As South Africa enters level two of its national lockdown, international travel remains restricted. One of the few exceptions are repatriation flights, which require a mandatory quarantine period. But the toll of mounting stress and isolation may have long-term consequences on people’s mental health.
Jane Smith* saw a police car coming up and told the driver where to go before her group set off to an unknown location. She and the other passengers were allowed to disembark from their plane at OR Tambo in parties of 20 before being split in half and boarding shuttles.
The police car was escorting them.
Smith, 36, had been waiting for this day for eight weeks — on the couch of a friend’s one-bedroom apartment in New York City.
But now, she’s — once again — filled with anxiety.
She has no idea where the bus she’s been told to get on will take her to stay for the next almost two weeks. And her phone battery is dying, so soon she won’t be able to let her family know what’s going on either.
In early March, Smith’s life was turned around — literally.
The young lawyer thought she was travelling to New York for a three-week business trip. But within 24 hours after her arrival, the city had practically closed down and South Africa had shut its borders to international travellers.
Smith had flown into a disaster zone.
Both New York and South Africa had just reported their first COVID-19 cases — within days of each other. Smith, along with tens of thousands of other South Africans around the world, were stuck in the cities they had travelled to.
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They sent dozens of desperate mails to the department of international relations and cooperation, contacted embassies, scoured Facebook groups and WhatsApped friends and family in South Africa to find out when they’d be able to return.
No one knew. Some couldn’t find a place to stay, many ran out of money.
But today, after an 18-hour repatriation flight arranged by the department of international relations and cooperation (Dirco), along with 275 mask-wearing passengers, Smith finally set foot on home soil — just as the sun was about to set.
Quarantine: necessary, but stressful
By August 17, over 19 000 people had been repatriated to South Africa after the country had closed its borders in March, Dirco’s records show.
Although domestic travel resumed during level 2 lockdown, which was announced on August 17, the country’s borders remain closed to international travellers, with repatriation flights remaining one of the few exceptions.
All repatriated citizens are required to spend at least 10 days in a state-sponsored quarantine facility to prevent them from spreading SARS-CoV-2, the virus which causes COVID-19, in case they had contracted it in the country where they were based. National guidelines stipulate that those who test positive for the virus on their arrival, or during quarantine, are transferred to an isolation facility, or the isolation section of a quarantine facility, where they will spend the rest of their isolation period with other COVID-19-positive patients.
People in quarantine or isolation must stay in a separate room and have no contact with anyone for 10 days (when Smith arrived in South Africa in May, that period was 14 days, but was later reduced to 10 days after the World Health Organisation issued new guidelines to countries).
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But while it is essential for the containment of COVID-19 to quarantine people returning to South Africa, this process can be extremely stressful for repatriates and take a huge toll on their mental health — even before they are placed into quarantine.
For many, like Smith, their arrival is preceded by months of being stranded in another country with no clear return date and flights often arranged at the last minute. Some had lost their jobs or savings during their waiting period, some had spouses who had given birth and there are those who had lost family members to illnesses, including COVID-19, without being able to say goodbye or be there to support them.
“One of the things that we can do is to recognise the difficulty of the entire period,” says Zamo Mbele, a clinical psychologist and board member for the South African Depression and Anxiety Group (Sadag).
“This includes the anxieties of being away and not knowing if you’re going to get back or how you’re going to get back. Then getting back and having to further be isolated for an additional period is incredibly distressing. It can result in a lot of anxiety and depression for the person.”
Arriving at quarantine — disoriented and alone
When Smith’s bus arrived at the quarantine facility the government had allocated her to, she was led to a dorm room on the first floor of the building. The room had a single bed, an en-suite bathroom and a built-in desk in one corner next to a small closet. An old TV was mounted on the wall.
“You’re in this room, you don’t really know where you are,” she remembers. “In my case, I arrived at night and was really disoriented. I had just gotten off a long flight and landed up in a facility where there was no WiFi and my phone battery had run out.”
