The devastating impact
of the corona virus worldwide has shattered our belief that people will be safe and remain immune from the corona virus in the United States. On September 11th, 2001 people no longer felt safe from terrorism on U.S. soil. The country is sheltering in place in 2020 not from the fear of terrorist attacks; rather, from a deadly invisible enemy, COVID 19, that has rapidly crossed oceans and continents. The corona virus has filled people with fear and dread. Persons unknowingly transmit the virus to other persons, not knowing where its droplets might land but knowing there is no cure or vaccine yet.
When natural disasters strike,
counselors are often second responders in their own communities where they experience the same trauma that their clients experience. We–counselors, clients, responders, doctors and nurses–are all at risk. The corona virus has forced counselors to live and work differently as we help others while doing no harm. This includes
not
spreading the virus.
As disaster mental health counselors
and counselor educators, we (Barry and Jane) prepare counselors to respond to persons affected by natural disasters, such as floods, hurricanes, and tornadoes. COVID 19 has drastically different effects. In the fourth edition of our book
Disaster Mental Health Counseling: A Guide to Preparing and Responding,
we inadvertently omitted the chapter on “Responding to Pandemics: Preparing Counselors.” This omission likely rose from our misbelief that after SARS, we would be spared another public health pandemic, at least for a long time.
In the beginning of the chapter in the third edition,
Barry described his conversation as a young boy at the cemetery with his grandmother. He didn’t understand how her two brothers had died, Barry said, “Ma, no one dies of the flu.”
The Spanish Flu
that killed her brothers has been the deadliest pandemic, killing about 30% of the world’s population or between 20 and 50 million people. However, as COVID 19 rapidly and invisibly spread around the world, humans are transmitting the virus, often not knowing they have it. It is a disease out of control: thus, the enormous need for public health prevention to contain and reduce infection, as well as counseling support to struggle through it.
When we moved online
this month to teach, I (Jane) felt some discussion and sharing about the impact of the pandemic was needed, as well as talking about self care–emotionally, physically, and personally as this crisis spreads exponentially. Ironically and perhaps tragically, I discussed existentialist therapy and its key ideas of death, isolation, freedom, and meaninglessness with my Advanced Theories students as they read
Night
by Eli Wiesel
and
Man’s Search for Meaning
by Viktor Frankl.
I encouraged them to read
The Plague
by Albert Camus about a fictional plague in Algeria. The story paralleled the Black Death in the mid-fourteen century that killed an estimated 30% to 60% of Europe’s population. The main character, Rieux, a physician, is asked what decency is. Doctor He responded: ‘In general, I can’t say, but in my case I know that it consists in doing my job
.’
Existentially, in a world of chaos,
people live with fear and dread. As counselors, we must find ways to maintain and foster our connections and relationships with others, albeit in different ways to help everyone survive. In my own experience, we must provide telehealth support and services especially to first responders–EMTs, doctors, nurses, medical staff, police officers, and the National Guard–who do their job to help victims of COVID- 19.
I trust in our ability and skills as counselors
to help others in our communities at this crucial time. Reinvent yourself and advocate for others in new ways, putting your oxygen mask on first before helping others. Count on your ability to listen, to support, to hear what is not said, and to be patient. In his essay, “Return to Tipasa,” Camus concluded, “In the midst of winter, I discovered in me there was an invincible summer.”
Responding to Pandemics: Preparing Counselors
b
y J. Barry Mascari and Jane Webber.
(See preceding April 2, 2020 update)
At 8 years old, I was at the cemetery with my maternal grandmother. She was caring for gravestones with the names of her parents and two brothers, both of whom died under the age of 20 in 1918. I asked, “Did they die in the war?” She replied, “No, they died of the flu.” I said, “Ma, no one dies of the flu.” She never spoke of the flu again, and, like many who remember 1918, the horror was once again buried inside. We can only imagine what pain and traumatic memory remained and how, without the benefit of intervention, those memories took a toll on a generation (Mascari, 2009).
