by: Lina Sagaral Reyes

Cagayan de Oro City – The specter of death by suicide continued to be a staple of radio news well into the third year of the Covid-19 pandemic in this highly urbanized city.

But nothing sent a singular shockwave of concern among local government officials as a particular case in mid-May 2021: A young man in his early 20s ended his life right inside a campus dorm room turned as one of the city government-run temporary treatment and monitoring facilities.

He was recuperating from moderate symptoms of coronavirus infection, set to be released from confinement, and yet his vulnerability succumbed to self-harm in the wee hours of dawn.

Fissures

Mayor Oscar Moreno expressed condolences with the grieving family at the daily press briefing that day. “We understand he was alone in the room. We respect the need of the family for privacy as they grieve,” he added.

Moreno later directed the local mental health board to convene and review the circumstances of the incident and suggest steps to strengthen the mental health and psychosocial support services (MHPSS) at the more than 20 isolation and treatment units in hotels, inns, and campuses throughout the city so that suicide prevention is better enforced.

The board is a multi-stakeholder body and adjunct to the local health board mandated under the Local Government Code composed of mental health care professionals, non-government leaders and persons with lived experience of mental illness, with advisory and recommendatory tasks under the office of the local chief executive, particularly on mental health policies. It was formed in 2015 through an executive order aligned with the national government’s Mental Health Action Plan, 2015-2021 at the Department of Health, in consonance with the Mental Health Global Action Plan of the World Health Organization (WHO). These policies at the global and national levels of governance seek to empower local communities and healthcare professionals to do their share in sustaining a mental health service program amid a dearth of psychiatrists and psychologists in poor and developing countries like the Philippines.

Seismic

That seismic one-death-too-many moment also marked a dark milestone in the Oro government’s Covid response more than a year after a community quarantine was declared on March 19, 2020, and as hundreds of frontliners were mobilized to prevent the spread of the virus. City hall employees manned barangay health centers, hospitals, ports, airports, and roadside checkpoints to transport individuals to isolation units, cook meals for the confined or disinfect roads and buildings.

As breakthrough infections rose among frontliners, community transmissions increased, causing three-digit reports of cases. In a few weeks, the number of active cases would breach the thousandth-mark, most of whom were housed in the isolation units as the hospitals raised the code red status, or all beds occupied. In less than two months, Cagayan de Oro suffered the worst surge of Covid cases and was declared under an Enhanced Community Quarantine (ECQ). At its peak, there were more than 3,000 active cases in a single day.

“Burn-out and fatigue are real, we’ve nodded off. It was a wake-up shake for us to get wide awake again,” recalled Jaymee Leonen, director of the psychosocial division of the city social welfare and development (CSWD) office.

Mental health support

The Bayanihan: We Heal as One National Covid Response Act stipulates that isolation units and treatment facilities must be provided with MHPSS (mental health and psychosocial support services).

These tasks fell mainly on the shoulders of the understaffed and underfunded psychosocial division as the city health office focused on dealing with Covid cases, plus other health programs on major diseases. The Mental Health Act also mandates that the CSWD psychologists and social workers must provide post-disaster stress debriefing and psychological first aid to populations hit by calamities like this disease outbreak.

Solutions

By the end of that week in May 2021, loopholes were addressed as two dedicated hotlines were made available exclusively for those who were housed in the government facilities, including those Covid positive but asymptomatic, or exhibiting mild or moderate symptoms.

Previously, three other lines provided counselling on mental health-related issues such as domestic violence and referrals to in-depth therapies.

These lines are on top of other measures, including keeping infected persons together in wider ward-like  spaces such as dormitories in groups of 10 instead of keeping single individuals solitary in separate bedrooms. Nursing staff went on monitoring rounds at night and dawn, more watchful of specific at-risk individuals like youths, the immunocompromised and those living with mental health disorders.

The WHO, along with scientists and medical professionals, had warned of a spike in mental health problems, such as cases of suicidality, which had  worried officials as early as prepandemic January 2020.

Pre-pandemic data show 800,000 die by suicide globally. The significance of addressing suicide-related crises is highlighted by the inclusion of suicide rate  as an indicator of mental health and well-being in the Sustainability Development Goals (SDGs). Under SDG #3, suicide rates are targeted to be reduced to a third of 2016 data by 2030.

