Mental wellness
It was with great sadness that I read the Straits Times and Channel NewsAsia reports on the number of suicides in Singapore – 2020 saw 452 cases, the highest since 2012 and a 13% increase from the 400 cases recorded in 2019.1
Studies have shown the adverse impact of the COVID-19 pandemic on mental health.2 The prolonged lockdown duration and many uncertainties are hard to endure, as they come relentlessly. When do people give up? When there seems to be no hope, no reprieve and their current suffering seems to be persistent. How can a seemingly manageable event push someone over the edge?
Suicide counselling is a specific skillset – advice such as "look on the bright side", "it'll get better" or "don't think so much" may do more harm than good. Someone may feel very stressed about a seemingly minor event and tell a friend about it. To the friend, it may seem like a minor thing, but to the person who has been fighting against many stressors for a long period, there's a whole lot of unspoken burdens which the well-meaning friend may not know about.3
It does not matter what your actual trigger is. It is the dreadful sense of doom hanging over you – that there is no end to the current bad situation and that there is no way out – that makes it feel so hard to carry on living.
Over the course of my general surgery training, aside from learning about surgical conditions, what fascinated me the most was the diverse range of responses. Some examples of major life-changing treatments include having a tracheostomy, a stoma, a permanent suprapubic catheter, an amputation or having to go on dialysis. When I talk to patients and ask how they feel about their treatments, I have noticed a few common responses.
Some accept it, as "no choice, I have to endure – but it's just for now. Things will get better in time." When it's permanent however, few may be able to accept it from the beginning, but most will have varying degrees of change adjustment: denial, anger, or grief before acceptance – if that ever happens. For those who cannot accept their diagnosis, they might progress to lifelong depression.
Prolonged COVID-19 fatigue
Looking back at the past year, how many changes have occurred and how many were mostly negative? What was our collective reaction?
Initially, people were worried about contracting COVID-19, as mortalities worldwide rose and international reports on shortages of hospital beds and oxygen supplies reached us. Singapore went into a circuit breaker beginning April 2020. Businesses rallied, with many food and beverage (F&B) outlets stepping up to provide delivery services. Subsequently, we seemed to enter a new normal and everyone meandered along. As a nation, we adapted to the idea of eating in groups of twos, fives, then eights. We joked and created online memes to cheer ourselves up.
Vaccines were greeted with great enthusiasm by some, but with mistrust by others. Open letters by a few medical professionals made headline news, and the Ministry of Health (MOH) had to undo the damage done to public confidence in science. Ongoing concerns about side effects, safety and investigations into cardiac complications cause lingering worries in parents. Updates on vaccine efficacy and announcements on booster shots have led to mixed responses. Even I feel that everything is changing too fast, and that I don't fully grasp the technology. I have to trust my specialist colleagues and the Government to have done their due diligence in keeping up to date and giving us the best recommendations.
International news are mixed as well – some countries are opening up, some are battling minor clusters and outbreaks, while others have rising numbers and increasing mortalities which fill me with concern and sadness. The evanescent nature of travel bubbles bring recurrent waves of rising hope and disappointment.
The Tan Tock Seng Hospital (TTSH) outbreak in May 2021 brought about the "segregation order". Out of concern that roommates from different hospitals might pass COVID-19 to each other, and that some healthcare workers (HCWs) were asked to leave their rental accommodations by their landlords, the hospitals helped to find alternative lodgings. This then extended to an order for families with two or more HCWs in different hospitals to ensure that they are "segregated" – either living in separate rooms, or moving out to hospital-provided facilities. The abrupt separation caused some inconvenience to young families, as their kids did not understand why their parents had to move out, and being a temporary single parent was difficult. Reports of discrimination against TTSH HCWs also made the news, which was highlighted by Member of Parliament Dr Tan Wu Meng in parliament as well.4
The rise of the Delta variant in the community brought about more stresses to the nation, increasing tensions along national and racial lines.5 There are more open national conversations about this now, and I welcome it. There must be no discrimination. The virus does not discriminate, illnesses and death do not discriminate. We are in this together. Subsequently, the heightened alert phase came along and the economy faltered. The F&B, taxi and transport services, and retail sectors suffered. I sense that people are resigned and a few have given up. We see businesses closing for good.
On social media, there were a few reports of public nudity, and I personally witnessed a few incidents of road rage by commercial drivers, prompting me to ask for a Parliamentary written answer.6 I note that the actual reports of road rage are stable (but then again, there are a lot less cars on the road) and verbal assaults have decreased, but cases of physical assault and nudity/indecent exposure seem to have risen. I cannot help but wonder, are these also signs and symptoms of a weakening of social cohesion and gradual deterioration in mental health?
Having to close down TTSH for a few weeks in May while the outbreak was contained brought about other stresses to the healthcare system. To prevent another similar outbreak, MOH decided to implement rostered routine testing to all inpatient HCWs, patients and visitors. This comprised the deep nasal swab for polymerase chain reaction testing every two weeks if vaccinated, or weekly if not vaccinated. This has been carried out on construction workers and maritime workers since June 2020.7,8
As we had learnt in medical school, a screening test should have various criteria.9 Regarding the use of deep nasal swabs as a routine screening, I personally question its acceptability to the population and the cost-benefit.10 I am still learning more about this, and asking colleagues in public health and infectious disease for my own learning.
I am a simple female surgeon – I can only think of simple analogies. Would I advise digital examinations for rectal or prostate cancers, or PAP smears for cervical cancers every two weeks? Of course, those are for cancer checks, which does not spread to others through droplets, so it is not a direct comparison. I look forward to more studies11 to validate other more acceptable modalities of screening, which are just as sensitive and perhaps more cost-effective for the country.
Resilience and support
The closure of international borders has affected the global economy. The world is struggling together to get back on its feet. From our survey of Members in 2020,12 we are aware that doctors in private practice are also facing financial challenges. We may be able to ride this out, but for how long more?
I personally believe that even though one may feel alone and abandoned during stressful times, we should reach out and lend each other strength and support. Thank you, to friends and colleagues who have been keeping in touch over emails, social media or even just a simple wrinkly-eyed smile while masked. These acts of friendship are deeply appreciated.
As always, we welcome feedback from our Members – so, do write in to sma@sma.org.sg. Stay well, and stay united.