Almost two weeks in but AS* has still not been able to get over the shock of being laid off, that too, over the telephone. That awkward conversation with the HR manager of the company she worked with keeps replaying in her mind.

"She talked about recession and global crisis and that they had to let go of some people to save others...," says AS*. She says she was "angry" and also misbehaved as "it hit me so hard and at a time like this", AS says, referring to the lockdown caused by the Covid-19 pandemic. Her voice trembled and she often broke down as she went over the details of her sacking.

Professor emeritus at Aga Khan University Hospital's department of psychiatry, Dr Murad Moosa Khan, fears that the mental health consequences, such as anxiety, depression, post-traumatic disorders, from the pandemic will be enormous and unimaginable. He warns that this could lead to self-medication and that "unemployment, job losses, and decreased income will further exacerbate these".

"Losing a job is a huge trauma and one of the biggest causes of stress," says Dr Ayesha Mian, associate professor at the AKU, who practices as an adult and pediatric psychiatrist. "It’s up there with the loss of a loved one or a divorce," she says.

Also read: The Covid-19 emergency and prioritising public health in Pakistan

Feeling betrayed, AS, who is a 28-year young marketing strategist, says had one of the company's owners, who happened to be her friend and who had convinced her to leave her previous job a year-and-a-half ago, had "had an honest conversation" with her, she would perhaps not have felt so "broken-hearted".

"I'd have offered taking a three-month unpaid leave but the HR person said they didn't want to commit given the uncertainty. It feels terrible; I feel betrayed," says AS.

Be generous

While it helps to understand that at this moment, we are all in the same boat, it also helps to be "kind, generous and compassionate", says Dr Mian, adding that that is also "good for one's mental well-being".

"Even if you can’t promise full salaries, can you manage half, can you manage a minimum? Can you promise a job back in three or six months?" she says, adding that this is the time to build goodwill and loyalty. Luckily for AS, she does not depend solely on her monthly paycheck as she lives with her parents, both of whom are working.

For 30-year old MS*, a barber and sole breadwinner with four family members relying on his daily wages, the pandemic has closed all avenues of employment for now.

"I would earn anywhere between PKR800-1000 (for every Rs250 per haircut the salon charged a customer, he would get only Rs15]," but the tips from customers (on good days he would make as much as Rs2000) helped enormously.

Two weeks into the lockdown, the strain is already showing on MS's household. "We were never big spenders, but now we have become very mindful about what we are eating," he says and whispers hesitantly: "I never thought a time would come when I'd have to ask people to help me with rations."

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"In our context, if the man is the only earner in the family or the only one who is primed to work, this brings upon an additional layer of responsibility," says Dr Mian. "Loss of job means loss of self esteem and a sense of self," she says, warning that it could lead to other issues like increase in anxiety, depression, anger outbursts, even domestic or child abuse in the household.

Living in a world of uncertainty

To Lahore-based Dr Ali Madeeh Hashmi, an associate professor of psychiatry at the King Edward Medical University (KEMU), the uncertainty is the biggest stressor. "How long will this last; what is going to happen, who will get sick, how many people might die, all of that is frightening for everyone, especially when you see what is happening in Italy, in Spain and now in the US," he says, adding that "instant communication" with photos, audios and videos going viral in seconds was just adding to people’s stress.

He has been advising people he sees to do a few basic things. "Get off your screens; stop looking at your smartphone, your tablet, your computer, and your TV all day and all night. The news coming from the media and social media will only stress you out more. Go outside and take a walk; don't violate the lockdown and maintain appropriate social distance of six feet or more from another person; enjoy the mild spring weather; sit with your family members and learn again how to talk to another person without a screen distracting you. I have been teaching my children how to ride a bicycle and they are enjoying that. You can play board games at home, read books, do yoga or take up another exercise. Do the things that can actually help with relieving stress. If you or a family member is not sick, stop worrying about it."

The KEMU, where he teaches, and its affiliated hospitals, including Mayo Hospital (Lahore's designated hospital for Covid-19 patients) has just started a telemedicine department including a Corona/Covid-19 helpline which is manned round the clock. "Our telemedicine department is offering free of cost, expert advice in all the major specialties including psychiatry and mental health," informs Dr Hashmi.

The telepsychiatry service offers services 24/7 especially keeping in view the Covid-19 situation. "We have both a Skype ID and a cell number and land line number all provided by the government of Punjab. Our psychiatrists are available round the clock for anyone who needs advice about mental health issues, either related to Covid-19 or about pre-existing mental health issues which have been aggravated by the lock down," says Dr Hashmi.

In addition, because movement is restricted due to the lockdown, he says, people can call in and get their medicines refilled if needed; get counseling or basic advice about how to cope with stress, depression, and anxiety about Covid-19 etc. "So far, the volume of calls is low because it a very new service and people in Pakistan are still not used to getting medical services online (although it's an established form of healthcare delivery) but we are putting the word out that we are available if people need help," he adds.

Family as shock-absorbers

In the absence of well-developed social welfare systems, like in the west, where people can easily access and make their claims, the impact of economic recession will be different in Pakistan, specially given the already high unemployment rate and poverty levels, says Dr Khan. Prime Minister Imran Khan unveiled a Rs 1.2 trillion economic plan to minimise the damage to the vulnerable. But Dr Khan is unimpressed. The package announced by the government is "nowhere near what is required to address the problem", he points out, adding: "We also do not have systems which can disburse the funds."

Meanwhile, Dr Hashmi argues that Pakistani workers are also not completely at the mercy of their employers. The "family is our safety net" he says, emphasising that the main benefit of the extended family is provision of "support and help for young children, the sick and the elderly".