In an article in The Journal of Public Health, Prof. Jeff Clyde Corpuz of De La Salle University rang alarm bells as historically, suicide rates rose during disease outbreaks as the 1918-19 influenza epidemic in the US and the 2003 severe acute respiratory syndrome (SARS) in Hongkong.

Corpuz also wrote that the Philippine Statistics Authority (PSA) saw a 25.7 % rise in deaths by self-harm in 2020, the start of the pandemic, compared with 2019 data.

CSWD data show suicide rates in Oro increased slightly from 2.3% in 2020 (18 cases) to 2.45 (19 cases) in 2021. In Northern Mindanao, with 123 cases in 2021, suicide rate was calculated at 2.5%, an increase from the previous year’s 2.0%.  The PSA however noted that the country’s suicide rate remained at 2.2% from 2016 to 2019.

Below 20

“The trends (in Cagayan de Oro) show that they are getting younger. Ga kabanata, the youngest is a nine-year-old,” Leonen told a forum in September 2021.

Her insight presaged the WHO findings that suicidal behaviors among children and young adolescents aged 20 and below were on the rise globally even as global suicide rates were stable in the early part of the pandemic.

Kids at a neighborhood in Barangay Balulang, Cagayan de Oro, gather to watch YouTube and Tiktok videos on a smart phone connected to WiFi from a nearby Internet cafe during the second year of the pandemic. In a briefing paper in March 2022, the World Health Organization had noted that deaths by self-harm among children and adolescents below 20 years old are on the rise during the Covid-19 pandemic. Photo by LSReyes

Dr. Ginger Ramirez, who monitored youth suicides in the country, also saw a sharp rise (58 %) in the number of youth suicides from January to October 2020, compared to 2021 data of the same period.

But a March 2022 WHO briefing paper said available national data from several countries showed no increase in suicide rates in the early months of the pandemic even with rising prevalence among the young.

Faultline

A critic of the city government’s Covid-19 response strategies, however, insisted that these are only stopgap measures. “The real faultline lies in the use of private commercial establishments like hotels instead of empowering barangays and neighborhoods to establish community-based facilities as envisaged in the Bayanihan Act.”

“We are not used to leave our sick and ill alone. That is so Westernized. Our culture is more caregiving. Isolating the sick like this in a strange environment invites despair and depression, and alienation and anomie. We give them attention and presence which are denied (the infected) due to the viral contagion,” she said, adding that Covid funds were centrally handled by city hall, leaving most barangays empty-handed and disempowered throughout the pandemic. (The mayor was contacted for comment and this story will be  updated as soon as he replies).

Leonen said the trends in previous years indicate that more children as young as nine were reporting suicide ideation, attributing it to the pandemic impact on family life and social relationships. “Distressed parents beget distressed children.”

Disruptions

Meanwhile, awareness of the exclusive crisis hotlines was further enhanced by placing the contact phone numbers in leaflets handed out to clients as they checked into facilities.

But these lifelines were disrupted around late July till early September when the lines were burned to communicate with cash-strapped families competing to receive cash grants to stave off hunger as the local economy was on a standstill because of the ECQ status. The lines were flooded with calls and text messages from thousands of angry citizens who felt discriminated and excluded from the controversy-ridden distribution of the cash grants.

Leonen begged for sobriety and compassion for the caregivers as surreally, the phone messages turned into  online abuse, filled with obscenities and threats, which spilled into the discussion threads of the psychosocial division’s Facebook posts.

As this was happening, those confined at the isolation rooms and wards could no longer avail of the counselling services. “I kept on calling the numbers since day one, but someone would have pushed the end button. It happened for days,” Rowena Taperla, 28, a young professional and former cultural worker, recalled her experience when she was confined for 10 days at an isolation unit.

Despite their unavailability, the exclusive lines were still announced and shared for several weeks during the daily briefings. Obviously, there was a disconnect between the CSWD and the information staff hosting the briefings as the latter was not informed of the disruption of services. The mixed-up was corrected only in September.

24/7

Asked for suggestions on how to improve the lifeline, Taperla said the service and the other hospital-based telehealth services must be made available 24 hours a day, seven days a week. Presently, telehealth services are only available during office hours, 8 am-5 pm, Mondays to Fridays.

Under the Mental Health Act , suicide prevention hotlines are mandated to follow this 24/7 dictum.

“The night makes people more vulnerable,” Taperla explained when asked why she thought night duty is necessary.

