Lessons on the Plagues from History

By Claudio Lehmann, MD

This piece was originally published in the March/April issue of the Tarrant County Physician. You can read find the full magazine here.


We can all learn in many ways from the intellect of Greece and Rome. This principle applies to infectious events which took place in those societies in the long distant past and were well documented by ancient writers in their descriptions of early epidemics. 

In these difficult COVID-19 times we still rely on these empiric approaches obtained from past management of epidemics in times of war and peace. We have also learned how to complement this management with careful scientific research and study to develop more specific treatments and successful vaccination programs. Additionally, we have learned that it is important to have consistent, well-coordinated public education. 

The Athenian Plague 

This plague occurred in the setting of the Peloponnesian War, a long war caused by conflicts between the states of Athens and Sparta and their allies.1,2,3 Democracy originated in Athens in 500 B.C. It was brought about through the assembly of the 500, a group chosen to make important decisions regarding essential affairs of the city. 

Athens, expanding into Attica and controlling the surrounding Ionian Islands, established the Athenian (also called Delian) League and built a naval empire. It became wealthy by exporting olive oil and wine and trading silver from nearby mines. It thrived under Pericles, a leader who built the Parthenon and encouraged culture and creativity in the city. 

Sparta, by contrast, was a land-locked military state comprised of rigorously trained soldiers. It was ruled by kings that controlled underclass servants. They also expanded into neighboring city-states. Athens and Sparta became rivals that clashed due to their different styles of government and policy.1,2,3 

The Spartans also built their own defensive alliance, the Peloponnesian League, which antagonized the Athenian League. 

Athens protected its neighboring states from Spartan attacks and built walls between Athens and Piraeus (also spelled Peiraieus). To prevent further clashes Athens and Sparta signed a peace agreement, but the Spartans and their allies disliked the democratic and expansive Athenian approach and felt it needed to exercise greater restraint. Therefore, in 431 B.C., Spartan troops and allies made several incursions through Attica into Athens. This started a long series of battles with inconclusive results that were fought for 26 years in different sites either by land or sea. This ruined the Greek economy, adversely affected the lives of many families, and changed the course of Greek history. 

This so-called Peloponnesian War has been described at length by the brilliant general and historian Thucydides and is still studied by contemporary researchers.1,2,3 The final downfall and cultural deterioration of Athens was caused by the combination of damage to its fleet after a failed invasion of Sicily and by the enormous loss of life caused by the Athenian plague. 

This epidemic started in the second year of the Peloponnesian War, after the Spartan invasion and siege of Athens in 430 B.C. As reported by Thucydides, this disease appeared suddenly, with high fever, red eyes, sore throat and tongue, hoarseness and cough, vomiting bile, severe diarrhea, restlessness, purplish cutaneous pustules and ulcers, and also lesions over fingers and toes, sometimes with gangrene. Recent review articles suggest that the most likely epidemiological diagnosis was smallpox, with typhus being less probable.5 It did not appear to be bubonic plague. 

Thucydides described the overcrowding in the walled city of Athens where he proposed the important concept of contagion of disease. He defined it as the transmission of illness from a sick person to a healthy individual. He was then influenced by the ideas of Hippocrates, who claimed that the secretions of a sick individual would contaminate the air during an epidemic.6

This proposal anteceded by thousands of years Pasteur’s and Koch’s observations on germ transmission. Thucydides also noted that death could occur on the seventh or eighth day of disease but observed that those who recovered might acquire partial immunity and did not die from a second round of disease. 

Waves of infection affecting the local population led to the death of one-third of Athens’ inhabitants. So many of the dead remained unburied that at times the corpses piled up on the street. Thucydides blamed this on lack of humanitarian response of the survivors. He himself, who got the disease and recovered, suggested avoiding overcrowding and exposure to the sick; however, Pericles, who was leading Athens at the time of the infection, suggested the transfer of rural refugees to the walled city. This increased the risk of their contagion. He also became a victim of the illness, from which he did not survive. 

Euripides, who also lived at the time of the war in 415 B.C., described in an allegorical drama, “The Trojan Women,” a prophecy for a tragedy that predicted the disaster that would befall Athens after the failed Sicilian campaign when Athens lost her entire fleet, and a large number of young sailors became enslaved. This was a message on bad war planning in a Greek drama written in the fifth century B.C.7

As Rome conquered Greek territories, the Roman Empire in turn was deeply influenced by Greek culture, which became integrated into buildings and sculptures. The Roman Empire was also influenced by their religious beliefs and images. Hellenistic centers created in Alexandria and in cities of Asia Minor were later absorbed and integrated into Rome. 

Antonine Plague 

The first recorded epidemic in Roman times was called the “Antonine plague.” It appeared in A.D. 165 to 180, and waves of disease followed between 211 and 266. To Galen, the observant Greek physician, the victims presented with fever, chills, sore throat, bloody diarrhea turning black, and a pustular rash on the ninth day consistent with smallpox. The acute phase of the disease lasted two weeks. It affected large numbers of Roman residents, with high mortality due to the density of population and excess of waste and sewage.4 It killed Marcus Aurelius Antoninus and Lucius Verus, the two reigning emperors.8 It is believed that the Roman soldiers brought the organism from Egypt and the Middle East into Rome. 