Smith landed up at a converted Telkom training facility in Johannesburg. The facility is one of a few public buildings that have been transformed into COVID-19 quarantine sites, as opposed to facilities run from hotels and lodges.
At the time of Smith’s arrival in May, the site was run by a non-profit, the Centre for HIV-Aids Prevention (Chaps), on behalf of the state.
The Telkom site lacked some of the amenities available at hospitality sites, for instance, it offered only three television channels, there was no intercom system and there was, at least initially, no WiFi available in the building.
After she had dinner and looked around, Smith says she realised there were no two-pin plug adapters in her room, so she couldn’t charge her phone and started to panic.
She recalls: “I became very, very anxious about causing my parents stress if I could no longer communicate with them.”
Repatriates at the facility were not allowed to have any contact with each other — their food was delivered outside their rooms and if they wanted to go outside to exercise, they had to do so during restricted time periods and maintain distance from others.
Several studies have found that the loss of routine and reduced contact with others can be distressing for those in quarantine by creating a sense of isolation, boredom and frustration. A 2004 study in the journal, Emerging Infectious Diseases, also found that the length of a person’s quarantine could also play a role, with people in isolation for more than 10 days showing more symptoms of post-traumatic stress disorder than those who quarantined for shorter periods.
“Something that adds to the distress is loss of control during this time, because people are now being told what to do and when they’ll do it resulting in a loss of agency,” explains Mbele.
People will also experience “a great deal of internal distress when they’re in isolation because they know that they’re under investigation and that there’s a possibility that something is wrong with them”, he says.
Regular screening visits from nurses, although necessary, can sometimes make the process more difficult for repatriates as the examinations serve as constant reminders that something could potentially be wrong.
“If health workers in the facility are scared of getting infected and are reluctant to interact with people in quarantine, it furthers the feeling of disconnect for those that are there.”
Mbele concludes: “It’s an incredibly distressing experience of people shutting you out or people ostracising you — it leaves a scar on the person’s psychology forever.”
Back in her quarantine room, Smith was exhausted. She sent her parents one last text saying she was turning off her phone. Then she went to sleep, unsure what the next weeks would hold.
‘I talked him off committing suicide three times during that period’
A lack of information at a quarantine facility during an outbreak can be an immense source of stress and also make people less likely to comply with rules, according to a 2004 study published in the journal Biosecurity and Bioterrorism: Biodefense Strategy, Practice and Science.
The study was conducted during Toronto’s 2003 Severe Acute Respiratory Syndrome outbreak, and found that a lack of consistency in how quarantine was implemented created considerable confusion among those placed in isolation.
This is also something seen locally, Chaps’ CEO Jacqueline Pienaar, says.
“If you want to build a holistic quarantine site first and foremost you need to provide routine information or access to information from a credible source. We shouldn’t be relying on people to educate themselves, especially in a quarantine facility.”
This includes providing basic information about what quarantine entails, how long people are required to stay, the facility’s rules and the procedure to follow for when someone’s stay at such a site has come to an end.
Pienaar explains: “This could be done with pamphlets in rooms upon arrival, educational videos for younger children, in-person discussions or information sessions with on-site staff.”
READ MORE: COVID-19 has changed the way South Africa’s only toll-free mental health helpline works. Here’s why it matters
But repatriates in quarantine’s most common need, by far, is counselling, says Pienaar.
Quarantine facilities are, however, not required to have on-site counsellors. Although national quarantine guidelines stipulate that sites housing more than 20 people should have a nurse present for at least eight hours a day, there is no requirement for mental health practitioners — such as psychologists and psychiatrists — to be stationed at facilities.
But the national health department’s spokesperson, Popo Maja, says “counselling is available to anyone in quarantine or isolation on request or by referral”.
Maja says depending on “the severity of the condition, the person [in need of counselling] may be transferred to a relevant hospital or visited by a mental health practitioner or consulted telephonically”.
