Bruno Lima Awardee Designs Public Health Approach to COVID-19

“I haven’t seen myself as a disaster psychiatrist, but we are all disaster psychiatrists now, reacting not just to COVID but also to broader social disruption and climate change,” said Giuseppe Raviola, M.D., M.P.H.

Raviola was one of six recipients of APA’s 2021 Bruno Lima Award for Disaster Psychiatry. He is an assistant professor of psychiatry and associate director of the Chester M. Pierce, M.D. Division of Global Psychiatry at Massachusetts General Hospital; an assistant professor of global health and social medicine at Harvard Medical School; and co-director of mental health of Partners in Health (PIH).

Raviola was recognized for his role in developing and implementing the mental health component of Massachusetts’ contact-tracing program in the early months of the COVID-19 pandemic. The mental health component was designed to complement a comprehensive approach to the disease that would—ideally—combine physical distancing, fast and accurate testing, isolation of active or suspected cases, and possible treatments.

“Among public health professionals, reaching out to the contacts of people who were infected or had screened positive was a standard best practice to contain an epidemic,” said Raviola.

However, it quickly became clear that contact tracing, while well-known in the public health community, would require some explaining to the general public.

Also, while contact tracers were informing the people they called about COVID-19 and asking about their recent contacts, they soon found themselves at the front lines of the mental health system.

For some of the people contacted in that early stage, the news of illness was a shock as well as a fact. Under Raviola’s direction, PIH trained 1,400 tracers in the basics of Psychological First Aid, listening to the person at the other end of the line, and, when needed, linking them to telephone helplines run by Massachusetts Behavioral Health Partnership and associated mobile crisis programs.

Then there were the tracers themselves. They were a diverse group, said Raviola. “Some were clinicians, some therapists, some nurses, some college undergrads. The key to training was to get them to be safe, empathetic, and compassionate in an evidence-based way.”

As time went on, they also had their own problems—such as worrying about positive test results, stress on the job, or their personal exposure to the virus. In May 2020, PIH developed a peer-support network of weekly online support groups of 30 to 70 contact tracers. The network was based on PIH’s experience overseas with community-based management of other infectious disease outbreaks, including Ebola in Sierra Leone and Liberia, multidrug-resistant tuberculosis in Peru and Haiti, and HIV in Lesotho, among others.

Joshua Morganstein, M.D., a captain in the U.S. Public Health Service, also a recipient of the Bruno Lima Award this year, said the mental health program was the local result of prior experience elsewhere. “We need to be aware of what we can learn from others that have the potential to help our society.”

He is an associate professor of psychiatry; assistant director of the Center for the Study of Traumatic Stress, and assistant chair of the Department of Psychiatry in the School of Medicine at the Uniformed Services University in Bethesda, Md.

Eventually, Massachusetts hired a full-time peer-support specialist to train volunteer peer-support leaders among the contact tracers.

“Peer support helps to sustain the well-being of the workforce, but it is underutilized,” said Morganstein. “We’ve learned in the military that people who won’t talk to health care workers or counselors will talk with their peers and then will reach out to other peers.”

For some of those contacted, the pandemic was yet another crisis stacked on top of existing ones. They were poor or grieving or had preexisting medical or mental health conditions. COVID-19 was one more burden that pushed their lives to the brink. Contact tracers became their first line of support.

Like many others working in public mental health, Raviola sees a convergence of “Trauma” and “trauma.” Uppercase Trauma covers big-scale, singular events like natural or manmade disasters or major violence. The lowercase variety includes the poverty, abuse, low-grade violence, neglect, structural racism, political strife, civil unrest, economic recession, and health inequities that grind down their victims day by day. When upper- and lowercase trauma collide, they intersect and reinforce each other—as they have during the COVID-19 pandemic—and the result is a synergistic epidemic, or “syndemic.”

“Syndemics ask us to reframe how we build mental health systems but also how to buffer our societies in an uncertain, post-COVID future,” said Raviola. “Maybe I have not seen myself as a disaster psychiatrist, but my work [overseas] has been about strengthening community mental health services over the long term in response to acute and chronic crises.”

Relatively wealthy countries like the United States can take notice of the ways that low-income countries have often fared better in the pandemic by depending more on public health models than on privatized, individual medical care, said Raviola. It’s a lesson PIH and the Commonwealth of Massachusetts sought to adapt last year as the pandemic ramped up.

“In many low-income countries, psychiatric interventions can be delivered by peers or communities,” he said.

These are the other winners of the 2021 Bruno Lima Award: Leslie Hartley Gise, M.D., the Mental Health Lead for the Maui Red Cross, was involved with disaster psychiatry after September 11, Hurricane Katrina, and the Hawai’i lava disasters; Katherine Koh, M.D., M.Sc., the co-chair of the Disaster Readiness Committee for the Massachusetts Psychiatric Society, has studied the mental health response to the Boston Marathon bombing and designed a systematized mental health response for homeless patients during COVID-19; and Frank G. Sommers, M.D., a child survivor of the Holocaust, is the founding chair of the Canadian Psychiatric Association’s Section of Disaster Psychiatry and Disaster Psychiatry Canada in the Department of Psychiatry at the University of Toronto. ■