PROTECTING MENTAL HEALTH

DURING EPIDEMICS

THS/MH/06/1
Original: Spanish
Document prepared by: Mental Health, Substance Abuse, and Rehabilitation Unit
Technology and Health Services Delivery
Pan American Health Organization (PAHO/WHO)
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Protecting Mental Health During Epidemics Page I

Contents

Page

I. Introduction .............................................................................................................. 1

II. Psychosocial Vulnerability........................................................................................ 2

III. Impact on Mental Health .......................................................................................... 3

IV. Mental Health Care .................................................................................................. 7

V. Management of Dead Bodies................................................................................. 13

VI. Psychosocial Care for Response Teams Working to Provide

Care During the Epidemic ..................................................................................... 15

VII. Mass Communication Strategies: The Importance of Truthful,

Appropriate, and Timely Information ...................................................................... 16

VIII. Final Considerations............................................................................................... 18

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I. INTRODUCTION

In his recent remarks to the 46th Directing Council of the Pan American Health
Organization in September 2005, Dr. Lee Jong-wook, Director-General of the World
Health Organization (WHO) warned all the attending Ministers of Health from the
Americas about the risk of a threat with incalculable health, social, and economic
consequences, stating that “failure to take this threat [avian influenza pandemic]
seriously and prepare appropriately will have catastrophic consequences.” He also
called the certainty of a world avian flu pandemic a “critical moment,” an event of
enormous consequences in which “no Government, Head of State, or Minister of Health
can afford to be caught of guard.” He continued, stating that “every country must also
have a communications strategy. It should be ready and able to inform the public about
the pandemic, what is happening, and what to do.”

"Humans will have no chance to develop a natural immunity to a new influenza

virus,” stated Dr. Lee, referring to the highly pathological H5N1 flu virus, which has
already sounded many alarms.

The issue has been discussed as a potential microbial disaster. “As human
impact on the earth increases exponentially, the chances for unpleasant surprises from
the microbial world will also grow.” “The new virus spreads quickly because no one has
any significant immunity to the novel strain, and the illness it causes can be unusually
severe.”1

PAHO/WHO authorities have exhorted the countries of the Region to prepare for
the possible emergence of a new strain of influenza capable of producing a pandemic.
They have been urged to make contingency plans specific to their circumstances and
limitations (availability of appropriate vaccines and antiviral drugs, as well as equitable
access to them).

The descriptions above are a preamble for emphasizing the need to assess this
threat from a behavioral perspective. Indeed, the responses of the affected population
groups and how to address them need to be better understood. Also, active community
participation is necessary in preparing and implementing epidemic control measures.

Preparations for an epidemic have traditionally emphasized aspects such as the

implementation of national plans, epidemiological surveillance, vaccine and drug
requirements, improved vaccination coverage among high-risk groups, as well as the
economic impact and burden. Psychological and social aspects were absent from
programming.

This is the case, even though many of the problems affecting the population as a
whole stem from fear and its multiple expressions. Since the problem affects everyone, it

1
Peters, C.J. “Hurrying Toward Disaster?” In Perspectives in Health Magazine, Pan American Health Organization.
Special Centennial Edition, Volume 7, Number 2, Washington, 2002.
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makes sense to address it with collective activities. Studies conducted in populations

facing a threat that generates fear or terror have shown that more than 80% of the
people in obvious proximity to the danger show symptoms of fear or panic.

II. PSYCHOSOCIAL VULNERABILITY

Vulnerability, whether born with it and/or acquired as a result of a traumatic threat

or event, is the internal state of an individual or group that causes harm due to a
dynamic process in which various factors interact.

The high number of people who sicken and die and vast economic losses
associated with an epidemic or pandemic lead to a high psychosocial risk. A rational
approach to mental health care implies recognition of different types of vulnerability
among different population groups, particularly differences related to gender, age, and
socioeconomic status. There are also occupational risks--for example, to the members
of response teams working during the emergency.

It should be pointed out that the most vulnerable groups are those that have the
greatest difficulty rebuilding their means of subsistence and social support networks
during and after the catastrophe.

Below is a list of conditions that generally influence vulnerability. Normally, it is

not a single one of these conditions that determines the degree of vulnerability, but
rather a set of them under certain circumstances. For example, being a member of an
indigenous population does not make a person vulnerable, unless it is combined with
other factors.