“In cases of severe depression or suicidal behaviour, people should be referred to specialised mental health services.”
Access to these services are, however, not always available on the ground, Pienaar says. “During the time Chaps ran the Telkom facility, it was particularly challenging, at least during the early stages of running the facility, to get counsellors on-site because people were afraid of getting infected with the new coronavirus.”
READ MORE: The coronavirus outbreak & mental health: What you need to know
Madeleine Hicklin, who serves on the portfolio committee for public works and infrastructure, has personal experience of how difficult it is to access mental health services while in quarantine. She’s a parliamentarian who helped to start a WhatsApp group “home away from home” that provides repatriates stuck in overseas cities with information and then keeps in touch with them once they’re back home and in quarantine.
In April, Hicklin dealt with a man who had been repatriated from Saudi Arabia and was placed in a quarantine hotel in Johannesburg on his arrival. Before he left for South Africa, the man had already been placed in isolation for 45 days as part of Saudi Arabia’s national COVID-19 lockdown. “He was therefore quite emotionally fragile on his arrival,” Hicklin explains.
“He got my telephone number and called me. I literally spent 96 hours over a three or four day period where I was on the phone with him in between trying to get hold of a psychologist and a psychiatrist to evaluate him to get him out of this hotel and put him into a psychiatric facility. I talked him off the ledge, I talked him off committing suicide three times during that period.”
Hicklin warns that this was not an isolated incident. Over the past five months, she has received several similar calls from people who are struggling with severe depression while in quarantine.
At the Telkom facility, Pienaar, who is a psychologist, trained on-site nursing staff to help identify patients struggling with the isolated environment and provide informal counselling to those who need it.
This process would involve nurses spending more time with patients and having conversations with them throughout the day, as opposed to just doing daily temperature checks. “The idea was to create a less rigid environment, so it felt less like a prison or punishment,” says Pienaar. “We also tried to introduce more activities for people to do while in their rooms, such as supplying books or games.”
Maria Sardini, a clinical manager at Chaps, ran the Telkom facility in May. She says before COVID, nurses worked with their patients in a considerably more “hands-on way”. “The loss of physical contact that came along with COVID-19, has been difficult for nurses to adjust to. So being able to maintain a relationship with people through conversations also helped the staff feel more comfortable with their jobs.”
Adjusting to a new normal: ‘You’re not in quarantine anymore’
Akshay Mothie*, 33, who had also been waiting for a repatriation flight since March, arrived in Johannesburg on July 8 from Iraq. His group was assigned to quarantine in the Saint George’s Hotel in Pretoria.
When he got to his room, there was a two-page list of rules inside that outlined what the quarantine experience would entail. It detailed meal times, which were left on a chair outside the room, three times a day. The document also informed him during which time slots he was allowed to go outside.
The hotel rooms had phones, which repatriates could use for free to call reception or the nurses’ station if they needed anything.
Smith says she wishes she had access to this level of information at the Telkom facility.
“It would have been helpful if there had just been a sheet of paper with some information in my room. The only time I had any interaction with a person was when a nurse came to take my temperature or when someone brought me food. Besides that, we were not allowed to step outside of our rooms.”
Smith says “even just knowing what was going to happen the next morning would have helped make the experience easier”.
“We didn’t have an intercom, apparently the hotels had intercoms where they could make announcements. So information was not being disseminated fluidly. It would be disseminated to one person, who happened to catch a facility manager or someone else. Then if they got an answer it was shared on the Whatsapp group, but you never knew if it was factual.”
Once Smith was back at her home in Johannesburg, she struggled to return to a normal routine — and her battle hasn’t ended.
“It’s like 10 o’clock at night and I still can’t sleep. I try to go to sleep, but I wake up in the middle of the night because I think there is a knocking on the door like in quarantine.
“Then I have to turn around and remind myself: ‘No, you’re not in quarantine anymore, go back to sleep’.”
* Not their real names