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 Table of Contents  
INVITED COMMENTARY
Year : 2020  |  Volume : 36  |  Issue : 5  |  Page : 95-97

The pandemic and social psychiatry


1 Senior Consultant, Departmen of Psychiatry, Sitaram Bhartia Institute of Research and Science, New Delhi, India
2 Senior Professor, Departmen of Psychiatry, National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India

Date of Submission05-Aug-2020
Date of Acceptance05-Aug-2020
Date of Web Publication02-Oct-2020

Correspondence Address:
Dr. Alok Sarin
Sitaram Bhartia Institute of Research and Science, New Delhi
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/ijsp.ijsp_254_20

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How to cite this article:
Sarin A, Jain S. The pandemic and social psychiatry. Indian J Soc Psychiatry 2020;36, Suppl S1:95-7

How to cite this URL:
Sarin A, Jain S. The pandemic and social psychiatry. Indian J Soc Psychiatry [serial online] 2020 [cited 2020 Oct 26];36, Suppl S1:95-7. Available from: https://www.indjsp.org/text.asp?2020/36/5/95/297150



As the world struggles in horrified disbelief with the multiple impacts of the present pandemic, the challenge before the social psychiatrist remains that of the making sense of an increasingly unreal world. The social causes, and consequences of disease, have been endlessly debated, for perhaps all of known human history. “Scientific progress” over the past few centuries replaced demons, witches, and eclipses as causes of epidemics, for an equally unreal (for most of the population) world of viruses and pathogens. Whether this is knowledge, or belief, is still debated in many circles. Notions of progress, and a stable society, are thus at best a delicate balance, and sudden or overwhelming stress can bring the whole edifice tumbling down.

It is by now fairly clear that the virus has spread to nearly all corners of the globe. It also seems clear that some countries and communities are certainly harder hit in terms of morbidity and mortality. There remain, however, many questions as yet to be answered. While many of these will remain outside the scope of this reflection, there are certainly some that mental health disciplines may want to unpack further.

The first of these is undoubtedly the starkly clear fact that while the virus and its impact is doubtlessly real, a fairly large part of the impact that we see happening is because of the response to the fears about the spread of the virus. We expect that the debates around the justification of the responses will perhaps continue for a long time, and like in all things, develop a multiplicity of narratives. Depending on the lenses of ideology, politics, development concerns, human rights, and perhaps most importantly, economics, myriad stories will be constructed.

The one aspect that will perhaps stand out in these many tellings of this tale will be the very large humanitarian crisis that has unfolded in many places in the world, and especially in India. Here, by all accounts, many hundreds of thousands of people have left their places of work to head back “home.” Rendered “homeless” by the countrywide “lockdown,” bereft of earning, and often driven by a poorly articulated yet paralyzing fear of contagion, these “migrant workers” have left the states where they work to head back, ironically to the very villages which they left because of fears of penury and destitution, to chase chimeras of dreams in a metropolitan, unified India. The many stories of how people walked, and continue to do so, even as this piece is written, across hundreds of dusty kilometers, often stopped at state and district borders, occasionally being mowed down by speeding locomotives and trucks, sometimes helped by state government machinery, often harassed, supported patchily by civil society and philanthropy, is an on-going saga that a heart-broken nation watches, torn between shame and denial.[1],[2] In many ways, perhaps the closest parallel for the historically minded are the endless “kafilas” of refugees who walked across the borders in Bengal and Punjab, rendered homeless overnight by the much-awaited independence of India in 1947.