Conditions influencing vulnerability Population groups

Age and gender Boys, girls, and adolescents
The elderly
Women
Ethnicity Indigenous populations
Minority groups
A history of physical and/or psychological Disabled people
illness Psychiatric patients with a long history of
illness and previous psychiatric disorders
People with chronic diseases
Economic and social conditions Groups living in poverty and extreme
poverty
Marginality in large cities
Migrants from the countryside to the city
Illegal residents
History of traumatic events Population groups that have been victims
of violence in its different forms
Communities that are frequently hit by
natural disasters
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Working conditions in catastrophes. Members of institutional and community

Examples: working with large numbers of response teams
patients, handling corpses, witnessing
situations that cause pain

The losses experienced can affect men and women differently. Social and
cultural patterns determine how they will react. For example, men tend to repress painful
emotions, and expressing them is interpreted as a weakness. Their emotional response
may be to drink heavily or become violent. Women tend to communicate with each other
more easily, to express their fears, and to seek support and understanding for
themselves and their children.

In some communities, the elderly are a source of experience and wisdom and
have a historical memory of how, over time, populations have dealt with critical
situations. However, some may run the risk of being vulnerable because they suffer from
chronic, disabling diseases and because they are isolated and lack family and social
support networks.

Children can also be a vulnerable group; they have less understanding of the
traumatic event and are limited in their ability to communicate what they feel. Some
children go into complete denial or act with indifference when they learn that they have
lost one or more members of their family. The emotional impact is so intense that they
often do not speak about what they have experienced. Some adults may assume that
the child has forgotten, but this is not the case. Children are able to recall and talk about
their traumatic experiences once their fear is under control.

Catastrophes like a large-scale epidemic can lead to violations of children’s rights

(to health, education, nutrition, recreation, protection, the right to live with their parents,
etc.). The situation created by an epidemic affects all aspects of child development
(physical, psychological, and social), but generally the people responsible for helping
children have concentrated on their physical vulnerability without fully taking their losses
and fears into account.

III. IMPACT ON MENTAL HEALTH

Epidemics are health emergencies in which human life is threatened and there
are significant numbers of sick and dead. Local resources are generally overburdened,
and the community’s safety and normal functioning are threatened. As a result, outside
assistance is urgently needed. But, as with other catastrophic events, epidemics are also
real human tragedies, and thus the grief and psychological consequences also need to
be addressed.

In terms of mental health, a major epidemic implies a psychosocial disturbance

that can exceed the affected population’s capacity to handle the situation. It can even be
said that the entire population experiences stress and anguish to some extent. Thus, it is
estimated that there is an increase in the incidence of psychological disorders (between
one-third and one-half of the exposed population may suffer some psychopathological
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manifestation, depending on the magnitude of the event and the degree of vulnerability).
However, it should be pointed out that not all the psychological and social problems that
occur can be described as diseases; the majority are normal reactions to an abnormal
situation.

The effects on mental health are usually more marked among populations living
under precarious circumstances, who have limited resources and access to social and
health services.

Psychological Disturbances among Survivors

At the individual level, many people can experience a crisis, defined as a

situation caused by an external life event that exceeds a person’s emotional response
capacity. Essentially, that person’s coping skills are insufficient, and a psychological
imbalance or failure to adapt occurs.

Certain feelings and reactions are common in very emotionally significant

situations, such suffering from a serious disease and/or the death of a loved one.
Moreover, the memory of what happened will be part of the victims’ lives and will never
be erased from their memories.

However, while some psychological manifestations are the understandable and

transitory response to living through traumatic experiences, they can also be indicators
that the person is developing a pathological condition. The assessment should be made
in the contexts of the facts, determining whether these manifestations are “normal or
expected,” or, on the contrary, if they are psychopathological manifestations requiring
professional assistance.

Some criteria for determining whether emotional expression is turning into a

symptom of something else include:
• Prolonged suffering;
• Intense suffering;
• Associated complications (suicidal behavior, for example); and
• Significant impact on an individual’s routine and social functioning.

The most common immediate psychological disturbances among survivors are

depression and acute, transitory stress reactions. The risk that these disturbances will
appear increases according to the circumstances surrounding the losses and other
vulnerability factors. An increase in violent behavior and excessive alcohol consumption
has also occasionally been observed in emergencies.

Some of the delayed effects reported include pathological grief, depression,

adjustment disorders, manifestations of post-traumatic stress, abuse of alcohol or other
addictive substances, and psychosomatic disorders. Patterns of prolonged suffering are
also manifested as sadness, generalized fear, and physically expressed anxiety—
symptoms that frequently become serious and long-lasting.
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Adjustment disorders are characterized by a state of subjective discomfort,

emotional alterations affecting social life, and difficulty accepting the changes wrought by
the loss.

