*An earlier version of this commentary was published on Medscape Psychiatry
Lloyd I. Sederer, MD
May 14, 2021
Credit: Lloyd Sederer
We have no way of precisely knowing how many lives might have been saved, how much grief and loneliness spared, and economic ruin contained as a consequence of COVID-19, had we risen to its myriad of challenges in a timely fashion. However, I think it is safe to say that the United States deserves to be graded with an "F" for its heretofore management of the pandemic.
To render this failing grade, we need only to read the countless verified reports of how critically needed public health measures were not taken soon enough, or sufficiently, to substantially mitigate human and societal suffering.
At first, at hospitals and among first responders, there was the failure to protect doctors, nurses, technicians, EMTs and others by supplying them with the personal protective equipment needed to prevent their infection and diminish the risk to their loved ones. That soon extended to our entire country's failure to adequately protect its citizens and residents. COVID-19, of course, rained its grievous consequences disproportionately upon people of color, those living in poverty, and those with housing and food insecurity — those already greatly foreclosed from opportunities to exit their troubled circumstances.
We all have heard, "Fool me once, shame on you; fool me twice, shame on me."
What has happened, perhaps not happened, did so despite the spectacular efforts of so many human service and essential workers. Where the responsibility lies is with a dysfunctional, divisive, politically and self-interested menagerie of government agencies and elected officials, at federal and state levels. If there is to be redemption, the past year plus of failures points to where we can and must do better.
Bear witness, colleagues and friends: It will be our further collective and shared shame if we continue to fail in our response(s) to COVID-19.
But failure need not happen. Protecting ourselves and our country is a solvable problem; complex and demanding for sure, but solvable.
To battle trauma, we must first define it
The sine qua non of a disaster is its psychic and social trauma. I asked Maureen Sayres Van Niel, MD, chair of the American Psychiatric Association's Minority and Underrepresented Caucus and a former steering committee member of the US Preventive Services Task Force, to define trauma. She said, "It is [the product of] a catastrophic, unexpected event over which we have little control, with grave consequences to the lives and psychological functioning of those individuals and groups affected."
The COVID-19 pandemic is a massively amplified traumatic event because of: the virulence of the virus (and its variants) and its highly contagious properties; the absence of any date on the horizon for when it will become past tense; that the pandemic’s grave injustices disproportionately fall on the majority of our populace already experiencing racial and social inequities; and the ironic yet necessary imperative to distance ourselves from those we care about and who care about us.
What drives the magnitude of trauma from a disaster?
Four interdependent factors drive the magnitude of the traumatic impact of a disaster: (1) the degree of exposure to the life-threatening event; (2) the duration of exposure and the threat of its recurrence; (3) an individual's preexisting experience(s) of trauma (natural and human-made), as well as having had a mental or addictive disorder, and (4) the adequacy/inadequacy of family, and fundamental resources such as housing, food, safety, employment and access to healthcare (the social dimensions of health and mental health). These factors, in fact, highlight the "who," "what," "where," and "how" of what should have been (and must, with urgency, aim to be) an effective public health response to the COVID-19 pandemic.
There used to be “categories” to identify the differences expected from a disaster’s traumatic impact on victims, witnesses, and bystanders. Covid has erased those differences.
Dr Sayres Van Niel asserts that we have a "collective, national trauma." In April, the Kaiser Family Foundation's Vaccine Monitor reported that 24% of US adults had a close friend or family member who died of COVID-19. That's 82 million Americans! Our country has eclipsed individual victimization and trauma, because we are all in its maw.
Vital lessons from the past
In a previous column for Medscape, I described my role as New York City's mental health commissioner after 9/11 and the many lessons we learned during that multiyear process. Our work served as a template for other disasters to follow, such as Hurricane Sandy. Those lessons surely now pertain to COVID-19.
We learned that those most at risk of developing symptomatic, functionally impairing mental and addictive disorders had prior traumatic experiences (e.g., from childhood abuse or neglect, violence, war, and forced displacement from their native land), and/or a preexisting mental or substance use disorder.
By identifying these at-risk individuals and communities, we can prioritize their detection, treatment and social supports. Doing so requires mobilizing both inner and external (social) resources, before disaster strikes or in its wake.
For individuals, adaptive resources include developing any of a number of mind-body activities (e.g., meditation, mindfulness, slow breathing, and yoga); sufficient but not necessarily excessive levels of exercise (as has been said, if exercise were a pill, it would be the most potent of medicines); nourishing diets; sleep, nature's restorative state; and perhaps most important, attachment and human connection to people who care about you and whom you care about and trust.
One, at first unexpected yet now consistent, predictor of resilience in the wake of disaster is faith. This does not necessarily mean holding or following an institutional religion or belonging to house of worship (though, of course, that melds and augments faith with community). For a great many, myself included, there is spirituality, the belief in a greater power, which need not be a God - yet instills a sense of the vastness, universality, and continuity of life.
For communities, adaptive resources include safe homes and neighborhoods; diminishing housing and food insecurity; education, including pre-K; employment, with a livable wage; ridding human interactions of the endless, so-called ‘microaggressions’ (which are not micro at all, because they accrue) of race, ethnic, class, and age discrimination and injustice; and ready access to quality and affordable healthcare, now more than ever for the rising tide of mental and substance use disorders that COVID-19 has unleashed.
Every gain we make to ablate racism, social injustice, discrimination, and widely and deeply existing resource and opportunity inequities will produce greater cohesion among the members of our collective tribe. Greater cohesion, a love for thy neighbor, and equity (in action, not polemics) will fuel the resilience we will need to withstand COVID’s continuing trauma; as well as the other, inescapable disasters and losses that lie ahead. The rewards of equity are priceless: especially the dignity that derives from fairness and justice — given and received.
This unprecedented disaster requires a bold response
My, what a list. But to me, a bold, ongoing response to this (and all disasters) means that we can make differences anywhere, everywhere, any time, and in countless and continuous ways.
The measure of any society is how it cares for those who are foreclosed, through no fault of their own, from what we all want: a life safe from violence, secure in housing and food, with loving relationships and the pride that comes of making contributions, each in our own, wonderfully unique way.
Where will we all be in a year, two, or three from now? Prepared, or not? Emotionally inoculated, or not? Better equipped, or not? As divided, or more cohesive?
I imagine that depends on each and every one of us.
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Lloyd I. Sederer, MD, is a psychiatrist, public health doctor, and writer.
He is an Adjunct Professor at the Columbia University School of Public Health; Founder &
Director of Columbia Psychiatry Media; Chief Medical Officer of Bongo Media, and chair of the Advisory Board of Get Help.
He has served as Chief Medical Officer of McLean Hospital, a Harvard teaching hospital; Mental Health Commissioner for New York City (in the Bloomberg administration); and Chief Medical Officer of the NYS Office of Mental Health, the nation's largest state mental health agency.