The Next Surge: The Behavioral Health Crisis Following COVID-19

ROBERT JOHNSON:
This is Public Health Review. I'm Robert Johnson.

On this episode: depression, suicide, and substance misuse; getting ready for the pandemic's next attack, this time on Americans' mental health.

DR. ANNE ZINK:
I think we've known for years that the tie between physical health, mental health, and the economy are close, and I worry about what this looks like when more and more people don't have a health insurance and don't have a job.

DR. JOE PARKS:
If you think about it, there was a big surge of suicide and depression and addiction after 2008, after the recession. This is as big or bigger of a recession than 2008, and it would be foolish not to expect the same increased rate of addiction, depression, and suicide coming out over the coming months.

DR. SAUL LEVIN:
So, what we've got to do is our leaders need to think not just what they can do now to help acutely, but also the long term. Let's really put away the old ideas and start thinking of what's a healthcare system that really works for us.

JOHNSON:
Welcome to Public Health Review, a podcast brought to you by the Association of State and Territorial Health Officials. With each episode, we explore what health departments are doing to tackle the most pressing public health issues facing our states and territories.

Today, new worries about the impact of the COVID-19 virus on public health, raising the possibility of more cases of depression, suicide, and substance misuse.

As public health agencies and professionals continue to battle the infection, Americans sit at home out of work, isolated from friends and family, worried about loved ones, stressed about paying bills, perhaps unable to see the counselors, or receive drug and alcohol treatments.

We are examining the effects of the COVID-19 virus on our mental health, the networks that serve patients, and possible solutions to the challenges ahead. Our guests draw from a variety of experiences.

Dr. Anne Zink is chief medical officer for the Alaska Department of Health and Social Services. She talks about leading a response that's hampered by geography and haunted by memories of the last pandemic.

Also, Dr. Saul Levin, CEO and medical director of the American Psychiatric Association, joins us with a reminder that we've been here before.

But first, we visit with Dr. Joe Parks, medical director and vice president of Practice improvement for the National Council for Behavioral Health. He's thinking about the problems that lie ahead.

PARKS:
The people that are more at risk are people that are newly isolated that are not used to being isolated. Now, not everybody lives the real connected life with a lot of people around them. And for them, this isn't that different than how they've been living. They're happy that way, they're okay that way, or at least they're adapted to it.

I think some of the people that it's the most difficult for our people that are newly isolated. And I think that the other people where it's the most difficult is where there's higher concentration of COVID deaths and cases where everybody knows someone that's gotten sick and most people know somebody that's died. And especially health care workers who have been working there on the COVID wards in cities like New York City, doing 12 to 14 hour shifts—that it is a heavy burden to bear.

JOHNSON:
And you're talking about people who probably didn't have a behavioral or mental health concern before the pandemic. Talk about those who were already struggling with an issue. Now, this is on top of that, something they have to worry about or deal with.

PARKS:
Well, many of the people in this 20%—there's about 20% of people at any given time that have some kind of a problem with substance use disorder or with mental illness, and about 50% at sometime during their lifetime—so it's pretty common if you're in this that you know someone or you yourself may have had problems with depression, anxiety, drug, or alcohol use. So I wouldn't assume that this is a new stress for everybody.

However, I think the other group is there's a lot of people that have been traumatized out there. There are a lot of people who have been treated poorly as a child or in a relationship or in military service, that have been in traumatic situations where they had to just bear up with being in danger over time. And, you know, this is kind of like that. We're in danger over time and we don't feel like there's enough for us to do to protect ourselves.

JOHNSON:
For some people, would the pandemic qualify as the straw that breaks the camel's back?

PARKS:
Absolutely. And again, the multiple factors: maybe it's getting sick themselves; maybe it's the fear of getting sick; and maybe it's losing their job, not having the income; or maybe it's just not having the social interaction that they're used to—four major ways that this could be in additional stress that could lead you to have distress impairment and not be able to take care of yourself and your family.

JOHNSON:
What are the case loads increasing in this area?