Post-traumatic stress (or certain symptoms of it) appears later or is a delayed

type of disorder brought on by exceptionally threatening or catastrophic events;
experiencing a major epidemic, particularly for people who have experienced major
losses, can trigger post-traumatic stress symptoms.

Grief

Sadness, suffering, and grief are expected following the death of one or several
loved ones. The grieving period is when the person assimilates what has happened,
understands it, overcomes it, and rebuilds his or her life. This is a normal process that
should not be rushed. Neither should one seek to eliminate it or regard it as a disease.

All societies have rites, standards, and ways of expressing their grief based on
their different concepts of life and death. Performing the rituals established by the
collective culture is an integral part of the survivors’ recovery process.

Grief is experienced as a mixture of sadness, anguish, fear, and anger. At its

most critical point, it reaches the extremes of very intense emotional pain and despair.
Afterwards, gradual relief comes, and the process ends with expressions of renewed
confidence and hope. The grieving process implies:
• Freeing oneself from or leaving behind the relationship with the deceased person;
• Adapting to the world under other conditions; and
• Making efforts to establish new relationships.

Facing the loss and grieving appropriately is closely linked to the following
factors:
• The survivor’s personality and coping mechanisms;
• The relationship with the deceased person;
• Circumstances in which the death occurred; and
• Social support network (family, friends, and community).

The most frequent psychological manifestations of mourning are: very vivid and
repetitive reminders of the deceased and what happened, nervousness, fear, sadness,
weeping, desire to die, sleep and appetite disturbances, memory and concentration
problems, fatigue, apathy and difficulty resuming normal activities, little motivation and
difficulty returning to a normal level of activity, tendency toward isolation, mixed feelings
or emotions (such as self-blame, blaming others, frustration, impotence, anger, feeling
overwhelmed, etc.), neglect of personal appearance and hygiene, and various
nonspecific physical manifestations (such as dizziness, nausea, headache, chest pains,
tremors, difficulty breathing, palpitations, and dry mouth).
In a major catastrophe, grieving means dealing with many other losses and
implies a broader, more community-oriented feeling. It implies interrupting a life plan that
not only has a family dimension, but also a social, economic, and political one.
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Complex grieving is grieving that does not progress “naturally” and becomes
pathological. It normally leads to a depressive disorder characterized by deep sadness,
loss interest and the ability to enjoy things, reduced activity levels, and extreme fatigue.
There are other symptoms, such as decreased attention and concentration, loss of
self-confidence, feelings of inferiority, guilt, a bleak future outlook, thinking about or
attempting suicide, sleep disorders, and loss of appetite.

Many circumstances can make facing the grieving process more difficult, but
personal vulnerability and the scope of the loss can be cited among them. Complex
mourning frequently leads to the appearance of psychiatric disorders that require more
specialized interventions.

In epidemics and situations involving mass fatalities, several authors have

described the survivors’ fears and feelings:2
• Grief and distress due to the loss of family members and friends which sometimes
coincides with material losses. There are also more subtle and sometimes
intangible losses, such as loss of faith in God, loss of the meaning of life, etc.;
• Practical fears: having to assume new roles imposed by the disappearance of a
family member (for example, the widow who becomes the head of the household, or
the widower who must take charge of the children);
• Recurrent fears that something can happen again or that death will befall other
members of the family or community;
• Personal fear of dying: fear of the unknown or fear of facing God;
• Feelings of loneliness and abandonment: it is common for survivors to feel that
family members and friends have abandoned them at a difficult time;
• Fear of forgetting or being forgotten;
• Anger toward the deceased, which is taken out on family members or close friends;
• Some degree of guilt for someone’s death; sometimes, what happens after the
death of a loved one increases this guilt;
• Shame following the death of a loved one because of circumstances surrounding
the death of that person (your behavior, humiliation, etc.); or shame about the
conditions in which a family is left following a disaster.

IV. MENTAL HEALTH CARE

2
PAHO/WHO. Management of Dead Bodies in Disaster Situations. Published by PAHO/WHO. Washington
DC, 2002.
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Experience shows that mental health plans cannot be limited to expanding and
improving the specialized services offered directly to the people affected; rather, the
perspective needs to shift toward a much broader area of expertise.

For example, emphasis can be placed on the relationship between mental health
services and a broad range of activities, such as:
• Humanitarian and social assistance;
• Counseling for the population and at-risk groups;
• Mass communication.

