The Kerala government’s robust health system took threads from the lessons it learned from the Nipah outbreak to manage the COVID-19 epidemic. It has garnered attention all around the world. Most of the reports have drawn focus on the physical health interventions taken up by the state. However, the mental health interventions are under-reported.
Studies on similar infectious disease outbreaks like SARS, equine influenza, H1N1 influenza pandemic, MERS and ebola highlighted that the outbreaks lead to the occurrence of many mental health concerns. Depression, anxiety, panic attacks, psychotic symptoms, delirium and suicidal tendencies were majorly reported. In Kerala, COVID-19 with similar characteristics predominantly led to the emergence of anxiety, stress, depression and stigma. Thus, it necessitates focus on the mental health interventions which are part of the highly lauded Kerala model.
Soon after the cases reported from Wuhan and the viral outbreak transformed to an epidemic, the state begun preparatory measures through its emergency response model. The state constituted a 24-member Rapid Response Team chaired by the health minister. The team receives on-ground information and updates from 18 state-level committees that coordinate various aspects in liaison with district-level committees. To deal with the aspect of mental health, a Psychological Support Team has been instituted. The team has devised many strategies to manage stress and other mental health concerns resulting from the outbreak.
Major categories of people in need of mental health care includes those in isolation or quarantine, families of affected people especially children, healthcare workers and the general public. Specific to Kerala, isolation wards are set up to house symptomatic suspected and confirmed COVID-19 persons. Others were referred to home quarantine.
A recent Lancet study urging timely mental health care for COVID-19 notes that the people in isolation are likely to experience fear about the consequences of the contagion, anxiety, insomnia and mental distress. While people in quarantine might experience boredom, loneliness, anger, anxiety and guilt about the effect of contagion and stigma on family and friends.
Another significant study on ‘The mental health of medical workers in Wuhan, China dealing with the 2019 novel coronavirus’ reported that the medical workers encountered high risk of infection, inadequate protection from contamination, overwork, frustration, discrimination, isolation, patients with negative emotions, a lack of contact with their families, and exhaustion. These resulted in stress, anxiety, depressive symptoms, insomnia, denial, anger and fear.
To address these issues, the government of Kerala adopted an inter and intra-departmental coordination approach, with a meticulous self-designed protocol. Various projects like District Mental Health Programme (DMHP), DISHA under Department of Health and Family welfare are brought together to strategise and implement mental health initiatives.
The multi-disciplinary team under DMHP provides counselling and psychosocial support for people in isolation and quarantine. This facilitates people to share their emotions, concerns, and clarify queries openly without fear of stigmatisation. The experts are trained to address these situations in a positive way with empathy, deep listening and confidentiality. DMHP coordinates with the local panchayat authorities for community level interventions, primarily with regard to stigma. Regular follow-up is also done.
Measures are taken to lessen the boredom and loneliness experienced in isolation wards. Wi-fi access is provided in some districts. A collaboration with DC books and The Hindu was initiated to give books and daily newspapers, respectively. The books were on the theme of mental wellness and motivation. Motivational messages and SMSs are sent to them. Providing nutritious meals with priority to the person’s choice helps in balancing their mood and enhancing mental health. The health minister’s visit to the isolation wards is also likely to reassure the affected.
There is growing public fear and panic regarding the outbreak. It primarily results in discrimination against families and acquaintances of quarantined and isolated people which would eventually risks everyone. To combat these, spreading awareness, fact-checking, making services transparent and people-friendly are essential. .
DISHA, a 24×7 tele-health helpline under Arogyakeralam, is used for this. DISHA played an active role in providing general physical and mental health support during severe crisis including floods and Nipah. This team of trained professional social workers and counsellors handle queries regarding appropriate precautions, home quarantine and travel among others. Meanwhile they often encounter confused, upset, frightened and in some cases annoyed people. Empathising with the predicament they address the concern and convey the need to be alert but not panic. For providing counselling services the calls are rerouted to the DMHP team. The timely guidance, support and sensitivity lessen fear, confusion, mental distress, social stigmatisation and discrimination.
Another initiative, the GoK Direct app, is a mobile application launched by the Kerala Start up Mission and Information and Public Relations Department. It can be recognised as people friendly for its capacity to send SMS alerts to basic phones. When people gets fearful, they seek information to minimise the uncertainty. Subscribing to news from reputable and trusted sources becomes all the more important. The Kerala Online Health Training YouTube portal is another digital platform which uploads educational videos related to COVID-19.
The Kerala health minister holds multiple press meets a day to communicate the seriousness of the issue and share crucial updates about the outbreak. This not only provides credible information but also exhibits transparency and boosts confidence among the public about the government’s activities.
The Government launched “Break the Chain”, a mass hand-washing campaign to initiate behaviour change. The campaign has been well received. Studies show that campaigns are efficient and effective means of communicating information to the general public. However, many a time awareness is not succeeded by action and the behaviour change initiated by it could be short-lived. Thus, prolongation of this campaign’s influence on hygiene practices needs to be analysed in the long run.
With these diverse interventions emanating from the self-designed protocol and other national and international guidelines, Kerala makes an effort to safeguard the mental health and well-being during the COVID-19 outbreak. Healthcare workers’ constant exposure to the outbreak and its possible impact on their mental health needs to be considered in Kerala’s future interventions.
Catherine Elisa John is currently pursuing MPhil in Social Work at Delhi School of Social Work. Her research interests include mental health, disability and homelessness.
Indhusmathi Gunasekaran is currently pursuing MPhil in Social Work at Delhi School of Social Work. Her research interests include disability, community development, political ecology.
Rincy Maria N. is currently pursuing PhD in Social Work at Delhi School of Social Work. Her research interests include mental health, caste, culture and livelihood.