PARKS:
You know, the case loads of COVID infection are clearly increasing. The general medical utilization is down in other areas because people are avoiding elective care. You know, they're only getting care that is absolutely necessary. They are putting off routine checkups, and there will be a cost to that down the road.

On the mental health side, you know, people are getting their therapy on the internet, they're not going into the office. That's usually pretty adequate, is the good news. It's been kind of impressive in behavioral health, the marked expansion of service by video and, even more, new services by telephone.

And if you think about it, Robert, there's a lot of people in this country that don't have a good wifi hookup like you and I do, people that are out in rural areas or can't afford the fees to get good bandwidth. And for them, they would have to take hours to go in and see somebody for either a general medical or behavioral health care. And if they can get it by phone now, in some ways they're in a better situation than they were before.

JOHNSON:
Have you seen those numbers drop because of the isolation and the difficulties of getting access to care, or is the technology holding its own? Are we still are able to treat people with mental and behavioral health challenges throughout this pandemic?

PARKS:
We saw a drop in March while all the providers were pivoting to figure out how to use technology. And much of it, especially on the outside on the outpatient part, has caught up.

Inpatient is a little different. You know, we are still minimizing services where people have to be in close quarters, like residential treatment or inpatient programs. We want only one person in a room, we want the social distancing, even if it is a healthcare setting.

So, those volumes remain lower, but the outpatient volumes have picked up pretty good. Now, that's where we are right now.

The other danger here is economic. Behavioral health providers tend to have low rates and run on thin margins. Many of them only have 30 to 60 days have cash on hand.

We recently did a survey of our members of the National Council, and half of them had already initiated furloughs and layoffs. And, of the rest, another 70% thought they would have to in the next 30–60 days. So, unless there's some substantial financial relief to behavioral health providers, I think we're going to see the volumes drop through the floor.

JOHNSON:
All of that while cases go up?

PARKS:
Yup. Well, just because your therapist or your doctor's out of business, can't cover the salary, can't pay the rent, that probably doesn't make you feel any different about being depressed or anxious or traumatized due to the death of a family member.

JOHNSON:
Are you expecting more cases to hit the system sometime in the second half of this year?

PARKS:
You know, we are. If you think about it, there was a big surge of suicide and depression and addiction after 2008, after the recession.

This is as big or bigger of a recession than 2008, and it would be foolish not to expect the same increased rate of addiction, depression, and suicide coming out over the coming months. And, frankly, we need to get ready for it, both as healthcare providers and as public health agencies. It's going to be coming.

JOHNSON:
Well, that was my next question. How would you advise the people listening to this show who are public health leaders, officials, team members—what should they be thinking about now if they wanna try to address this issue in their state or territory?

PARKS:
Well, the first thing they should do is engage their local association of providers, have a discussion like you and I are having a discussion. These are groups that are not always talking on a regular basis and don't understand each other's situations and constraints and pressures, and you can't partner with somebody until you understand their situation. So, that would be the first major step.

The other thing is I would be strategizing with them about what can be measured so you can do some hot spotting, so you can see what towns, what communities, what counties are having some upticks and problems. It might be increasing alcohol sales. It might be increasing prescriptions of opiate medications or benzodiazepines, drugs for treatment of anxiety, increasing prescriptions for anti-depressants.

JOHNSON:
And you talked about telehealth, telemedicine, delivering counseling services over the telephone. You have also talked about the ability to write prescriptions without a face-to-face meeting.

PARKS:
You know, that has been another huge sea change that I think is a great service to the patients and actually allows psychiatrists, providers, clinicians like myself to see more patients because I don't have to travel around to get that piece of work done.

It also is more accurate than writing a paper prescription because it's done on an electronic platform. The software prevents errors of spelling or errors of dosage or transcriptions or a misunderstanding.

Most importantly, there has been a federal relaxation of some of the rules that were previously in place restricting treatment of opiate disorders. Use of buprenorphine, use of methadone, use of long-acting, injectable naltrexone—we can now do that more readily, which allows a significant expansion of service.

