memory clinics almost completely stopped. There has been a reduction in the workforce taking care of older people (as carers are diverted to work on COVID-19) and border closures (particularly in Europe) are preventing migrant workers - who provide a large proportion of care for the elderly - from entering host countries.
The long term impact is not yet known, however there is speculation that given the level of risk for older people from COVID-19, they are likely to be in lockdown for the longest time and therefore at risk of greater social isolation and lack of physical activity. This in turn raises the risk of dementia and other related conditions. COVID-19 is forcing countries to re-conceptualise ways to provide health and social care services e.g. through remote delivery and technology based solutions. The WHO is working with countries as they consider these options. Overall we all need to strengthen the workforce caring for older people .
At the societal level, we need to foster a more positive attitude towards older people. We need to emphasise resilience and the positive contributions that older people can provide to the COVID-19 response - using their life skills to comfort all of us. They have experienced previous crises and can help us through this one.
Julian Eaton
Many people with mental ill health are in institutions, although the Convention on the Rights of Persons with Disabilities (CRPD), Inter Agency Standing Committee (IASC) all talk about the need to deinstitutionalise as a priority. Can you share what you have been doing to address the needs of those groups?
Victor Lizama
The Convention on the Rights of People with Disabilities mentions in its article 11 the responsibility of the States Parties to guarantee the safety and protection of people with disabilities in situations of risk. However, on March 17, the United Nations Rapporteur on the Rights of People with Disabilities, Ms. Catalina Devandas, expressed that not enough has been done to provide guidance and support to protect people with disabilities in the face of the situation of emergency by COVID 19, even when it is a high-risk group, a concern that is summarised in this phrase: “People with disabilities feel that they have been left behind.”
Sanitary measures are impossible to carry out for many people with disabilities – it is difficult to maintain prolonged isolation – they have caretakers. Conditions in psychiatric institutions also raise the risks to people including overcrowding, and negligence in the provision of food and medical care. There is a lack of access to dignified quarantine measures. Historically people with mental ill health have been isolated from society, stigmatised and forgotten.
Mexican data has shown in 2018, 2600 people were committed to psychiatric hospitals. Already there are cases now of 4 people in psychiatric hospitals testing positive for COVID-19.
[Victor then provided an update on the work of his NGO to ensure the government protects the rights of people in psychiatric hospitals and provides the services they need in the context of COVID-19. He called for action by the Government of Mexico and all governments to uphold the rights of people with mental ill health including those in psychiatric hospitals and advocated for reform of health systems in line with human rights conventions and the deinstitutionalisation of people. He said, learning from the response to HIV/AIDS in the 1980s, there should be, “guidelines for intervention and responses built from a human rights perspective, that is, they focus on evidence, empowerment and community participation, principles that are also worthy of concern for people with disability. We must focus on removing barriers for people to protect themselves, either individually or as part of a community.”. He concluded: “the challenge, even in these complex moments, is not to leave anyone out, to rebuild the social fabric and strengthen support and accompaniment to generate inclusion and respect for the dignity and rights of all people.”]
Julian Eaton
Thank you and congratulations for all that Victor has been able to do in such a short time.
Of course the response is not just about people with pre-existing mental illness, but the wider population’s wellbeing being affected. Martin will talk later about mental health and distress of people in the general population, but now we will think about how people needing support in the community are being affected.
Sudipto how have people living in the community been affected by the response to COVID-19 of the Indian government?
Sudipto Chatterjee
The impact has been profound for those living with mental ill health. In India, an early and stringent lock down strategy was implemented and now we are easing out of that situation. Many of those with mental ill health find it difficult to participate in society and access services and treatment normally and even more so during the pandemic. At a personal level many people we work with have experienced stress and anxiety. Some have relapsed and there is a huge burden of caregivers. The system of care and support has disintegrated due to the disruption of supplies and group activities (day care, access to employment etc). The Indian health system – as with many parts of the world – is now relying more on digital treatment which have been useful but this is also a matter of concern as it can reinforce a set of exclusions for those who cannot access technology or pay for services. The lockdown and wider response to COVID-19 has had a dramatic impact on personal and family situations. It is expected these challenges and barriers to access will markedly increase particularly for people with serious mental health illnesses who are currently often being left to fend for themselves. We need to protect people from harm and exposure of COVID-19.