It has also been recognized that following major catastrophes, prolonged care is
needed for the mental health problems of survivors while they face the task of rebuilding
their lives. This raises the need for devising medium- and long-term psychosocial
recovery plans.

In terms of care, three time periods (before, during, and after the epidemic) can
be identified, along with four groups of people:
• The sick;
• Those who had the disease and survived;
• Those who are not sick, but could get sick, and who have experienced major
losses (death or illness among family members, friends, or neighbors); and
• Members of the emergency response team.
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Mental Health Actions by Time Period

Period: psychological and social Mental health actions

manifestations among the population
Before:
− Expectation of the inevitable high level − Communication of risk to the
of stress among the population population, emphasizing vulnerable
− Over- or under-estimation (denial) of groups.
the potential epidemic − Sensitization about and information on
− Exaggeration of preexisting personality the subject
traits (positive and negative) − Location of competent mental health
− Anxiety, stress, insecurity, and hyper personnel
vigilance for symptoms of the disease − raining of mental health teams and
PHC workers in this area
− Preparation of emotional support and
counseling groups
− Identification of vulnerable groups from
a psychosocial standpoint
− Preventive protection: imposed in an
authoritarian manner, if necessary
− Promotion of community spirit and
community participation
− Organization of mental health services
for adequate response during the
emergency, particularly the formation
of mobile teams, crisis intervention
units, and liaison services in general
hospitals
− Interinstitutional coordination
− Creation of work networks

During:
− Fear and a sense of abandonment and − Rapid evaluation of the psychosocial
vulnerability needs of the population depending on
− Need to survive the specific conditions of the location
− Loss of initiative where the epidemic is unfolding
− Spontaneous leadership (positive or − Support for the basic activities of early
negative) detection, reporting, care, and control
− Behaviors that can fluctuate between the spread of the disease
heroic and horrible, violent and − Mass communication: Information and
passive, and sharing or selfish recommendations on: what is
− Adaptation to changes in the normal happening, what is being done, and
patterns of living: restriction of what people should do; Transmission
movement, use of masks, reduction in of: organization, safety, authority,
direct physical contact, temporary morale, calm, support, and
schools closures, etc. encouragement
− Anxiety, depression, grief, peri- − Continuation of in situ training during
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traumatic stress, emotional and panic the emergency

crises, group reactions to disturbances, − Individual and group support and
regression to preexisting psychological psychosocial care for affected people,
disorders, and psychologically-based families, and communities
sleep disorders − Promotion of self-help and mutual
assistance mechanisms, including
groups and peer assistance
− Recovery of initiative and improvement
of self-esteem
− Helping to control social
disorganization
− Emotional first aid from nonspecialized
personnel (health and humanitarian
assistance), especially for grieving
families
− Psychiatric care for people with defined
mental disorders
− Specialized services to deal with the
pandemic: mobile groups to work in the
community and PHC, crisis intervention
units in selected sites (such as
morgues, large hospitals, etc.) and
liaison services in general hospitals

After: the pandemic is under control

− Fear of a new epidemic − Continuation of a good mass
− Aggression and protests against communication strategy to promote
authorities and institutions recovery
− Sedition and/or criminal acts − Continuous in-service training for
− Social and mental health side effects: teams of recovery workers
depression, pathological grieving, post- − Individual and group mental health
traumatic stress, alcohol and drug services for affected people, families,
abuse, as well as violence and communities, as part of a medium-
− Start of a slow and gradual recovery term psychosocial recovery plan (6
process months at the very least)
− Mental health care for those who
helped during the crisis (response
team)
− Rehabilitation is moving forward and
hope is reappearing; new life plans
should be strengthened
− Consolidation of interinstitutional
coordination and community
organization
− Discussion of experiences and lessons
learned
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There are three basic messages:

1. We should not think only in terms of psychopathology, but also in broad terms
about collective problems.
2. The area of expertise of mental health professionals needs to be expanded.
3. The majority of psychosocial problems can and should be addressed by
nonspecialized personnel.

Psychological and Social Care

At first, crisis intervention techniques will need to be used for people who are not
sick but are experiencing major psychological reactions. The health and humanitarian
assistance workers should be trained in basic emotional first aid techniques. It is
especially important to have mental health services with crisis intervention capabilities in
the main health centers where the sick are being cared for, creating an entity to provide
care for family members and companions.