JOHNSON:
I assume this idea is one that you would only want to see in place while we are trying to get back to normal, that you like the safeguards that come from the face-to-face interaction when you're normally writing a prescription if you can have that meeting?

PARKS:
I think it is going to be a policy by policy discussion. There are trade-offs. For more safety, you get less access, and you have less safety if you never get in to see somebody at all because you didn't have a car, you didn't have the money to do the transport. So, I would, of course, prefer to see my patients directly, but I can do almost as good on the telephone.

And a lot of them don't have enough gas money, they don't have access to a car, their car isn't in good shape, they have kids have to take care of, elderly parents to take care of—and I end up seeing them every three months just 'cause they can't get in. I'd much rather see them once a month, and this allows for that.

JOHNSON:
In the end, you're trying to just keep them healthy and on track so that this additional challenge doesn't push them over to the edge.

PARKS:
And I'm trying to meet them where their life situation and need is. It's different to take care of somebody that lives in town in a nice neighborhood with resources than it is to take care of a person without resources or someone that's an hour and a half away from my clinic. I can't just let that be their problem. I guess I could, but I shouldn't, it wouldn't feel right.

JOHNSON:
How much time do we have as a public health community to get prepared for this swell of cases that we think might be coming down the line?

PARKS:
You know, there's no time to start like the present. I would hate to try and predict. The uptick in addiction and suicide started about three to four months into the great recession and really took off six to nine months.

But, of course, even now we're seeing increases in anxiety and worry related to the trauma of getting worried you'll get infected and, for healthcare workers, that trauma of taking care of large groups of people that are desperately ill, where you don't have the equipment you think you ought to have, and you don't have the treatments that you would hope to have.

JOHNSON:
So, using that 2008 experience as a guide, we really don't have much time at all. We hope we do, but it doesn't look like that we will.

PARKS:
No, and these programs and structures take time to put in place. If we want them out there and running in 90 days, we better start working on it now.

JOHNSON:
For a time, Dr. Saul Levin led the District of Columbia's Department of Health, leaving him familiar with the challenges facing public health leaders today. He says every disaster brings mental health concerns.

Levin:
I think it's always been in any disaster—be it a hurricane, you know, a man-made disaster—that mental health gets forgotten in the beginning, but it very quickly becomes overt to everyone that there is a mental health component to it.

I always make the comment that the two teams that went up at 9/11, off to the plane, went into the Pentagon, the first one was essentially the triage primary care tent, you know, for those, but there was a second tent right next to it, which was the mental health tent for both the responders and also people who were injured but could still walk. But sometimes people forget that those two are always together as a hand holding another hand.

JOHNSON:
Are your members getting busier? Are they seeing more people?

LEVIN:
So, as you know, telehealth, or telepsychiatry, was not very well done in this country, you know, the providers didn't pay for it.

Clearly, you've got to give congratulations to CMS. They immediately, followed by the insurance companies, immediately said, "We're doing away with all the rules and regs of telehealth and telepsychiatry." So, a lot of the psychiatrists, who now have to be just at home, were now able to contact their patients. So there has been a huge increase.

We recently did the study—well, we're actually in the middle of it but we are beginning to get earlier results—that show that it's gone from, if I remember correctly, something around 20–25% telepsychiatry up to 75% of those that aren't on the front lines in the hospitals, that clearly the psychiatrists have adapted very quickly to telepsychiatry.

And the patients are turning up for it. There's less no shows. Often in a clinic, a patient doesn't feel well or say, "I'm not going," or just don't show up. In telepsychiatry, they are showing up more, and statistically more, than when you are in a clinic. So the psychiatrists have really adapted to it. And it has been a real change for them, because psychiatrists like to sit with their patients. They like to look at them in the eye, they like to see what their body is doing. Where's the anxiety—sometimes it can be shown in the face, but sometimes it's in the tapping of a foot.

And all of a sudden, telepsychiatry, you don't do that, which has been the resistance. But I would say the overwhelming response from the psychiatrists is this has been very successful in keeping the continuity, you know, with their patients.

