CARTAS AL EDITOR

The upcoming mental health unrest in Ecuador

Daniel Romero-Alvarez[1], [3]
María Sol Garcés[2]
Manuel Calvopiña[3]
Paul Mena-Mena[4]
Daniel Garzón-Chávez[5]*

1. Biodiversity Institute and Department of Ecology & Evolutionary Biology, University of Kansas, Lawrence, Kansas, United States
2. Instituto de Neurociencias y Colegio de Ciencias Sociales y Humanidades, Universidad San Francisco de Quito, Quito, Ecuador
3. One Health Research Group, Facultad de Medicina, Universidad De Las Américas (UDLA), Quito, Ecuador
4. Carrera de Periodismo, Colegio de Comunicación y Artes Contemporáneas, Universidad San Francisco de Quito, Quito, Ecuador
5. Colegio de Ciencias de la Salud (COCSA), Escuela de Medicina, Universidad San Francisco de Quito, Quito-Ecuador

Doi: https://doi.org/10.23936/pfr.v7i1.237

PRÁCTICA FAMILIAR RURAL│Vol.7│No.2│Julio 2022│Recibido: 24/03/2022│Aprobado: 24/07/2022

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Abstract

The pandemic of COVID-19 has unsettled every aspect of our functional society. Its consequences are still waiting to be fully appreciated since, after more than a year of the pandemic declaration in March 2020, we are still facing its raging impact. From the plethora of complications related with COVID-19, the non-pharmaceutical approaches that have become the cornerstone of pandemic management, have set the ground for a potential wave of mental illness. Ecuador is in a particular position to rise this discussion considering that it is one of the Latin American countries most affected by the pandemic as shown by the huge excess in mortality registered in 2020. Moreover, with lack of actual mental health policies, well-connected infrastructure, or a monitoring program, we argue that the epidemiology of mental health should be highlighted for either a reinvention of its current approaches or to allocate resources to offer attention to a population that might be heavily affected by psychological disorders.

Keywords: excess of mortality, mortality, COVID-19, mental health

Anticipando el deterioro de la salud mental en el Ecuador

Resumen

La pandemia de COVID-19 ha perturbado todos los aspectos de nuestra sociedad funcional. Sus consecuencias aún esperan ser apreciadas en su totalidad ya que, después de más de un año de la declaración de pandemia en marzo de 2020, todavía estamos frente a su furioso impacto. De la plétora de complicaciones relacionadas con COVID-19, los enfoques no farmacéuticos que se han convertido en la piedra angular del manejo de la pandemia han sentado las bases para una posible ola de enfermedades mentales. Ecuador está en una posición particular para levantar esta discusión considerando que es uno de los países latinoamericanos más afectados por la pandemia como lo demuestra el enorme exceso de mortalidad registrado en 2020. Además, con la falta de políticas reales de salud mental, bien conectadas. infraestructura, o un programa de monitoreo, argumentamos que la epidemiología de la salud mental debe ser destacada, ya sea para reinventar sus enfoques actuales o para destinar recursos para brindar atención a una población que puede estar fuertemente afectada por trastornos psicológicos.

Palabras clave: exceso de mortalidad, mortalidad, COVID-19, salud mental

 

The COVID-19 pandemic has claimed more than 6.3 million lives worldwide and is by far the most significant health threat reported in modern times [1] . Public health measures implemented to stop COVID-19 progression include mobility restrictions and mainly social isolation [2] . These measures have a profound impact on economic activities and well-being, which translate into stress, uncertainty, and emotional isolation; known risk factors of mental health [3] .

Ecuador has one of the highest excess mortality per population in the world [4] . Death excess, calculated here as the difference between 2020 monthly death reports and the average number of reports from 2018 and 2019 according to the data from the National Civil Registry (https://www.registrocivil.gob.ec/cifrasdefuncion/), show at least two peaks of excess mortality during April and July 2020, with a decreasing—but above the average—trend for December 2020 (Fig. 1). Although not shown, this trend rises again above the average up to February 2021.

