COVID-19 Case Study: Trauma and Traumainformed Care
South Africa is a nation that has been and is Deeply traumatised. A large part of the population
lived through horrific civil conflict and oppression less than 30 years ago. The mental scars and
the vast inequality that was created from this county’s history, leave certain groups of people
more vulnerable to harm from the government’s response to the COVID-19 pandemic. The
Government proposed a stay at home order or lockdown, that acts as a primary preventative
health measure. Only 30 years post-apartheid, black south Africans disproportionately occupy
densely populated settlements that experience poor service delivery on the periphery of the city
(Socio-Economic Rights Institute of South Africa, 2018). This case study will explore the
psychological and physical effects of the lockdown on the people in these areas and how this can
be detrimental to the lockdown efforts. An opinion piece, titled South Africa's response to Covid19 and the ghosts of apartheid by Susan Levine and South Africans Protest Police Brutality
Against Poor, Black Communities Under Lockdown by Kim Harrisberg, will help to discuss the
potentially traumatic effects of the lockdown, especially in some of the most disadvantaged
areas. This discussion will guide the analysis of trauma informed care as a responsibility the
healthcare system is ignoring in the case of the lockdown.
The introduction of the novel corona virus to South Africa, was via generally wealthy
international travelers but, as is common in epidemic situations, the poorest in society ended up
being the most affected. The country took quick action and a State of disaster was declared.
Following the UNs guidelines, strict curfews and bans were implemented, and the government
made the decision to deploy military forces to help enforce the lockdown. A drastic response was
necessary, but the lockdown system seemed to have been designed for countries without high
levels of poverty and inequality; where most people can afford to buy large stocks of essentials
and live comfortably in a home with all the basic amenities. The reality for a large part of the
South African population, is nowhere near this ideal. At least 9.6% of the populations lives in
informal settlements while 40% lives in townships. People live in overcrowded dwellings
without basic amenities making compliance with lockdown regulations incredibly difficult. The
unemployed and those working for low wages, are left without a financial buffer to deal with a
sudden loss of income. Furthermore, Informal settlements have shown some of the highest rates
of HIV and TB infections as well as poor mental health. (Socio-Economic Rights Institute of
South Africa, 2018)
Given that these areas have such a high risk of rapid spread and complicated infections, health
measures must be focused on these areas. The lockdown conditions aim to prevent the spread of
infection which is a primordial preventative measure, an essential component of the health for all
vision promoted by the WHO (World Health Organisation, 2019). Viewing the lockdown as a
health measure; people must adhere to it, for it to remain effective as disease prevention. People
living under the conditions outlined, however, have very little reason to adhere and will view
infection control as less of a priority compared to making money or escaping an overfull
household without the amenities necessary to prevent the spread of disease.
Unfortunately, the proposed solution lay with the deployment of army forces who are trained for
war and apparently not peacekeeping. In the article for Global Citizen, Kim Harrisberg writes
about the death of Collins Khosa and at least 10 others at the hands of lockdown enforcers,
among other cases of abuse of power by the police or the Defence Force. The article also
highlights the fact that affluent areas were protected from the sort of brutality seen in townships
like Alexandria where Collins Khosa lived with his family, as forces were mostly deployed to
poor, high density, black areas. The article states that this sort of violence is not unique to the
lockdown, as there are prior reports on brutality in police and military custody, hinting at
ongoing trauma. Exposing more people to more law enforcement with a history of brutality is
volatile scenario.
Another important aspect of mental health, explored by Susan Levine, is how the lockdown
measures can be a powerful reminder of conditions experienced during apartheid for those who
lived through it. She talks of a town called Zwelethemba, a place that was hit very hard with
police brutality during apartheid when the government used violence to enforce curfews to quash
protests. Levine writes of the reflections of young men, who remember, vividly, electrocutions,
beatings and being held in detention centres as children. In the 80’s, police had become
militarized and were given unlimited permission to use force when policing black people and
many of the largest townships, like Alexandra, have a bloody history with the police (Scharf,
1989).
Trauma is defined as “an event, series of events, or set of circumstances that is experienced by an
individual as physically or emotionally harmful or life-threatening and that has lasting adverse
effects on the individual's functioning and mental, physical, social, emotional, or spiritual wellbeing.” Causes of trauma include; experiencing or observing abuse or community violence,
childhood neglect, having a family member with mental health or substance use disorders,
poverty or systemic discrimination. This sets up a grim picture for communities like
Zwelethemba, Alexandra or many of the other townships that experienced the full might of a
scared government. The treatment experienced, sets up a cycle of trauma. Not only are people
directly traumatised by community violence, but also by historically arranged poverty and
discrimination that is still obvious in these areas. Poverty is a hard cycle to break and the trauma
of the past manifests in mental health and substance abuse issues, that families and children must
witness, such that the trauma is inherited. Repetitive traumatic experiences in children, are
shown to increase their susceptibility to developing PTSD due to trauma in adulthood (Breslau,
et al., 2014). This is especially relevant for people such as those described by Levine, who had
experienced police brutality as children under the apartheid government and are now wary of
their communities once again being flooded with armed forces. These sorts of experiences in
childhood are termed ACES (Adverse Childhood experiences).
Research has shown that a poor mental state and trauma are linked to poor health outcomes.
Adverse childhood experiences are linked to increased risk-taking behaviors. Smoking, drug use,
overeating and promiscuity are the sorts of coping mechanisms that people who have faced
adverse childhood experiences- or even trauma as teenagers or adults, will use. These could be
manifestations of the large percentage of undiagnosed mental health issues seen in people living
in informal settlements and townships. These behaviors could lead to health issues like obesity
diabetes and a higher risk for HIV infections. Even without the risk-taking behaviors, the trauma
causes a toxic stress response which independently causes health problems like decreased
immunity, chronic inflammation and pain, primary pulmonary fibrosis or coronary artery
disease. In the pandemic, this leaves a population that is facing enhanced mental health issues as
well as an increased susceptibility to a complicated coronavirus infection (Felitti, 2009).