JOHNSON:
Have cases gone up or is that yet to come?

LEVIN:
So, I think cases have begun to come up because, in some ways, this whole situation that has helped a little in the parity and people's minds of, "I need to get help."

But the real problem is all the people that are sitting locked up in their homes, and that's how they feel about it. They may be able to go out to a store or go out for a walk, but the bottom of the line is they're sitting there day in, day out. And if they've lost their jobs, it makes it even worse.

And the issue there is how do they get that access? And there's always been, you know, a workforce burden in that we don't have enough psychiatrists in this country. There's a cap on how many psychiatrists can be trained each year, as well as with other professionals.

So, what's happened is the professionals who are now seeing patients are pretty full. So how do they then begin to then take care of this increase? And as we look at the legislation that's hopefully going to be done, you know, in the next stimulus package, to really begin to put money towards the mental health and substance use disorder care, for patients to be able to have more people come into the system.

And, if you remember, the bulk of medications are prescribed by primary care folk, the primary care docs. Now they're busy already. If they're not, they're also turning to telehealth. They can truly pick it up, and they do have, obviously being physicians, the knowledge of psychiatry and the medications to a point.

So, we do hope that we'll begin to see more and more people calling their primary care doc to say, "Doc, I'm just not feeling good, I'm depressed," or whatever. And if it is a more serious case, they invariably have connections to the psychiatrists who then they can call to say, "Can you help me out on this case?"

I think the system for now is coping, but it's about to become overstressed. As soon as we begin to open up the doors and say, "You can go out," and COVID then maybe begins to come back again, you're gonna begin to see really the sequelae of the depression, the anxiety, the PTSD coming off of that.

JOHNSON:
Our audience is made up of public health professionals, leaders, practitioners, teams at all levels of government. What's your advice to them? What can they do to help? How could you direct them in those efforts?

LEVIN:
So, I would say to them, having been being a SHO before, the best thing is to say, "What rules and regs do you need released immediately to open up those doors?" In some ways as the federal government did do it or CMS did do it with telepsychiatry and telehealth, I mean, they really just jumped on board on it. I'm hoping that, at the end of this pandemic, they'll keep it. It's clearly shown it saves people hours of not having to travel to the doctor, see the doc, wait there, see the doctor, and then go back. So there's real benefits for it. So, I think that's the first thing.

And then the other thing is, just like we were having to do with the stimulus money, if you're seeing more and more patients, the money, you know, eventually Medicaid, Medicare, and the insurance companies who have all these rules and regs as to who you can see, what you can prescribe, prior authorizations, becomes then just another aggravating force for both the patient and the doctor.

So, it's those sorts of things that this is where the country could truly, as we come out of the pandemic and we begin to look at re-inventing our system and our healthcare system, because we clearly see it was broken. And now, it wasn't just broken, now it is truly becoming severely broken, particularly in the mental health world, the substance abuse world. And I think same for the primary care.

So, what we've got to do is our leaders need to think not just what they can do now to help acutely, but also the long term. Let's really put away the old ideas and start thinking of what's a healthcare system that really works for us.

JOHNSON:
This may be the only time to get these changes made.

LEVIN:
Correct. I mean, as you look at all these stimulus packets as they're given—I mean, we were in the trillions now, you know—you're not fixing one of the biggest problems that is occurring in this pandemic and this is the time to do it. This is the time to really look at rules and regulations and not maybe go back on some of them that you know really worked. And that's the important thing.

I think we've got to really, SHOs really persuade our legislators to say this is the time. The public is ready for it. I think everyone will eventually have touched at least one person, hopefully not in their families, but maybe in their families or work colleagues or friends.

I just attended a memorial service for a very close colleague of mine in South Africa that was done virtually. And it's sad. He was an amazing younger man and clearly succumbed to the illness.