Quoting the writer Diane Ackerman who volunteered for the night shift of a suicide prevention center in the 1990s, she further said,” As Ackerman observed, ‘people are most alone at night. They drink until they fill their minds with darkness forever. They have the pre-dawn crazies…If they can just get through till daybreak, the gloom might just break a little, and familiar people and routines offer hope.”

Fortunately, other private volunteer groups are filling the gaps by providing telehealth services via social media such as the Cagayan de Oro Mental Health Hour and Kamusta Youth Online Chat.

So far, only the DOH Kamusta Ka Hotline phone and social media lines are truly 24/7.

Three shifts of trained counsellors are manning three lines. By September 2021, the latest data indicated that around 15,000 calls had been received by the service, or around 25 calls per day, which could last for at least five minutes to an hour.

Lifelines

But Maria Dolores Mercado, DOH-10 regional coordinator on mental health, also urged that family members and friends can become lifelines themselves, as force multipliers, to be listeners and witnesses so that patients may not rely on crises lifelines. “If we cultivate the art of listening to these people, the call lines should serve as only the last resort,” she said.

“Usually these people would tell people their stories, their fears, their problems. They need a listening ear.”

“If any of your friends or a family member tell you they are suicidal, take them seriously. Do not dismiss them as ka-dramahan or just a mere joke. You must listen without judgment. Give them options, show and convince them they are not alone,” she suggested.

Aftershock

Another aspect that needs to be addressed is “postvention,” an activity that reduces the risk of suicide and debriefs the surviving and grieving family and friends in the aftershock of a sudden completed suicide. Persons whose attempt to end their lives did not succeed might also need support to process their situation.

As licensed social worker Ken Norton quoted, “It is said that a suicide dies but once and yet the survivors of the lost lives die a thousand deaths in the aftershocks of grief, guilt and shame.”

Postvention is considered “the third leg to the three-legged stool of addressing a suicide crisis,” aside from prevention and direct intervention but it is rarely included in programs such as this.

Better

Today, primary vaccinations in the city has reached beyond 100% for the target sectors. Booster shots continue to be administered to target groups. The schools have reopened for face-to- face, in-person classes.

The isolation units and temporary treatment facilities are now in back-to-normal business, serving tourists and travelers in hotels and inns. But the city’s infirmary in Barangay Lumbia, the JR Borja General Hospital and Treatment Facility in Barangay San Simon–- built and or refurbished with pandemic funds and other private hospitals — had increased bed spaces in preparation for a future surge.

Daily Covid-positives are either zero or in low single digits. There are barely a 100 active cases, mostly in isolation in their homes.

Leonen said the Sanggunian has approved, as its swan song before their term ended in June, the much-awaited Mental Health Ordinance, which is a community-based service delivery program under the City Health Office.

The ordinance  operationalizes the policies for local government’s roles laid out in the RA 11036.

With this legislation comes appropriate funding for more staff and counsellors to man the lifelines and serve the communities; more funding for training barangay health workers on psychological first aid and suicide prevention, and building facilities and providing free psychotropic medicines and mental health-care insurance for the mentally ill in barangays.

The implementation of the Mandanas ruling this year, in which local government units (LGUs) get a share of national tax revenues, heralds a bigger budgetary hoard for the LGUs and ensures better-funded mental health projects.

#Hawidlaum

But this September, ironically, suicide cases clustered during and after September 9, Suicide Prevention Awareness Day.

Eight completed suicide incidents and two attempts within a week brought mid-year incidences to 16, with 10 attempted cases. With three more months to go before yearend, it is predicted that the number of suicides in 2022 will far exceed last year’s 19.

Jaymee Leonen, chief, psychosocial division, Cagayan de Oro Social Welfare and Development Officescreen grab from Talakayan PIA-10

Leonen and Mercado agree that a challenge remains that of reining in the media as their coverage of suicide cases, especially of radio stations, become more of a sensationalized feeding frenzy that violates ethical protocols and risks social contagion or copycat cases.

But Leonen trusts that with frequent reminders from mental health advocates, the media will carry on its tasks to rally people to choose #hawidlaum: holding on to hope.

(This story was produced with a Health and Governance fellowship from the Philippine Press Institute (PPI) under the auspices of the Hanns Seidel Foundation-Philippines (HSFP). The contents of this story are the full responsibility of the journalist and do not reflect that of the publisher, PPI nor of HSFP.)