Much to our surprise,
as of the writing of this chapter, the Swine Flu (H1N1) pandemic is on its second wave, appearing first as rare spring flu and then as a declared pandemic. On June 11, 2009, the World Health Organization (WHO, 2009) declared it the first pandemic in 41 years. It returned in the fall with widespread outbreaks in 48 states and serious outbreaks around the world, raising fears of the possibility that the strain might mutate and become more lethal. Many counseling colleagues—shocked by the WHO’s declaration—sought direction on how to prepare. For traumatologists, and other counselors who will be called upon to respond in times of crisis, knowledge about pandemics and influenza is vital.
Our approach
to managing our own anxiety over the Avian Flu in 2006 was to read and learn as much as possible. During a trip to Barcelona, where street vendors on Las Ramblas were selling domestic birds as pets, we watched wild birds land on cages and were struck with the startling reality that a possible jump from bird to human was very real. This led to an even more frightening realization: the world is overdue for a pandemic, defined as when an epidemic spreads rapidly across many geographic locations, countries, or continents. Pandemic is not to be confused with an epidemic, when the observed number of cases exceeds the expected number of cases of a given disease in a defined time period. In brief, a pandemic is an epidemic gone wild, spreading beyond borders.
To respond to the threat
of a pandemic, we monitored the worldwide H5N1 flu outbreaks (more commonly referred to as Avian Flu) and SARS. Attendees at the 2007 American Counseling Association Annual Conference and the Argosy University Symposium on Trauma, Tragedy, and Crisis (Webber, Mascari, & Dubi, 2007) reacted to our concerns with a combination of fear and concern but lacked a sense of urgency. The final chapters on H1N1 and H5N1 are yet to unfold.
PANDEMIC HISTORY
There have been
10 known pandemics in 300 years, occurring approximately three to four times every 100 years. The Bubonic Plague (the Black Death) of 1348 killed 25% to 50% of the European population in 3 years; the next pandemic was the Spanish Flu of 1918. Infection estimates for the Spanish Flu ranged from 200 million to 1 billion people and number of deaths from 50 million to 100 million (Billings, 2005). The 20- to 40-year-old population suffered the most deaths, instead of elderly and children—who are usually the most at risk. In 2 years and three waves, nearly half the world was infected. Although these two pandemics were separated by centuries, one commonality is that the fields of public health and medicine had limited understanding, and crude forms of disease control were practiced.
Unlike world wars
that have celebrated veterans and honored the dead with stories shared by parents and grandparents, pandemics have no such history. Instead, what most people know comes from history books or children’s rhymes
(Ashes, ashes, we all fall down
) (see Chapter 31) or the children’s jump rope rhyme
(I had a little bird, its name was Enza, I opened the window and in-flu-enza
) (Crawford, 1995).
The Plague
(Camus, 1947) was a novel about a fictional plague in Algeria, although few people make the connection between Camus’ existential worldview and pandemic.
Modern pandemics
include the Asian Flu of 1957 (H2N2 strain) and the Hong Kong Flu of 1968 (H3N2 strain) that led to 1 to 4 million deaths. Recent outbreaks with pandemic potential include HIV/AIDS, SARS, the West Nile Virus, and Avian Flu (H5N1).
Pandemic is Not Seasonal Flu
Most people
have experienced a seasonal flu, often minimizing it as a bad cold, despite its ability to kill. Pandemics are different—they infect 15% to 50% of the population, placing all ages at-risk and producing severe illness and a high death rate. The US Department of Health & Human Services (2009) noted:
It is the sheer scope
of influenza pandemics, with their potential to rapidly spread and overwhelm societies and cause illnesses and deaths among all age groups, which distinguishes pandemic influenza from other emerging infectious disease threats, and makes pandemic influenza one of the most feared emerging infectious disease threats.