So, we're going to come out of this with a lot of PTSD of remembering those who were lost in this country. And when you're talking about figures going into 90,000, a hundred thousand, these are not small numbers. These are all the leftovers of someone who dies unexpectedly or because of an illness like that, the families and the kids who are going to have a long suffering, you know, for many years to come and we need a system to take care it.

JOHNSON:
Dr. Anne Zink became Alaska's chief medical officer last summer. Now she's commanding her state's way through a pandemic and a response that's as novel as the coronavirus itself.

ZINK:
I think of it in two different ways. I think about how does it relate to the individual patient and how does it relate in terms of the system. And so, for the system wide aspect, there have been some significant challenges. So again, we've got distance.

And so, for example, one thing we have required in the past that induction with buprenorphine be done in person. Well, that's really challenging if you can't fly. Our major airline in the state that did most of our both medical and nonmedical non-emergent transports went bankrupt within a week of the pandemic.

And so suddenly, we have, like, no transport within the rest of our state. And so that made a lot of other healthcare challenges really, really challenging. So we went through a process and basically waived the in-person induction of buprenorphine as a way to get things started.

We have an opioid section within our division that's really designed around in substance misuse and abuse, and they have been very proactive during this time. So, they have started at home delivery of naloxone, and so going around to communities. Instead of having people come in and get naloxone or having, you know, gatherings for needle syringes, they've been trying to be proactive and go out to people so that they're able to kind of provide those additional resources.

Been trying to do a lot around people's grants and funding to make it more flexible for a delivery of support services for people who are struggling with opioids in general, so that they've got additional support that can be moved or changed in other directions. They've also been moving to Zoom and telehealth and the rest of it. And so support groups have been moving that direction, what ways you can support each other.

I'm hopeful that we can utilize this opportunity to make our delivery of opioid, addiction, and substance misuse better than it was before. So, instead of just a meeting with your addiction specialists, you can now have a meeting with your addiction specialist and your primary care doctor and your support person all at the same time, and be having that same conversation.

Mental health is also a huge challenge in the ways that those interface and then don't interface. Some of our communities did a great job of having no telehealth prior to COVID and switch to 100% telehealth post-COVID and really saw no decrease in their behavioral health support the whole time. They were able to kind of maintain their support.

Some of our communities are finding that they're having an uptake in people wanting to do behavioral health and mental health because they feel more secure being able to do it from the comfort of their home and not having to come in, it helps to minimize the stigma. So, I'm hoping that some of that will continue.

There's definitely some people who the in-person, either group meetings and/or individual, counseling and therapy can make a difference. And so, really at the beginning of May, we started to open up a lot of our kind of elective and trying to open up other procedures.

Fortunately for Alaska, it's summer right now. I've been eternally grateful that this has not been happening in October because it would be getting really dark and hard to do a lot up here. And so, people have been having outdoor group sessions and what ways they can use outdoor space.

Even I think of mental health in our long-term care facilities, that those as being really kind of locked down and what that means for mental health for the elderly. And so, some communities have done a great job.

I was just visiting one. They, you know, created a bus transport system. So they take everyone from their long-term care facility who wants to visit their family and they keep them in the bus, and they go around. They visited the grocery store and they visit the dock and the harbor and they drive past all the family, loved ones, and everyone waves and they share it.

So they're not just stuck in the long-term care facility, but they had a little bubble of the van that is driven from long-term care facility employers to be able to kind of keep them safe.

JOHNSON:
Are you expecting more cases on the mental health and substance misuse side of the ledger?

ZINK:
I think the data is mixed on that one. Our suicide rate is about the same as it was the last couple of years. The people looking for inpatient treatment for psychiatric care is less than it was, but it's also, you know, nationally ER visits are down and people seeking care are down.

I think we've known for years that the tie between physical health, mental health, and the economy are close, and I worry about what this looks like when more and more people don't have health insurance and don't have a job.

And a lot of our normal social connections, the very humanity of us, has been challenged by COVID. We're social beings, and we like to give hugs and be in a group setting, for the most part, and grieve together and celebrate together. And COVID has asked us to limit so many of those things. So I worry about the mental health of people long-term.