ACES and the far-reaching health effects of trauma show that for holistic healthcare, trauma
must be acknowledged. This is the basis of trauma informed care, an approach to health care that
is sensitive to past or current trauma and how that affects health. Trauma informed care(TIC)
follows a framework that relies on four assumptions. The system and practitioners must realise
that trauma has an effect at all levels, from individual to whole organisations. They must
recognise that this trauma manifests with treatable symptoms. This requires a trauma informed
response on all levels of healthcare from patient/caregiver relationships to leadership. The
resistance of re-traumatisation is vital throughout this process, as it includes the care of people
who have already been traumatised. For interventions to be trauma informed, a set of principles
have been formulated. Patients must be both Psychologically and physically safe, there should be
trust and transparency, peer support, collaboration and mutuality, Empowerment by encouraging
autonomy by giving patients a voice and choice, lastly, cultural, historical and gender issues
must be recognized to aid healing and reduce re-traumatisation. (Brown, et al., 2020)
Viewing the lockdown measures in terms of these principles, it is clear that as an intervention, it
is not trauma informed. TIC relies on action at all levels, which includes the lockdown,
especially since it is a healthcare intervention. The article by Kim Harrisberg about complaints of
police brutalization shows that physical safety is an issue, which also undermines trust. the
presence of troops in communities with such a turbulent history with law enforcement, shows a
disregard of this population’s psychological wellbeing, especially if, as required by the
principles, cultural historical and gender issues were recognized. Levine’s discussion on the
historical effects of over policing in black areas is an obvious example of re-traumatisation in the
context of abuse of power by a heavy police presence. Historically the, the same communities
are more likely to deal with poverty or poor service delivery and overcrowding, which makes the
lockdown much more difficult. Social distancing is almost impossible with multiple families
living in the same small house and when it is necessary to travel for basic needs. This is another
consideration that would have been necessary for TIC.
The health professionals who had a say in the response to the pandemic should have made
decisions that acknowledge the potential trauma associated with a lockdown and worked to
prevent re-traumatisation and the mental health fallout of that. Two key principles of TIC are the
reduction of re-traumatisation and a focus on autonomy and empowerment, which makes the
approach to a community like Alexandra ill-advised. If the law enforcement was deemed
unnecessary in affluent areas, other methods could have been employed in areas like Alexandra.
Education and an understanding of people’s reasons for ignoring lockdown restrictions (like the
need to get water or overcrowding) could have been made a priority. A focus on community
leaders to encourage precautions or providing protective equipment and sanitisers considering a
lack of access to water, would have been more empowering. Even if the presence of police and
the military were necessary, everyone involved in a healthcare intervention should be traumainformed, so training in handling peaceful civilian interaction, should have been thorough.
Given South Africa’s past, it is clear that a trauma-informed approach has been necessary since
long before the novel coronavirus appeared. The lockdown, however, not only ignores the effect
of inequalities and trauma, but it is also actively causing continued trauma. There is a predicted
rise in mental health issues like grief, stress disorders, burnout, depression and anxiety among
patients and healthcare workers during the COVID-19 pandemic, so a proactive response to this
must be implemented. Trauma informed care would have been a viable method of limiting this
response. (Brown, et al., 2020) In the context of our country, an approach that is sensitive the
patient’s experiences, is necessary for an effective primary prevention measure to be
implemented. This is not only good for people reliving previously similar situations, but it is
necessary for all patient interactions. In a country where violence is the norm rather than the
exception, health care should always aim to approach patients in a manner that acknowledges
trauma at all levels.
For caregivers working in the areas most prone to trauma, it is important to approach treatment
through the lens of trauma both during and after the pandemic. The predicted rise in mental
health related issues following the pandemic might manifest with physical symptoms, so
healthcare professionals will need to determine if trauma or mental health is the root cause.
Recognizing the pandemic and lockdown as traumatic is not only important for patients, but also
for caregivers to be able to look after themselves. Patients with COVID-19 will be isolated,
without peer support and very susceptible to distress. Making use of TIC principles, like
maintaining trust and patient autonomy while helping them maintain control with collaboration,
can help outcomes. Oftentimes wholistic treatment requires a multi professional team, which
isn’t always readily available especially in under-resourced areas. This is where the leadership
and organizational level of TIC is important. Advocating for TIC and the necessary people and
resources, is important to help with adjusting policies and protocols from leadership, down to
primary care. (Brown, et al., 2020)
The COVID-19 pandemic required South Africa’s leaders to step up to the plate and act to the
benefit of the entire country. While the ‘stay at home’ lockdown order was necessary to prevent
the spread of infection, the trauma of a large part of the country was ignored when lockdown
enforcement was deployed to population dense townships and informal settlements. Police and
army presence added to the trauma of an already-traumatised population, which could worsen the
predicted rise in poor mental health following the pandemic. This poor mental health and a cycle
of trauma has already left the population susceptible to complicated infection, due to the physical
health manifestations of toxic stress and health-harming coping mechanisms. A trauma-informed
approach would have been a more sensitive approach to enforcing preventative measures. This
would have worked to prevent an increased burden on the health care system in the future. All
levels of care should adopt a trauma-informed approach to health care. Hopefully large-scale
epidemic measures will not be necessary for a long time, but even if it is difficult to implement,
any health care intervention would benefit from Trauma Informed Care in the long term.
References
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