National mental health access, concerns, and resources

The national “Health Sector Emergency Response Plan for Novel Coronavirus (COVID-19)” was published by the Federal Government on the February 18, 2020 (Australian Government Department of Health, 2020b). The strategic objectives in this plan include characterizing the clinical severity of the disease in Australia, minimizing transmissibility of the virus, minimizing health care system burden, and informing and empowering the public.

Although initially access to mental health services fell under the post-crisis, “stand-down” phase of the national response plan, the federal government (Australian Government Department of Health, 2020c), as well as peak healthcare organizations across the nation, soon realized the need for ongoing and improved access to mental healthcare services. For example, telehealth items have been greatly expanded across all professions, for all Australians irrespective of COVID-19 status, including psychotherapy items for psychologists and psychiatrists, and both telephone and videoconferencing items have been included (Australian Government Department of Health (2020d). Access to flexible ways to deliver “care at a distance” is important with respect to the treatment of older adults, who may have difficulty connecting with mental healthcare providers over videoconferencing platforms and are at increased risk of hospitalization and death from COVID-19. This has not been the case in all countries’ responses to COVID-19, for example, in the United States, the Centers for Medicare and Medicaid Services had stated that services by psychologists count as telehealth only if they include two-way audio and video components (American Psychological Association, 2020a), and this has only very recently been modified to include telephone-only consultations (American Psychological Association, 2020b).

The timing of the coronavirus reaching Australia in many ways could not have been worse. In late 2019 and early 2020, Australia was ravaged by intense bushfires which resulted in great human and wildlife losses, and the devastation of (largely regional) businesses and important national park areas. This national disaster affected all Australian states and territories and followed several years of severe drought that had adversely affected the health and financial well-being particularly of regional and rural farming communities. Although the cumulative fiscal effects of these events – drought, bushfires, COVID-19 – have been written about (The Guardian, 2020b), less attention has been paid to the cumulative health and particularly mental health effects of these sequential traumatic events on the Australian public and the difficulties accessing mental health services. Older adults aged 60–69 lost their life in the greatest numbers in Australian bushfires over the last decade; many of these were older persons attempting to save their property, or not evacuating in time (PreventionWeb 2020). Loss of homes, death of partners, lack of mental health support, and (for some) the subsequent trauma of severe flooding following the fires exacted an enormous toll on older adults. Now with COVID-19 restrictions, psychosocial support is for the most part obtained only at a physical distance, over the telephone or other electronic means, and for older persons doubly affected by these disasters and COVID-19, this is a huge strain. Both the recent natural disasters as well as the COVID-19 situation also have severely tested the disaster preparedness of Australia’s nursing home care industry.

Older people in the community, particularly those living alone, who rely on community services such as meals on wheels, home help and community nurses, or access to day centers and communal activities, now find that these are curtailed or ceased with the lockdown conditions. Others decide not to allow services into their home for fear of being infected, with potential deleterious effects on their well-being. Community announcements have been urging neighbors to provide help for older persons by offering to shop, pick up medications, provide food parcels at their door, or simply telephone or leave a note of support. Many older persons may benefit from this outreach, but those at greatest economic disadvantage and socially most isolated may well fall through the cracks.

Older people awaiting elective surgery or having treatments for comorbidities are having to wait, sometimes in pain or to the detriment of their health. Unanticipated risks, such as a greater risk of falls for those waiting for hip replacements, may also lead to premature nursing home admissions. Although elective surgery will be gradually opened back up nationwide in May 2020, because of concerns about their increased vulnerability to the virus, both older adults themselves as well as providers may still be deterred from undergoing such procedures.

The shutdown due to COVID-19 has resulted in major unemployment and an economic crisis that have wreaked havoc globally. Australia has a strong welfare system which has now been boosted by massive government spending in financial support for businesses, the unemployed, rent assistance, and deferred or reduced tax payments. Families have been advised not to visit their older relatives, and some face additional burden in how to provide financial support. Older adults themselves are concerned about their superannuation given the state of world markets, which has also caused much worry and distress for them. These stresses increase the risk of anxiety and depression for older adults as well as younger persons.

Unique Australian circumstances of COVID-19 transmission

A significant proportion of confirmed cases of COVID-19 acquired the virus, while overseas (64%), persons returning from Europe and the Americas, as well as those returning from cruise ships, make up by far the three largest components of these cases (Australian Government Department of Health, 2020a). In 2018, Australia was the 5th largest cruise market globally, with 1.43 million Australians accounting for approximately 5.2% of all global cruise passengers (from an estimated 30 million each year) (Cruise Lines International Association, 2019; Moriarty et al., Reference Moriarty2020). Importantly, a third of the world’s cruising passengers in 2018 were over the age of 60, with 19% aged between 60 and 69 and 14% over 70 (Cruise Lines International Association, 2018).