I really worry about the mental health this fall and winter. Again, we always see an uptake—it's dark up here in the winters. Alcohol is a real challenge for our community, and I'm worried that that's when the impacts of the economy and the lack of relief from other measures is really gonna start to hit.

A huge percentage—I don't know the exact numbers—of our state make a lot of their money in the summer. Just with tourism on the other is coming up and to have that just decimated—our economy's based on oil, which was in negative dollars for a while. So, we're not doing so well there.

Tourism, which has been decimated—half of our tourists come from cruise ships alone, and that is just gone. And then a lot of construction and other industry, which is pretty limited as well right now because of the travel aspect.

So we're going to be in a hard place financially for a long time, and I'm worried about the mental and health impacts on our state long-term from that aspect.

And I also just think that the divides that we're seeing between people. When people are able to come together around an earthquake or something finite, then that can be helpful. But I think that the political divides and the social divides and how different communities are being hit.

And then the last thing I would say about mental health, too, is that the 1918 pandemic decimated rural Alaska. And, in general, our native population has had somewhere between three to five times the mortality with every major flu and pandemic that comes through. And the history, the oral history of the 1918 pandemic, lives large, and the stories that have been told.

There are communities that stood at gunpoint and wouldn't let anyone into their community and they survived. And those are the communities that have language still. And those are the communities that have art and history still. And the communities that had people come in because of fishing or other things just got decimated.

And so there's a lot of reliving of that history right now. There's a lot of retelling of that history, a lot of grief and loss, that's being reprocessed as well as blame for letting people in and not wanting to repeat history.

And then, seeing the social inequities across the world, and how it's hitting different communities really hard, and how it's hitting the Navajo nation really hard, is like watching this big tidal wave come forward and the fear of repeating history.

And so, what ways can we learn from our past and not act out of a place of fear, but act out of a place of strength and try to write a different history. But it's challenging when essentially every flu and every pandemic has not written a different history. And so, seeing that coming forward is humbling and makes us very nervous.

JOHNSON:
And what can you do to help manage those fears and, ultimately, manage the number of cases? Is there anything from a public health perspective you can do between now and, say, the end of the year?

ZINK:
Yeah, no, I think it's a great question. I mean, I think there's both physical and mental things that we can do.

So for physical things, when the federal government was up here, I guess two weeks ago, we were looking at what ways to kind of help mitigate the risk of COVID. You know, we were looking at multiple communities that don't have access to water or sewer.

And so, what ways can we put time, effort, and money in this summer to help create some physical things? It's one thing to say, "Make sure you wash your hands." It's really different if you don't have the resources to wash your hands. So, we're looking at what ways we can provide physical structure for that to happen.

There's different ways in that we can allocate resources, pre-positioning resources, getting additional resources. I keep reminding our team, and we keep discussing the fact, that our mission is the health and well-being of all Alaskans. But sometimes that means distributing resources in an inequitable way because different communities take different resources to be able to stay safe. And we know that, and we do that in all sorts of things.

So for long-term care facilities, we don't question screening prior to coming in and having increased PPE, compared to a childcare center. And I think we need to think about that in terms of our rural communities.

So, we're looking at many of our rural communities almost as long-term care facilities—they have multi-generational homes without running water or sewer and live in close quarters with significant underlying medical components.

And so, what ways can we help support them to minimizing people in and out, to screening prior to coming in, to testing prior to coming in, to regular surveillance? What ways can we use the tools that we've learned from COVID to protect other high-risk individuals? And that does require more resources and more time than uniformly across the board.

I also think that communication is huge. And so, we are doing in these communication mitigation conversations with city councils, with tribes. The fishing industry has been a huge part of that recently, and you can never do enough communication. So, we're working on that.

We've set up mental health lines for both healthcare providers as well as individual Alaskans to try to provide culturally relevant support.