The following are recommendations for survivors and people who have suffered
major losses.
• Treat them as active survivors and not as passive victims;
• Do not medicalize care or necessarily treat people as psychiatric patients;
• Assist them and show concern for their physical safety and health;
• Ensure that basic needs are met;
• Provide emotional support and a sense of connection to other people;
• Ensure privacy and confidentiality in communication;
• Help them vent about or tell their stories and express their feelings;
• Develop a responsible, careful, and patient way of listening among those offering
psychological assistance; response team members should explore their own ideas
and concerns about death and should not impose them on those they are helping;
• Rather than giving advice, allow survivors to reflect on what has happened and how
to face the future; the advice given should, then, refer to practical matters and the
available channels of assistance;
• Provide as much information as possible and listen to problems to help solve them;
• Encourage a return to daily life, as soon a circumstances permit
• Avoid the intrusiveness of the press or other groups; and
• Know that spiritual or religious support is usually a valuable way to calm family
members.

The criteria for referral to a specialist (psychologist or medical psychiatrist) are

limited and specific:
• Persistent and/or exacerbated symptoms not alleviated through initial measures;
• Marked difficulties in family, work, or social life;
• Risk of complications, especially suicide;
• Coexisting problems, such as alcoholism or other addictions;
• Major depression, psychosis, and post-traumatic stress disorder are severe
psychiatric conditions requiring specialized care.
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Drugs should be used only when absolutely necessary and only when prescribed
by a physician. Indiscriminate and prolonged use of psychoactive drugs is not
recommended. Certain drugs, such as tranquilizers, have major side effects and can
lead to addiction.

The vast majority of cases can and should be treated on an outpatient basis
within the family and community context. Hospitalization is usually not necessary. Daily
life is where psychosocial recovery begins for people after major traumatic events.
The following is recommended for child survivors:
• A flexible and nonspecialized psychosocial care strategy;
• Viewing the school, community, and family as basic therapeutic forums;
• Having teachers, community workers, women’s group’s, and young people’s groups
become agents that work with children;
• Strengthening the training, care, and motivation of the personnel who work with
children;
• Group techniques that include games and recreational activities as essential
instruments for the psychosocial recovery of children;
• Encouraging a return, as soon as possible, to normal life, including a return to
school;
• Taking advantage of widely accepted traditions concerning the care and treatment of
affected children.

Basic Principles of a National Mental Health Plan in an Epidemic or Pandemic Situation

• The Plan should NOT be centered only on the traumatic impact (the epidemic
disease), but should be broad and encompass the individual and his or her
context, and should make use of positive coping strategies with an ideological,
cultural, and religious (for those holding such beliefs) dimension.
• Objectives should be realistic and objective. The main goal is prevention (to
reduce the likelihood of psychosocial damages).
• Short-, medium-, and long-term actions should be defined on the basis of the
objectives established. In carrying out each activity, the responsible party, the
implementers, and the dates of completion should be clear.
• Psychosocial intervention should be early, fast, and efficient.
• Work methodologies should be expeditious, simple, concrete, and adaptable to
ethnic and cultural characteristics.
• At the outset, a rapid evaluation should be made of the psychosocial needs and
of situations where vulnerability is higher; this serves as the basis for action
during the initial phase.
• Care should not be viewed only in terms of clinical psychiatric care.
• The plan should create safe environments, promote community life, and support
family regrouping.
• Active readjustment should be encouraged, represented by the community’s
resumption of daily activities like work and school in the case of children.
• Community forums should be created for mutual support, expression, sharing,
understanding, and listening where the impact is social, in order to reevaluate it
and mobilize resources.
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• Workers should listen to the demands of people in their own social or informal
settings and not expect them to come to the health services.
• Emotional support should be integrated into the daily activities of organized
community groups and be part of meeting the population’s basic needs.
• Emotional support should be provided for grieving people, emphasizing culturally
accepted funerals and rites.
• The gender approach should be incorporated.
• Partnerships should be forged, and various social actors should participate.
• At the operational level, priority should be given to the group and community
without prejudice to the family and individual.
• Flexibility is needed; the psychosocial dynamic in emergencies of this nature is
varies widely, which means that every plan should be very flexible.
• Actions should be sustainable in the medium and long term; the goal is
strengthen existing services and improve mental health care in the country.

Lines of Action
1. Rapid diagnosis of the psychological and social needs of the population;
2. Psychosocial care by nonspecialized personnel;
3. Direct specialized clinical care for people with more complex psychological disorders;
4. Priority care for groups at greater risk;
5. Training;
6. Health promotion and education;
7. Community organization, social participation, and self-reliance;
8. Mass communication; and
9. Intersectoral coordination.

Organization of Services

Services are organized according to the resources and needs of the country or
region in question.