Julian Eaton
This is a genuinely global experience – unlike many other work that we do in global mental health – and has brought some groups together in a shared experience. But Europe and North America are ahead of the curve on the pandemic. Looking to countries not yet at that stage, Martin, as you are monitoring the pandemic in Africa through ASSET, can you comment on the experience of partners in Africa – what strengths and vulnerabilities does Africa have in particular?
Martin Prince
We run a health systems strengthening research unit and work in countries including Ethiopia, Sierra Leone, South Africa and Zimbabwe. We switched our attention to the COVID-19 outbreak across 46 countries in Sub Saharan Africa (SSA) because they share considerable aspects of disadvantage around risks related to COVID-19 outbreak. The majority of the world’s least developed countries and fragile states, are the bottom fifth of health systems (on health quality and access). On the 28th Feb, the first case was reported in Nigeria – and by May it spread to all countries. Just over 52,000 cases and 1,217 deaths. The disease is spreading fast - particularly in recent days - last week alone a third of cases and quarter of deaths were recorded (of the total recorded for SSA as a whole). This shows the acceleration of the pace of pandemic across the region. Nearly 2/3 were from just 6 countries (Cameroon, Ghana, Guinea, Nigeria, Senegal and South Africa). These are countries where the population is relatively highly urbanised and interconnected. In total 1.1% of all cases of COVID-19 are from SSA but 14% of the world's population lives in SSA. Countries where - with early control - the outbreak hasn’t taken off include Botswana, Namibia and Eritrea. Is the trajectory towards widespread community transmission? Generally it is spreading slowest where there are low levels of urbanisation and low inter-regional connections. Also in countries that are able to do a good job on managing any imported cases, institute effective quarantine measures and control community transmission. Physical distancing measures are different from those in the global north.
Julian Eaton
Have countries been able to find ways to target the poorest or those most affected who are living on subsistence incomes?
Martin Prince
Most Sub Saharan African countries have not introduced total lockdown due to [the way the economy operates largely informally]. They are using a wide range of economic measures that will be quite costly including using existing mechanisms to boost cash transfers. For example in Togo they have used cash transfers to 800,000 informal workers; other countries have introduced food aid packages or waived requirements to pay utility bills.It is estimated such measures are costing African economies around 5% of GDP and governments are seeking support from external donors including investment in infrastructure – a Marshall Plan for Africa - to restart their economies. They don’t want debt moratoria and debt write offs because it reduces their credit-worthiness which constrains their development in the future.
Julian Eaton
Turning to the question of migrant workers. They are particularly hard hit by national government responses to COVID-19, and they have been a source of reinfection into the community e.g. Singapore, when they have been neglected. In India, what has been the effect on migrant workers?
Sudipto Chatterjee
94.3% of Indian economy is generated by the informal sector with limited protection, social security etc. Migrant workers feel abandoned and isolated which has implications socially and economically. It is a perfect storm for risk factors among a large section of the Indian population. COVID-19 demonstrates mental health is an issue for so many – it is a wake up call.
Julian Eaton
The impact across society has come through many of the talks.
Question to Katrin – older populations are particularly economically vulnerable. Is there a difference in the way different socio economic groups have been protected and responded to?
Katrin Seeher
We have not seen data on this yet so analysis is ongoing.This raises the important point of collecting disaggregated data for different populations and vulnerable groups and making sure they don’t miss out and are left out.
Julian Eaton
Thank you to all speakers. We have agreed here that what COVID-19 has done is expose and accentuate existing disparities. In the post-COVID world we must address the social determinants of mental health and how to better protect people from the risks of mental ill health.
Resource Documents: Links to relevant UN Policy Briefs
Policy brief: Impact of COVID-19 in Africa (20 May 2020)
Policy brief: COVID-19 and the need for action on mental health (13 May 2020)
Statement: Mental health services are an essential part of all government responses to COVID-19
Policy brief: A disability-inclusive response to COVID-19 (6 May 2020)
Statement: We have a unique opportunity to design and implement more inclusive and accessible societies
Policy brief: The impact of COVID-19 on older persons (1 May 2020)
Statement: Our response to COVID-19 must respect the rights and dignity of older people (Download EPUB file)
COVID-19 and Human Rights: We are all in this together (23 April 2020)
Statement: We are all in this Together: Human Rights and COVID-19 Response and Recovery (Download EPUB file)
The full list of policy briefs can be found here.