Each seasonal flu vaccine
is an educated guess based on the strains that have been identified the previous year. In a pandemic, new strains may emerge or old ones may reappear, with no effective vaccine available for 4 to 6 months after onset. Antiviral drugs such as Tamiflu have been effective, but their impact on a new or reappearing strain is largely unknown. Drugs will likely be in short supply and government stockpiles are limited. Preliminary data from the H1N1 outbreak in fall 2009 indicated shortages in Tamiflu and vaccine–production has not met demand (MSNBC, 2009).
In most pandemic outbreaks,
unlike seasonal flu, the healthiest individuals are at greatest risk, ironically, because they have the most robust immune system. Non-seasonal flu is devastating because of the cytokine storm, an extreme immune system overreaction that results in a ferocious assault on the lungs by immune cells. The inflamed lungs can become congested with dead cells and fluids, resulting in serious respiratory distress and suffocation (Ukrainetz, 2009). The H1N1 pandemic of 2009 has produced a more surprising at-risk group: the very young.
IS PANDEMIC INEVITABLE?
Based on historical patterns,
experts suggest a pandemic resulting from a new virus subtype within the next decade. This new strain will have little immunity in the current population, most likely because there has been no prior exposure to the new virus. Because this virus can replicate in humans, transmitting efficiently from one human to another, it can cause community-wide outbreaks (WHO, 2009). The current H1N1 pandemic might not become this long-dreaded outbreak because current death rates are much lower than feared. Taubenberger and Morens (2006) cautioned that:
Even with modern antiviral
and antibacterial drugs, vaccines, and prevention knowledge, the return of a pandemic virus equivalent in pathogenicity to the virus of 1918 would likely kill [greater than] 100 million people worldwide. A pandemic virus with the (alleged) pathogenic potential of some recent H5N1 outbreaks could cause substantially more deaths (p. 21).
Avian Flu (H5N1) Remains a threat
Avian flu produced
sporadic epidemics in migratory birds and poultry in Asia in 1997 and has remained active. Bird-to-human infection has been confirmed in the following countries where people live in close proximity to poultry: Vietnam, Cambodia, Thailand, Indonesia, Russia, Azerbaijan, Egypt, India, Iraq, Laos, Nigeria, and Turkey. It is not known whether human-to-human transmission has occurred.
Although the number
of individuals infected with H5N1 is small, nearly half of those infected die from it. Globalsecurity.org (2009) projected that 200 million United States citizens, 15% to 35% of the population, could become infected with 87,000 to 207,000 deaths and 314,400 to 733,800 individuals hospitalized.
PANDEMIC’S IMPACT
Unlike previous pandemics
that spread slowly through sea travel, the frequent use of air travel increases the probability of reaching all continents within 3 months. Also, the world’s population has increased, and the majority of people live in densely populated cities. In New Jersey, the most densely populated state in the nation, where nearly half the population lives in one-third of the state (near New York City), there could be 8,000 deaths, with 5,700 occurring in hospitals, and 41,000 hospital admissions. (See Chapter 38).
When the perceived threat
is greater than the actual threat in a health crisis, fear and anxiety are common reactions. Storming a vaccination or medication point-of-distribution site or a government building where supplies are believed to be stored can threaten to undermine governmental authority. In general, stress and fear lead to somatic complaints; more healthcare is sought, taxing resources and leading to the perception that the outbreak is worse than it is.
COUNSELOR ROLE STRESS
While helping
the general public, counselors also will be needed to help people cope with illness, death, mistrust, and scarcity. Counselors may simultaneously serve as caregivers to family members and others outside of the family, leading to role conflict. Working with death may lead to vicarious traumatization when counselors begin to experience the same symptoms as their clients.