Then too, the mandarins in Delhi expressed anguish, but on the whole, washed their hands off the mess created by the “scuttle” (by the British) and the squabbles (of the new rulers) over assets and liabilities. A massive migration occurred (though smaller than the current one), as hundreds of thousands trudged their way across the country. Long lines, often extending for miles, formed while antecedents and suitability of the migrants were confirmed. On top of the brutal violence, infections and dehydration caused untold distress. Medical staff despaired at the lack of equipment, of having a syringe to inoculate several hundred people before they were let in across a border that had just been created.[3] Then, as now, carriers of infection were the greater “unwanted.” The cholera outbreak in September–October 1947 at least distracted the humans from killing each other! The “refugees” found themselves in camps and in unfamiliar cities, often resented by the local citizens, and accused of bringing disease and disruption to their lives. Now, when meaningless lines are drawn across concrete check posts, and human lives and souls are ground into the dust, the recovery of the psyche will take that much longer. As every gardener knows, an assault on the root impacts the tree for decades.

Biological anthropologists have shown that in past disasters, it has always been the people on the margins of society who have suffered the most. COVID-19 is no exception to this rule.[4] Then, as now, the soul-wrenching misery of the individual on the dusty road, the lack of a concerted compassionate response, and the need for society to think about how to make sense of this is as real. The knowledge that overwhelming trauma of this nature can, and will, result in long-term sequelae for both individuals and societies is something that is now being clearly understood. The concept of transgenerational transmissions of the impacts of trauma, and that it straddles the psychological, the sociological, and the biogenetic domains, is also an understanding that we are developing. The huge differences in mortality across countries, and on ethnic groups within countries, could perhaps be attributed to genetic factors [5] that mediate resistance and resilience. Or it could also reflect the poorer health, the marginalized existence, and the lack of safety nets.[6] These social perceptions, unless explicitly addressed, would feed prejudice and suspicion for years hence. It is also clear that for a variety of reasons, for societies to talk about these issues has always been difficult, though it is painfully apparent that unless we do, we learn nothing from them.

To continue that thread, if there is something that we should learn from this, what can it possibly be?

We would like to think that the learnings might be in a few probable ways:

First, a more clearly articulated health policy, that actually works to support the most vulnerable and disadvantaged. On the eve of independence, it had been hoped that a universal primary health care for the entire country would soon become a reality, as the Bhore Committee had suggested. However, on the contrary, on the ground, the Indian Medical Service was disbanded, and all idea of a unified umbrella health-care service was soon abandoned. This was quite unlike transition of the other services (the Armed Forces, the Judiciary, the Police, and the Civil Service) from colonial rule. Health care thus became the primary responsibility of the states, and increasing and smaller political divisions negated any attempt of macro planning and co-ordination. For the individual, it made care dependent on their “citizenship” of a particular zone, and their care the responsibility of their “native” state. Unlike the expectation that the provision of universal health care would foster a greater sense of national engagement, the fragmentation has achieved the opposite. The poor are now faced with the Hobson's choice of not being assured of health and social welfare wherever they are in India, but have to go back to “Jhumri Talaiyan” to have a sense of engagement and civic entitlement. State governments vie with each other to provide balm to their “own” citizens, and thus make everyone else the “other.” The social and political impact of this sundering of the imagination and hope, of a larger vision of India, at the merest whiff of a crisis, could lead to the dangerous persistence of parochialism that Ambedkar had despaired at. The “Indian mind” may now, forever, be seen as a chimera, as the dispossessed have now experienced it as a complete shamble, literal, and metaphorical.

In this context, we may want to think “larger.” What the anxiety about the pandemic does is that it nudges us to think “small.” Homo sapiens became a successful species over the past few 1000 years by learning to co-operate and develop a “herd” mentality. Now, the herd has become, in a physical sense, a risk factor,[7] and humans are now expected to become solitary and fearful of the other. In this sense that we tend to think of proximally delineated limits, and tend to limit those delineations to self, community, state, or even nation. What will be needed here is to try to think beyond these arbitrary delineations. We also need to understand that traumas tend to layer on preexisting traumas, and traumas of this nature will undoubtedly tend to deepen and widen preexisting fault lines, be they communal, religious, economic, or ethnic, further accentuating the “narcissism of the small difference.”