Primary Level:
• PHC team with basic training in mental health, enabling them to deal with simple
psychosocial support processes (such as emotional first aid) and to identify
and/or refer cases that are more complex;
• Emotional support and counseling services; and
• Outpatient mental health teams (Community Mental Health Centers or others)
that offer PHC support, care for referrals, and are mobilized according to need
when these services are feasible.

Secondary Level:
• Crisis intervention units (specialized) in selected places, such as emergency
centers;
• Mental health units in general hospitals where large numbers of influenza
patients are hospitalized (liaison services that serve medical offices).
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V. MANAGEMENT OF DEAD BODIES

The presence of a large number of dead bodies following a pandemic generates

fear in the population because of inaccurate information about the danger they pose.
There is also stress and a widespread feeling of grief; the reigning chaos and emotional
climate can result in behaviors that are hard to control. This type of situation requires
appropriate psychosocial interventions for the individual and community on the part of
leaders.

There is an entrenched myth that corpses are dangerous and should be quickly
burned or buried. Accurate information needs to be disseminated about the risks that the
bodies (deceased as a result of the epidemic) pose to the health of survivors.

Regardless of the responsible authorities’ power to manage the emergency and

of the epidemiological reasons that could hurry disposal of the mortal remains, measures
should be adopted that respect and take into consideration the customs of the
population, avoiding the use of mass graves and cremation, which are generally
forbidden by law and violate basic human rights.

The management and disposal of corpses is a problem with serious

psychological implications for the family and the survivors, and also entails other
political, sociocultural, and health considerations.

Notification of Death and Identification of Bodies

Notification of death can take place in the home, health center, hospital, morgue,
or another setting. It is a critical moment and is difficult to handle because it can produce
strong reactions. The following are some recommendations for providing notification:
• Prior to notification, compile as much information as possible about the deceased
and the event (progression of the disease, complications, etc.);
• Obtain information about the people to notify;
• Make sure that the most appropriate adult family member is the first to receive the
news;
• Make notification in a direct and personal manner;
• Have two people make the notification, if possible;
• Observe common rules of courtesy and respect;
• Do not take personal effects of the deceased to the interview;
• Invite family members to be seated. The people making the notification should do the
same;
• Observe the surroundings carefully in order to prevent any risks, and be prepared to
attend to children or others;
• The message should be direct and simple. Most people will realize from the setting
that something terrible has happened, and their agony or anxiety should not be
prolonged;
• Be prepared to answer questions;
• Help the family members to notify others, if the family requests it; and
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• Listen and tend to the immediate needs of the family, as well as reminding them of
their rights.

Notification of death should always be done individually (case by case). Giving

information of this nature to a group should be avoided. Where necessary, several
teams or pairs should divide up the work.

People (sometimes adolescents) faced with the difficult task of notification and
identifying the bodies of family members or friends are exposed to a very traumatic
situation. Those going to identify or receive the bodies of loved ones can manifest this
trauma through expressions of despair, frustration, and occasionally protest or
disagreement with the procedures being used, etc.

Medical and mental health services should be as close as possible to the place
where identification of the body takes place to provide physical and emotional support to
family members.

Family members usually ask to see the body as soon as possible. The following
is recommended:
• The mourners should decide among themselves who will view the remains;
• Do not allow family members to enter the viewing area unaccompanied; it is
preferable for skilled personnel to provide them some form of emotional support;
• Offer privacy and respect, so that the family can say good-bye, even allowing them
to touch the body;
• Respect any type of reaction that the family members might have at that moment;
• It is almost always necessary to transport family members to the location of the body
and ensure their return;
• Provide comfortable conditions and guarantee compassionate treatment at the site
where the bodies are viewed.

An important element of dealing with grief is the speedy handling of the funeral,
which should be free or accessible to low-income people. Delay in handing over the
body and uncertainty over how to pay for the funeral can cause even greater anguish
and suffering.

Very often, the authorities do not place a great deal of importance on the problem
of funeral services, particularly in the chaos created by an epidemic. However, it is very
important for family members, and failure to do so can lead to protests and social unrest.

VI. PSYCHOSOCIAL CARE FOR RESPONSE TEAMS WORKING TO PROVIDE

CARE DURING THE EPIDEMIC

An especially vulnerable group includes members of the response teams working

during the epidemic and the people in charge of handling dead bodies. Also vulnerable
are the people responsible for conducting autopsies; they feel overwhelmed and over-
extended with the work load when mass fatality situations occur.
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Not all workers and volunteers are suited to these tasks; their suitability depends
on a variety of factors related to vulnerability and circumstances, such as age,
personality, previous experiences, beliefs about death, etc. They should be well-
informed about the nature of the tasks they will perform, and people under 21 should not
take part in or carry out work with a deep human impact.

