The lecture of Death and Dying in the context of pandemics has had me reflecting on what death has looked like in various public health crises. The scene of Mark’s death in “The View From Here” was one of the first times I have seen a death from AIDS. I grew up after the worst of the HIV/AIDS crisis and often feel removed from that disease in many ways. Thinking about how at one point death from AIDS was inevitable, and something that could be planned to an extent, is so different from other infectious disease epidemics.

The first time I became aware of pandemic death was really during the Ebola outbreak between 2014-2016 in West Africa. I had been studying the psychology of death through courses and even research, but was so struck by how scary death looked in this setting. News reports showed images of individuals in full PPE carting away body bags, with weary onlookers keeping a distance. The last days were often painful for patients, likely dying of profuse hemorrhage, encephalopathy, or sudden death. If medical care wasn’t available early, death was likely and would often occur quickly.

Of course, our most familiar experiences with ID death now come from the ongoing COVID-19 pandemic. Similar to death from both HIV/AIDS and Ebola, there is an element of fear. But unlike HIV/AIDS, Ebola and COVID deaths often times couldn’t be planned (speaking to HIV after the virus was identified and could be tested). There is a sudden finality to it, with people succumbing very quickly after exhibiting symptoms. There is little time to make arrangements, and no time to alert all loved ones. At points, there were no physical goodbyes, no after-death rituals, and very little closure. If you had not lived through the HIV/AIDS crisis, these events were so new and jarring. Regardless, with each disease, it never gets easier. While noncommunicable diseases are the most often causes of death, I’m afraid the future will hold more infectious disease outbreaks. This means thinking about how to handle death with both old and new challenges.

For this post, I’d like to talk about my experience as a front-line worker during the earliest parts of the COVID-19 pandemic. By March of 2020, I had been working as a flight attendant for just over 3 years. The career brought me a lot of joy and allowed me to have so much freedom. I genuinely enjoyed every aspect of the job. However, like a light turning out, that so quickly faded when the pandemic began. At first there was fear of infection, fear of keeping myself and my family safe. Then, as planes emptied and airports became ghost towns, a new fear of the greater global instability that lay ahead set in.

For a short period, there simply was no flying. My scheduled trips dwindled and when I did work, it was to fly passenger-less planes to hangars for maintenance. After a few months, people came back, but really only out of necessity. A few more months after that, flights resumed to at least 75% capacity. However, these passengers were unlike anything I had experienced before. They were angry, tired, stubborn, impatient, and probably afraid. It suddenly felt like every flight was a point of contention, a fight to have them mask, or simply just obey basic air safety instructions. The job became exhausting and anxiety-provoking.

I talk about my experience to give a little insight for those that maybe had the ability or luxury to stay at home. While I was so grateful to still have a job, it can still be okay to acknowledge how difficult that time was. As a result, so many in the aviation industry simply quit or retired early. There was a collective fatigue that formed not just within my field, but everywhere. In a good way, people began to realize there were other options for work. People also went back to school (me!), or began new trades, or found ways to work from home. The shift we saw, with individuals demanding more from their careers, was incredibly inspiring and still continues to be.

Last Tuesday we had the pleasure of listening to Dr. Thrasher speak about the “Viral Underclass”, a concept that had gained traction as the COVID-19 pandemic spread. In the introductory chapter of his book, he quotes his friend: ‘look at the map of COVID-19 rates. It is a map of poverty, racism, and overpolicing. People are dying in jail and because they have been to jail’. This struck me as a critical component of this ‘underclass’.

Last January, I had to opportunity to work inside of Fulton County’s jail to test individuals inside for COVID. We worked in teams to go from unit to unit, to each cell to offer tests. I had never before been so up close and personal to both COVID and the jail system. However, through discussions with these men, so many challenges to maintaining health became apparent. There of course was no where to social distance, no masks available, no regularly administered tests. Many of these men were awaiting trial or sentencing, existing in a limbo and vulnerable to infection.

The pandemic experiences of these men from those on the outside are so starkly different. Incarcerated individuals are infected with COVID at a rate more than five times higher than the nation’s overall rate (Equal Justice Initiative). Then, of course, there’s other factors. Race, poverty, systemic barriers all contribute to the perpetual problem of incarceration. To also allow people to suffer with infection and possibly death while under the supervision of the state is an injustice unlike any other. We know incarceration creates a cycle of oppression, but we have now opened the door to even more lifelong challenges. When the risk of death and long-COVID are added to the equation, there is no aspect of life that is untouched by this inequality.

I so greatly appreciated Dr. Dube’s storytelling and the impact of religious entities on stigma and health. Throughout the COVID pandemic, this has also been seen, but in other religions as well. In the Orthodox Jewish communities of both New York and in Israel, there have been ongoing conversations on striking the balance between religious law and controlling infectious disease.

Early in the pandemic, celebrations for Jewish holidays served as super-spreader events. This eventually led to tension between the government entities involved in curbing the spread and religious leaders. However, a key component of stopping infection is to work WITH communities and not against. There have been examples of this unity in both the United States and Israel where there are large populations of Orthodox Jews (see here and here).Similar to the stories Dr. Dube shared, community and respect for religious leaders are incredibly important to this population. By engaging both, a mutual benefitting relationship can be formed. Interestingly, in Israel experts had to use various strategies to educate the public on COVID safety. Not only did they seek out guidance from Rabbis, they utilized Orthodox telephone news hotlines called nayes to stop misinformation.

Like in Dr. Dube’s story, once these religious figures were educated on the risk, they saw the value in speaking on it and implementing safety measures. However, the Jewish Orthodox oftentimes being a closed off community, this meant a give and take had to take place. With the help of Rabbis, members of the Synagogue could worship together if masking was enforced and vaccinations were encouraged. We have learned from these stories of the pandemics that change occurs not from outside dictation, but from community buy-in.

With Tuesday’s lecture focused on effective communication strategies and both great and poor communication examples shows, I have been thinking of message tailoring. During the COVID-19 pandemic we saw more attention being paid to this. Diverse and marginalized groups have historically faced medical racism, or worse, medical violence. In the United States, there has been the forced sterilization of Indigenous women, the Tuskegee syphilis study, and experimental treatment on incarcerated individuals. How do you gain trust during a public health crisis when these populations have experienced trauma at the hands of experts?

Within the African American community, there exists a rightful hesitation with regards to the COVID vaccine. With time and attention brought to more tailored approaches of messaging, this has improved. However, as each new booster rolls out, oftentimes concern remains. When thinking about both acknowledging the mistrust and providing education, it’s a careful balance. After doing some more research, I found this interesting infographic published by the Association of Immunization Managers.

Association of Immunization Managers

While the issue of gaining trust is incredibly complex, what I appreciate about this message are the points of ‘acknowledge values and lived experiences’ and ‘support the process of decisions making’. I believe that a good public health message does include both aspects; saying ‘you have every right to feel this way’ and ‘you have the right to make this health decision’ returns autonomy to the individual. For tailoring communication, both must be included in order to even be heard. To use these techniques first and foremost with marginalized groups can not only get your foot in the door, but also considers the ethical principles of public health.