And then, a couple of our communities that were hit the hardest by the 1918 pandemic and have a lot of fishing and I think are really some of the most challenging communities right now, that are the most stressed—not only did they have mental health clinicians there, but there's a mental health, almost strike team that is going out there and working with them as well, both to kind of process everything that's happened from 1918 and be able to move forward.

Because I think that the fear of the past in some communities has made it so it's been hard to be able to see clearly the steps that need to be done in the present to keep themselves safe and to mitigate the risk of the COVID. And again, the goal is the health and well-being.

And so, to be able to move forward, I think some of our communities, we really have to look back and process that grief and that loss and that trauma as a way to be able to move forward together. And we have to do both in parallel. If we ignore that past or say that past isn't relevant, we only create division and we don't get to a place of working together and of better health and wellbeing. So, different communities for sure have different levels of that need.

JOHNSON:
That is such an unusual and interesting circumstance to have to deal with the last 100 years of history, a time that none of us were around for but still lives very large in the memories of people who are close knit and focused on generations of their families.

ZINK:
It's fascinating. I mean, so one of our major critical care hospitals is built in the orphanage that was created during the 1918 pandemic. You know, so it just, it lives right there.

Or, I was at this other tribal meeting and one of the tribal leaders showed me this of his grandmother on the wall, and he said, "That woman was scared of the 1918 pandemic and took my family out for a year and lived off the land for a year.

"And when she came back, her entire village had died, except for some kids and some dogs who were running around and my family lived because she took us out." And he's like, "I don't know if that's what I need to do for my community now."

It's incredibly tangible, and the history and the fears are so vivid. And, in so many ways, I'm very grateful because that history is important, and I think if we don't understand our history, we're doomed to repeat it. But what ways do we learn from that and be able to move forward. But, it's tangible, and everything from the buildings we're providing care in right now to the leaders of the community who were specifically protected because of it.

JOHNSON:
Ultimately, what do you think it will take to help people survive the mental stresses that are caused by this pandemic in your state?

ZINK:
I think what it will take is also different from what we can do. I think they're too far in that question. You know, I mean, I think what I would love to see is a communal understanding that this threat is real, but also a communal understanding that we together can be kind and can work through it together. And I think that that would be much easier for us to be able to move forward, both from a mental and physical aspect.

I feel like we were really trying to focus on the positive, on the good, on the patience, on the understanding. I love the idea of positive deviance. How do you highlight a community strength or what they have done well to inspire other communities to do it? Because I think if people can have inspiration and hope, they have a place to move forward.

I think, at the very beginning of this pandemic, I felt very challenged by this space between the realization and the understanding that I think all of us have, particularly as clinicians and as emergency medicine physicians, that life is 100% fatal and we're all gonna die. And that's just the truth. And then, there's this disease that's coming that's silent and hard to see and sneaky, and what ways do you balance those two truths?

And I have really personally come to the belief that the way that you balance those and mentally and physically move to a place of being productive is finding ways to be productive in that space. So what ways can we take the hurt of what makes life important to us and continue to celebrate that and continue to make that happen in a way that is less COVID-restricted.

I also think about some communities that, like the mayor of Cordova, all of these fishermen were wearing masks and everyone was like washing their hands and separated. And I was like, how did you do that? You have this rough and tumble, you know, industry.

And he was like, "Simple. I just go tell him, 'No shirt, no shoes, no mask, no service. Like you can go pants-less on your boat, but don't come in my town without a mask.'"

And he goes down and he has a beer with a lot of them every night. He just goes down with a six-pack and talks to another group of fishermen about what it means to be a community member and to take care of each other.

And as a result, people were happy and, you know, going out fishing yet minimizing the risk. And I think the more that we can build on that communal sense of that, "We are stronger together," the easier it's going to be able to be sustained both from a physical and mental standpoint.

JOHNSON:
You can find links to the resources mentioned in this episode in the show notes.

Thanks for listening to Public Health Review. If you like the show, please share it with your colleagues. And, if you have comments or questions, we'd like to hear from you. Email us pr@astho.org. That's PR at ASTHO dot org.

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For Public Health Review, I'm Robert Johnson. Be well.