In all these over-whelming discussions of vaccines, ventilators, mortality rates, the reverse transcription–polymerase chain reaction (PCR) of testing, and the “R noughts” of replicability, it may be wise to remember that the real tools to deal with contagion are what public health has been trying to teach us for many generations, namely hygiene, sanitation, and the prevention of contagion by appropriate distancing. The “PQR” of this epidemic (PCR tests, quarantine, and R factor) are all equally important components, as is the sharing of data and experience. The science is pretty simple, and most people with a high school education would understand the process. Well-established protocols for testing and sharing information have remained the same since Koch isolated the cholera bacillus in India, except for a greater refinement of the technology. Moreover, the response of Virchow to these discoveries was that “politics was nothing but medicine at scale.” Although the cholera bacillus was discovered in India, it changed the nature of social medicine in Europe, but had hardly any impact on the system of medicine, and its social engagement, in India. Most illnesses, even infection, are often seen here as a personal misfortune, or a malevolent machination, to be treated at great personal cost. The penetration of science and medicine, as a social imperative, not only as a public good, but also as a public common, has not been encouraged. Data and science can thus be seen as an elitist “ivory tower” or “navel-gazing,” out of touch, and blind to the “real” needs of the people. The threat of viruses is actually so much simpler to understand, and address, rather than the complex religious and caste calculations (the allegedly “real” issues) that seem to guide our polity.

We must also want to remember that within medicine as well, the conversations between public health and biomedicine have also always been skewed, and if in all this, we were to go away with a sense of the primacy of biomedicine, we would perhaps again not be learning what we need to. What is certainly needed is a more equitable conversation between the different domains of medicine, and a communication of that more complete holistic message.

How does this impact psychiatry? The globalization, the ravage and plunder of the earth and its ecosystem by one species, is likely to make that species vulnerable, even to a random reordering of base pairs in a RNA virus. The delicate web of ecology is not just the living and nonliving around us, but also us, who are embedded in it. The model is equally valid for social psychiatry, except that in this case, Homo sapiens itself is the host, vector, and environment. The intricate web of human and social relationships, ever complex, ever evolving, and capable of generating profound meanings and answers, should not be forced to regress to a short, selfish, brutal struggle for survival. With a psyche to match!

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Naveen P. Endless caravan of misery as migrants trudge home. The Times of India, Delhi, URL; 12 May, 2020. Available from: https://timesofindia.indiatimes.com/articleshow/75685313.cms?utm_source=contentofinterest&utm_medium=text&utm_campaign=cppst&fbclid=IwAR3ssTuCc-GSPX664JSJ32YKCpu60JqrSKbHQPsxfpw_tFO_KBbAw8X-YA4. [Last accessed on 2020 May 21].  Back to cited text no. 1
    
2.
Surbhi G, Smita N, Benita F, Vishnu V, Amrita D. How citizens are helping migrants stranded by the coronavirus lockdown. The Indian Express, URL; 19 May, 2020. Available from: https://indianexpress.com/article/express-sunday-eye/citizens-helping-migrants-stranded-coronavirus-lockdown-6412617/ [Last accessed on 2020 May 21].  Back to cited text no. 2
    
3.
Sanjeev J. Balm and Salve: The effect of the partition on planning and delivering health care. In: Jain S, Sarin A, editors. The Psychological Impact of the Partition of India. New Delhi: Sage Publications; 2018. p. 52.  Back to cited text no. 3
    
4.
Lizzie W. An unequal blow. Science 2020;368:700-3.  Back to cited text no. 4
    
5.
Casanova JL, Su HC, COVID Human Genetic Effort. A Global effort to define the human genetics of protective immunity to SARS-CoV-2 infection. Cell 2020;181:1194-9.  Back to cited text no. 5
    
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Khunti K, Singh AK, Pareek M, Hanif W. Is ethnicity linked to incidence or outcomes of covid-19? BMJ 2020;369:m1548.  Back to cited text no. 6
    
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Dezecache G, Frith CD, Deroy O. Pandemics and the great evolutionary mismatch. Curr Biol 2020;30:R417-9.  Back to cited text no. 7
    




 

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