There are certain risk factors that increase the likelihood of psychological disorders:
• Prolonged exposure to very traumatic experiences;
• Ethical conflicts;
• Simultaneous exposure to other traumas or recent stressful situations;
• A history of physical or psychological disorders;
• Unfavorable living conditions;
• A lax selection process for professional staff.

It is likely that the members of the response team will experience some
difficulties in returning to their daily lives. These problems should not necessarily be
regarded as symptomatic of illness and require, above all, family and social support.

There is no type of training or prior preparation for a person working with

seriously injured and dead victims that can completely eliminate the possibility that he or
she will suffer from post-traumatic stress or other psychological disorders. If major
symptoms of psychopathology do appear, the cases should be referred for specialized
treatment.

The following are some recommendations for the care of members of response
teams:
• Consider the characteristics and the specific behavior patterns of the team. Team
members generally feel satisfied about what they have accomplished and develop a
spirit of altruism;
• Keeping the team active is a positive thing; it relieves stress and strengthens
self-esteem;
• Promote work rotation and fixed working hours; for example, team members who
handle dead bodies for a certain period of time should be reassigned to other, less
difficult tasks;
• Encourage team members to take care of themselves physically and to rest
periodically;
• Those offering emotional support should listen conscientiously and guarantee
confidentiality and the ethical handling of personal and work situations;
• Redefine the crises as a potential for growth;
• Include the family in assistance and sensitization processes;
• Reduce stressors and assess underlying emotional states before and during the
emergency;
• Create opportunities for reflection, catharsis, and integration of the experience.
Recognize that someone’s anger is not personal, but an expression of frustration,
guilt, or worry;
• Whenever possible, the team involved in the emergency should attend group
counseling sessions.
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Recommendations for emergency personnel after resuming daily life:

• Return to your routine as soon as possible;
• Do physical and relaxation exercises;
• Seek contact with nature;
• Get enough rest and sleep;
• Eat regular balanced meals;
• Do not try to lessen suffering by using drugs and alcohol;
• Seek company and speak with other people;
• Participate in family and social activities.
• Observe and analyze your own feelings and thoughts; reflect on what you have
experienced and its meaning in life.

VII. MASS COMMUNICATION STRATEGIES: THE IMPORTANCE OF TRUTHFUL,

APPROPRIATE, AND TIMELY INFORMATION.

The availability of information that is truthful, transparent, appropriate, and timely

is vial for the emotional restraint of family members and the general population. This
should be provided at various levels:
• Directly to the individual;
• Directly to a group or community;
• Via the media.

The authorities and community leaders should be prepared to provide

information directly either to individuals or groups, as well as to respond to questions
and be ready to find answers to these questions.

The media have a dual nature: on the one hand they are profit-driven
enterprises, and on the other they have an enormous social responsibility for the public
service they provide. Information on disasters, like pandemics, can be can be used to
spark and manipulate the public’s morbid interest. However, ethical and sensitive
reporting about these events should be insisted on; the media should make a
responsible contribution to citizens’ peace of mind by providing truthful, balanced
information.

A common problem is the number of people who go to hospitals, health centers,

morgues, and other places in search of family or friends (sick or dead). This creates
problems of congestion and disorganization. Solutions to this kind of situation should be
found that are adequate, humane, and respectful to these people.

The health sector should coordinate with law enforcement and humanitarian
assistance organizations to contain, care for, and control crowds. In most cases, the
crowds are not aggressive, but they need to be organized so that they can be given
appropriate information. Entry to health facilities also needs to be limited to individuals or
small groups.
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Protecting Mental Health During Epidemics Page 17

For these communication tasks, it is important to seek the timely support from
neighbors and community organizations that, in addition to human talent, have extensive
knowledge about the population and its customs.

It is advisable for authorities and public institutions to have spokespersons who

are specifically responsible for managing information and who can call on the population
for emotional restraint. It is advisable to have regularly scheduled briefings and to make
use of official bulletins, avoiding any ambiguity.

Preparations Should Include Psychosocial Aspects

The Director of the Pan American Health Organization (PAHO), Mirta Roses,
recently stated in Valencia that that we should not be alarmed by avian influenza, but
we should be alert to it because all indications are that we are very close to a pandemic
of major dimensions and serious impact. She felt that the responsible attitude of society
and the authorities is to be ready to mitigate any impact that may occur and not to wait
for it to happen to regret the results. She also pointed out that this is not the time for
panic, but for activity, which is what she believes the world is doing.