As the unprecedented COVID-19 pandemic unfolded, cruise ships found themselves denied entry to scheduled ports as infection rates rapidly escalated in popular destinations such as Asia and the Mediterranean. Cruise lines faced no alternative but cancellation and return to home ports for ships mid-cruise. On March 15, 2020, Australia banned cruise ships arriving from foreign ports, but exempted four ships already headed to Australia. One of these, the Australian-based Ruby Princess has since become notorious as the primary carrier of cruise-based COVID-19 into Australia, responsible for 10% of returning traveler cases (The Guardian, 2020a) because passengers were allowed to disembark without quarantine. To date, the death toll from COVID-19 attributed to the Ruby Princess has reached 21, and up to 600 more have been infected across Australia (ABC News Australia, 2020). A criminal investigation has begun by New South Wales Police to determine why the ship had been permitted to dock, and passengers to disembark, without quarantine. Subsequent ships allowed into Australian ports have seen all Australian passengers quarantined immediately on disembarkation.

Risk is inherent in all travel, particularly for older passengers and those with chronic health conditions. Travel by older adults with disabilities is on the rise, fueled by an aging population and advances in accessibility and technology. In 2015, more than half of Australians over 65 had some form of disability. Cruise Lines International Association is the world’s largest cruise industry trade association, representing more than 95% of cruise capacity, and has no published guidelines specific to passengers over 65 although many individual cruise lines have internal policies about pre-existing conditions, medications, medical treatments, and mobility aids including guide dogs (Cruise Lines International Association, 2020).

For older travelers, this figure raises safety issues in cruise travel. Medical facilities on board can manage routine medical conditions and the most common shipboard issues, for example, respiratory infections, motion sickness, injuries, and gastrointestinal issues. However, stabilization and evacuation are realities for severe conditions. Medical care is expensive and travel insurance is essential.

Specifically, mobility, cognition, and the stability and management of existing chronic diseases are issues for older cruise travelers. Considerable walking, stability, and agility is required on ships to negotiate compact cabins, use stairs, elevators and gangplanks, and tolerate rougher seas. Wayfinding issues related to cognitive changes can complicate movement about the ship. Older passengers may have to walk more than they typically would at home, become “cabin bound” to avoid walking, or become easily disoriented and reliant on others for help. The capacity to understand and respond to safety procedures such as drills, public address announcements, and notices is critical. Ensuring a longer than adequate supply of all prescription medications, any regular supplements and a first aid kit tailored to individual potential needs is prudent. Remaining active and engaged on the ship and keeping healthy eating, sleeping, and hand hygiene habits all contribute to maintaining wellness.

Older travelers with concerns can consider selecting cruise lines that use sophisticated color-coded digital signage systems for wayfinding onboard, travelling with family or younger companions and taking shorter cruises of 7–14 days. Having effective ways to communicate with family and friends and stay socially connected are a challenge on ships at sea because the Internet is often unreliable and expensive satellite phones are expensive. However, knowing how to use a computer and the Internet, considering using social media, and designating an individual family member or friend to communicate with social networks on behalf of the older person should the need arise can make untoward events more manageable.

During the pandemic uncertainty about what would happen to travelers on board ships, news of the escalation of COVID-19 globally while on board ship with limited communication options, and the lengths of time in strict hotel quarantine affected all passengers, more so older and frailer passengers.

The example of the Ruby Princess cruise ship illustrates the complexity of safely dealing with large numbers of potentially infected people quickly to protect the health of the broader public. The US Centers for Disease Control and the World Health Organization provide general guidance on sea travel and safety precautions for passengers, crew and cruise companies, as do individual countries globally, and do note specific concerns for older people. However, the COVID-19 pandemic and the extensive unplanned at sea and quarantine periods required worldwide highlight the need for a greater level of focus on support of older passengers to ensure that they, their families and cruise lines understand risk. Robust guidelines and procedures relevant to older people must be in place if, and when, cruise travel resumes across the globe, including protocols reflecting scientific and medical knowledge about COVID-19.

Populations at risk in Australia

Final thoughts/summary

Global health crises have occurred periodically over the centuries. The pandemic of COVID-19 is the most devastating worldwide health crisis since the 1918 Spanish Flu. It has forced nations to reconsider their health plans and economic decisions. Gandhi in 1931 stated that “A nation’s greatness is measured by how it treats its weakest members”. We can now be judged by how well we support and care for our older population, the people most vulnerable to COVID-19.