Read further: With Covid-19, healthcare workers are having to choose who gets a chance to live, and who will be left to die

It also means that some of the "losses will also be absorbed," says Dr Mian. But in the Pakistani context, we see that large families are often dependent on just one or two people, as is the case of MS, and not all potential has been utilised. "In such cases, losing their sole source of income may be harder," she argues.

From a purely mental healthcare point of you, the family structure that exists will help blunt the blow of isolation. "Seek family counsel, make decisions taking everyone in confidence; share your worries without overburdening or spilling over your anxieties on to others," suggests Dr Mian.

And because the situation is really not under anyone's control it is important to keep things in perspective. It may also be a time to "reinvent", "re-imagine", and "think out-of-the-box" she proposes. "Another person in the family maybe in a position to help, like the wife, the mother, the sister, the son or the daughter, who has skills that have not yet been tapped," she adds.

Processing loss by the fortunate

But the more fortunate do not have it easy either.

"I am getting sleepless nights," admits forty-something, ZA*, an entrepreneur. In the last 14 years, she had devoted all her time and passion into her karkhana (furniture workshop) which today has a little under four dozen people in direct employment but there is a much longer list of suppliers and craftsmen who she outsources work to.

"Each one of these people, over the years, has become almost like an extended family member despite our very different backgrounds. We have shared successes and failures and overcome difficulties together," she says.

For me, keeping them safe and protecting them is paramount. However, she says she was unsure "how long I’ll be able to do this". All her workers received their salaries even before the month began. "Life for them, even before Covid-19 hit us, was already difficult," she says, giving the example of one of her workers. "He had to put his father into a mental asylum last month because of his repeated attempts at suicide after getting laid off; the same fellow lost his sister, brother-in-law and their two children in a motorcycle accident just two weeks back and only last month he had taken a loan of Rs25,000 to make ends meet." But then almost 40% of her workers have running loans due to a variety of reasons, ranging from illness or death in the family to home repairs to child birth and weddings.

"I am at a loss to understand how they will manage to survive under an even bigger economic crunch and an illness looming over their heads. When I think about them, the better air quality index and the new birds visible in my garden fail to cheer me up," says the young woman.

Dr Khan says many such people have reached out to him "both informally and formally" for help. "Many feel very guilty about laying off workers but there are many others who are keeping them on their payroll. They feel very helpless and distressed, which invariably affects their mental health," he says.

"Everyone has a lot of hard decisions lying ahead of them. The choice is in how those are communicated, with how much sincerity, authenticity and compassion," says Dr Mian, who agreed that company and institution leads are having to make some very difficult decisions. "An analogy is when a doctor has to decide which patient to put on a ventilator if we don’t have enough devices. Making those choices are overwhelming and emotionally exhausting and lead to a lot of anxiety."

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For now, ZA has a plan to ride the tide. "I know I can manage their salaries on my own for the next month, after that I plan on borrowing from my husband and family members." But she doesn’t know how long she can go on like this.

And it is in these times of uncertainty and despair that people do things that warm and melt your heart and rekindle your faith in humanity, she says. One of ZA's workers, whose salary is on the lower scale than several of his colleagues and who is also the sole bread winner with seven kids to feed, offered to forego his salary in case there was someone needier than him.

Philanthropy

To his mind, Dr Khan says rapidly setting up local committees of trustworthy people, disbursing the funds to them (or giving them foodstuff) and empowering them to distribute further could be an effective solution. "Here technology could be used to both register people as well to monitor them through apps etc," he says.

And that is where the Karachi Relief Trust (KRT) comes in. It has come up with just such an app called the Sindh Relief Initiative (SRI). "The idea came during brainstorming sessions which Chief Minister Murad Ali Shah was holding with philanthropists and charities," says Khayam Husain, a volunteer and trustee at the KRT. "The idea is to efficiently distribute and track rations and avoid duplication," he says.

The SRI, a very simple app, downloaded free of cost from Google's Play Store, will capture the beneficiary’s data (CNIC number, home address, mobile phone number, and location). A unique code will be generated which will send a message to the beneficiary's phone via SMS. When the rations are delivered to his/her doorstep, the code is entered into the app; a verification is received but data will remain preserved in the back-end for future.

To avoid people gathering to receive rations, KRT has partnered with Careem which will not charge the trust. However, the captains will be paid Rs100 per delivery as their income has been badly affected by the lockdown," says Husain. Further, Careem, has also integrated their app so that donations can be made to KRT via Careem Pay.

State of panic could lead to rioting

If things go all awry, there is a serious potential of social unrest, warns Dr Murad. "Even now, people are putting their experiences on social media where, when they try to help they get mobbed with their cars surrounded and vandalised," he says, fearing that it may get worse the longer this continues.

Prominent academic and human rights activist, Ammar Ali Jan can also foresees the "wrath of the people" if the crisis is not handled sensibly. People in food insecure households are already in a "state of panic", with the most agonising part being to "see their children and other family members going hungry" as it gnaws at their "sense of worth and dignity".

Teaching at Lahore's Forman Christian College, Jan fears that this build-up of shame and rage may explode in either "anti-government protests, or directionless rioting".

The solution, according to him is to "socialise food distribution". It would mean the production and distribution of food would be controlled by government representatives and will be based on needs. "We have surplus food; it's a shame that people should go hungry because some are waiting to make a profit. Basically, we have to erase the concept of profit till we are in lockdown as no new wealth can be produced. The existing wealth has to be redistributed," he says, adding: "Each family must receive enough food; nothing else matters for the moment."

A member of the Haqooq-i-Khalq Movement, Jan however, remains sceptical of these "redistributive measures" which the government has so far been hesitant to undertake due to the "influence of powerful businesses and landed interests".

*Names of people interviewed withheld on request