Mirta Roses indicated that she would like to see the virus contained, but stressed
the importance of bearing in mind that anything that humanity has no memory of--that
is, what it has had no contact with, is potentially very serious, adding that humanity still
does not have a response ready for this virus.

The Director of PAHO felt that very concentrated efforts are being made by the
media, the authorities, and the public.

Informing the public about the possibility of a major pandemic is not an option but
a step that should be taken without question. The reasons are clear:
• People can be prepared and can help prepare those around them (family,
community, workplace, etc.).
• The community can collaborate with official efforts by the government and other
authorities.
• Once the epidemic is under way, informed people can act more appropriately
and better protect themselves and their families.

Communicating risk is essential, and the basic strategy is to create an

atmosphere of mutual trust among the population, the authorities, and
communicators.

The goal of communication before the epidemic breaks out is to reach an

intermediate point where accurate information is given about the existing risks
and dangers, creating an appropriate level of fear through knowledge, while
offering help in addressing the problem and preparing the population. The goal is
to avoid extremes, i.e. tepid announcements that do not break through the
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Page 18 Protecting Mental Health During Epidemics

population’s apathy or, the opposite, alarmist reports that generate great fear and
could lead to panic.

Recommendations for communicating risk:3

1. Put yourself in the public’s shoes
2. Don’t be afraid to frighten people
3. Acknowledge uncertainty
4. Share dilemmas
5. Give people things to do
6. Be willing to speculate responsibly
7. Don’t get caught in the numbers game
8. Stress magnitude more than probability
9. Guide the adjustment reaction
10. Inform the public early and aim for total candor and transparency

Communicating risk is vital from a mental health standpoint. A good mass

communication strategy is critical to maintaining calm and an appropriate emotional
state; a well-informed population can act appropriately, protect itself better, and be less
vulnerable in terms of psychosocial aspects.

VIII. FINAL CONSIDERATIONS

Coping with an epidemic emergency that has produced a large number of sick
and dead is not only a problem for the health sector; other actors such as government
institutions, NGOs, local authorities, and the community itself are involved. The most
general immediate measures that help to create a climate of order and emotional calm
include the following:
ƒ Ensure a correct and orderly response on the part of authorities;
ƒ Provide truthful and timely information; a good mass communication strategy is
essential to maintaining calm and an appropriate emotional state during all
phases (before, during, and after);
ƒ Encourage interinstititional cooperation and community participation;
ƒ Guarantee basic health services, including the psychosocial component;
ƒ Prioritize mental health care for the most vulnerable groups, taking into account
gender and age differences;
ƒ Give emotional first aid to the sick and their families, largely through efficient
health care and humanitarian support;
ƒ Anticipate an increase in the number of people with symptoms of unresolved
grief or psychiatric disorders and facilitate adequate care for them;
ƒ Ensure the careful and ethical handling of bodies, establishing an orderly,
individualized system for the notification of deaths;

3
Sandman, P.M., Lanard, J. “Bird Flu: Communicating the Risk” Perspectives in Health Magazine. PAHO
Vol. 10, No. 2, 2005.
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Protecting Mental Health During Epidemics Page 19

ƒ Avoid cremation or burials in common graves. Support the speedy handing over
of remains to family members, so that the population’s desires and customs can
be respected.

Traumatic experiences as well as losses and grief necessarily take different

forms of expression according to the culture. The prevailing concepts of life and death
and funeral rites for loved ones are important for the acceptance and understanding of
what has occurred.

Mental health plans cannot be limited to improving specialized services and to

making them more accessible; rather, the area of expertise needs to be expanded to
address the range psychosocial problems and needs in the population.

Mental health services should be organized based on needs in an epidemic

situation. At the primary level, the PHC team should have basic training in mental health,
so that it can handle simple psychosocial support processes. The provision of emotional
support and counseling services also needs to be anticipated, as does outpatient mental
health teams that support PHC. At the secondary level, it is important to plan for crisis
intervention units in selected areas (such as emergency rooms and morgues) and for
mental health services in general hospitals where there are large numbers of influenza
patients.

Delayed effects (medium- and long-term) that arise in catastrophic situations

should be considered when designing appropriate intervention strategies for their
effective prevention and control. However, the most common institutional responses are
based on individual psychiatric care and reach only a very limited number of the people
affected.
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