Figure 1. Death counts and death excess in Ecuador in 2020. Number of deceased individuals for 2020, 2019, and 2018 were obtained from the National Civil Registry. In April 2020, Ecuador reported at least 150,000 excess of death across the country.

Only the non-continental province of Galapagos registered death excess in non- consecutive five months (Fig. 2), which might be a consequence of incomplete reporting or undisclosed information, since surveillance systems have been centralized and heavily affected by bottlenecks in laboratory testing, hospitalization, and epidemic response [5–7] . Our measure is based on a gross estimate, meaning that we have considered death by all causes. Regardless, there is quantitative evidence that this excess is driven mainly by the COVID-19 pandemic both in Ecuador and in other parts of the world [4,8].

Figure 2. Death excess in Ecuador depicted by province. Mortality in 2020 (blue line) largely excesses the average of 2018-2019 (black line) in all 24 provinces for at least two consecutive months except for Galápagos. We calculated incidence as the total number of cases divided by the total population for 2020 as estimated by the National Institute of Statistics and Census of Ecuador (INEC in Spanish: https://www.ecuadorencifras.gob.ec/proyecciones-poblacionales/).

From the five most affected provinces, Santa Elena, Guayas, El Oro, Manabí, and Tungurahua (Fig. 2), the capital of Guayas, Guayaquil, faced particular challenges that pointed the city as an example of poor COVID-19 management. Even before the pandemic, Guayaquil struggled with an unemployment percentage of 4.2% and only a 20% of adequate employment, earning less than $400 per month, which cornered people to avoid lockdown or social isolation measures to earn their living (21).

Guayaquil also reported two particular disrupting situations: (1) loss of cadavers due to wrong labeling [9] , and (2) corpses remaining at home for 3-4 days, or found in the streets during the first peak of the COVID-19 epidemic in Ecuador between March-April 2020 ( [9] ; Fig 2). As we historically have seen in other pandemics, a surge of mental health problems is highly likely after an appalling health crisis [10] . Ecuador, as other Latin- American countries, struggles with important disability and mortality rates due to mental health conditions together with neurological, substance use, and suicide (MNSS). According to the latest country profile reported by the Pan-American

Health Association (PAHO) Second Installment of 2018, MNSS in Ecuador are responsible for 19% disability adjusted life years (DALYs) and 36% of years lost due to a disability (YLDs) in the general population [11] . This considerable burden has been neglected since Ecuador lacks an active mental health-monitoring program and little research to account for its local morbidity [12–14] . Moreover, Ecuador does not currently have legislation related to mental health. Its budget—1.2% of national wealth—is lower than the already deficient average expenditure on mental health globally (i.e., 2%; [15,16]

A recent study among confirmed or suspected COVID-19 patients across the country showed that the prevalence of depression (52.6%) and anxiety (58.1%) disorders in this group is higher than previously reported [17] . Even before the pandemic, Ecuador ranked above the regional average on suicide rates with an adjusted rate of 7.1 per 100,000 inhabitants, only surpassed by Bolivia with 18.7 per 100,000 inhabitants [13] . Considering the excess of mortality on 2020, and the reported and underreported consequences of the COVID-19 pandemic in Ecuador, we expect a
burgeoning outbreak of mental health diagnosis that will exacerbate the quivering public health stability.

Grief is a normal reaction to loss, where the vast majority of individuals experiencing it will adjust and develop a sense of normalcy over a period of six to twelve months [18] . But if the bereavements occurred under traumatic circumstances due to additional stressors, the risk for dysfunction, trauma, as well as complicated and prolonged grief increase [19] . We argue, that due to the social circumstances that were faced during this pandemic (Fig. 2), mental health should be treated as a priority in Ecuador. Apparently, key public health players across Latin-American are aware of these needs and are, at least theoretically, ready to tackle this problem [20] . However, awareness must be translated into actions, which can only be structured with governmental support, well-established health infrastructure, and resources; three conditions that have proven short during the COVID-19 Ecuadorian response [5] . We hope that the catastrophic events driven by the pandemic serve as a motivation to restructure the way mental health has been addressed in Ecuador to prevent the potential upheaval of psychological problems in the months to come.

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