Altering the Delivery System for Counselors
In order
to ensure the safety of those providing disaster response, new methods of delivering disaster first aid and general social support to victims and survivors will be needed. With possible closings of schools, senior centers, or programs for the disabled and the canceling of social, religious, or cultural gatherings, social support could crumble. People will need help in other ways as social distancing, isolation, quarantine, and travel restrictions occur. These methods must ensure the “perceived” safety of counselors, while at the same time provide access to mental health services because there may be no way of knowing if vaccinated providers are safe. These delivery methods may include telephone counseling, home visits with face-to-face sessions outdoors at a safe distance, Internet sessions, drive-in window counseling using banks or similar facilities, or door-to-door delivery of psychiatric medication.
Lessons Learned from SARS
As we look back
to SARS, the first epidemic of the 21st century, we learned that first responders experienced role conflict because they were torn between protecting property and maintaining order and remaining at home with their family, while at the same time experiencing personal loss or illness (LeDuc & Barry, 2004). Unlike with fires and terrorist attacks, healthcare workers were the first responders to respond to the Hong Kong and Toronto SARS outbreaks. Studies of these workers found a higher degree of emotional distress than that of the public, although they were dying at same rate during the outbreak. Mackler, Wilkerson, and Cinti (2007) found that these workers stayed away from home to protect their family, refused work assignments, and avoided patients. Counselors may be faced with similar challenges in a pandemic.
A report
by the Central Intelligence Agency (2003) following the SARS epidemic warned that “...understanding and managing the public’s psychological and behavioral reactions to an unexpected outbreak of infectious disease are integral to successful response and containment.” Counselors may be a key factor in how well the nation handles the next pandemic and the challenges unique to a disease.
Ambiguous Loss
A number of human factors
will complicate the successful management of a pandemic:
·
Ambiguous loss, the process of losing a loved one without cultural funeral rituals or the ability to see or care for the dying person
·
A
psychological presence
with a
physical absence
, when family members are hospitalized or quarantined, disconnected from relatives, and experiencing profound uncertainty
·
Overwhelmed funeral homes and the potential for mass graves or mass cremation
·
Inability to travel to funerals leading to bereavement without closure
UNCHARTED TERRITORY
Most of what we know
about pandemics is from history. The good news is that unlike the 1600s or 1918, medicine, public health, and our understanding of disease have evolved. Equally significant is the fact that governments, the WHO, the Red Cross, and the Council for the Accreditation of Counseling and Related Educational Programs (2009) (with its infusion of the new disaster standards) suggest that counselors and the public health system in general are better prepared to respond to a pandemic. Still, diseases offer unique challenges that have yet to be tested in a large-scale 21st century pandemic. We now know that in addition to arming themselves with disaster and trauma skills, counselors who anticipate being on the front lines are advised to read more about pandemic and public health procedures to ensure they know what they may be facing.
REFERENCES
Camus, A. (1947).
The plague
. New York: Random House.
Centers for Disease Control and Prevention. (2009).
CDC resources for pandemic flu
. Retrieved from
www.cdc.gov/flu/pandemic
Central Intelligence Agency. (2003).
SARS: Lessons learned from the first epidemic of the 21st Century
. Washington, DC: Author.
Council for the Accreditation of Counseling & Related Educational Programs. (2009).
2009 Standards
. Alexandria, VA: Author.
Crawford, R. (1995). The Spanish Flu.
Stranger than fiction: Vignettes of San Diego history
. San Diego, CA: San Diego Historical Society.
Mackler, N., Wilkerson, W., & Cinti, S. (2007). Will first-responders show up for work during a pandemic? Lessons from a smallpox vaccination survey of paramedics.
Disaster Management and Response 5
(2), 45–48.
Taubenberger, J., & Morens, D. (2006). 1918 Influenza: The mother of all pandemics.
Emerging Infectious Diseases, 12
(1), 15–22.
*page not found
Webber, J., Mascari, J. B., & Dubi, M. (2007, March). Responding to pandemic flu: What counselors need to know. Presentation at ACA Annual Conference. Detroit, MI.