In those times, early Christians were persecuted for refusing to honor the Roman gods. However, they endeared themselves to the sick for providing them with some form of care. 

The Roman Empire later became stretched financially by excessive warfare, rapid emperor turnover, and increased civil wars. Rome was eventually sacked by invading Visigoths in 410, and the last western emperor was deposed in 476 A.D. 

Justinian Plague 

The Eastern branch of the Roman Empire was then established with Constantinople as the capital of what was to become the Byzantine Empire. A different type of plague appeared in 541 A.D. during the Emperor Justinian’s rule in Constantinople. Justinian (527- 565 A.D.) is known for military campaigns, civil law reforms (he wrote Codex Justinianeus), and for creating important buildings (Hagia Sophia in 562 A.D.). 

It has been claimed that this plague caused the loss of up to one-third of the total Mediterranean population. It may have presented in recurrent intermittent waves that, lasted up to 200 years. It has also been suggested that it led to the waning of the Roman Empire and the advent of the Middle Ages.11

The historian Procopius (500 – 565 A.D.) described the appearance of this plague in Pelusium, Egypt, on the Eastern Nile, and its spread to Alexandria and later to Constantinople, Asia Minor, and the Middle East. 

Procopius observed subjects with fever. They had “large painful swellings” in groins, armpits, and neck followed by delirium, black blisters, and vomiting, which frequently led to death. Occasionally, he noted, “The lumps start draining pus, the fever subsides, and the person sometimes may even recover.” There were similar reports from other observers at that time, like John of Ephesus.8

We know now that rats carrying fleas were brought in by ships supplying grain from Africa to Constantinople. Bubonic plague’s causative organism, Yersinia pestis, has been isolated and its DNA sequenced.10 This was obtained from tombs in sixth century Bavaria. It was found to represent a distinct genetic lineage originating from a different rodent reservoir for this pandemic than the one occurring in medieval Europe. 

States controlled by Athens (blue) and Sparta (red) at war1 

A recent detailed research paper by a multidisciplinary group questions the Justinian plague as being such a watershed event in history.9 After examining a series of independent fields of study such as papyri, inscriptions, and coins as well as pollen and burial sites, the authors conclude there is little evidence that the Justinian plague was a major driver of demographic change in the sixth century Mediterranean area. These findings indicate this plague was therefore very different from the devastating second pandemic that presented later in the Middle Ages. 

We have learned that two ancient pandemics, the Athenian plague in early Greece and the Antonine plague in early Rome, appeared in cities with overcrowded populations. Their disease presentation at the time indicated exposure to a highly infectious, rapidly spreading agent that caused an acute, devastating disease of high mortality. Both epidemics had similar clinical presentation, in which fever and mucosal and pustular skin lesions predominated. We know now that they most likely represented smallpox, and this disease became airborne from mucosal lesions but could also spread by contact of skin ulcerations. It affected people of all social classes, including leaders and emperors. Such a contagious disease would have made patient care very risky and difficult. No wonder the corpses piled up on the streets of Athens! 

Smallpox ravaged the entire world. It reached the Americas, including the U.S. and Mexico during colonial times. It decimated the Aztecs when the Spanish conquistadors arrived in Tenochtitlan, as the Aztecs had no previous exposure to this virus.

After Jenner published his spectacular results with vaccination in 1798, smallpox immunization was eventually adopted all over the world and the disease was completely eradicated by 1980. 

Prevention of social gatherings was applied during the severe 1918 flu pandemic with measures such as closures of schools, shops, and restaurants, mandated social distancing, and home quarantining when needed. In cities in which these multiple recommendations were implemented earlier and kept in place, transmission of disease and mortality were reduced. This beneficial result demonstrates that avoidance of contact between individuals can be helpful in controlling transmission of highly contagious disease, which is why this approach is being used for the management of the COVID-19 virus. 

References 

1RMorkot-HistAtlas Ancient Greece-
Penguin 1stEd 1996 

2D Kagan – The Peloponnesian War –
Viking 2003 

3VHanson-A War Like No Other-
RandomHouse2006 

4ErinyHanna-Cities,Disease,Trade,
Epidemics in Roman Empire
Vanderbilt-Uni 2015 

5RLittman-The plague of Athens.
Epidemiol and Paleopathology.
Mt.SinaiJMed 76:456 

6HippocraticWritings:The natureof man
Penguinclassic1983 

7Euripides TheTrojan women Signet classic 1998 

8GKohn; Encyclopedia of Plague and
PestilenceWordsworth1995 

9LMordechai-The Justinian Plague An Inconsequential Pandemic? PNAS 116-5125546 

10D Wagner – Yersinia Pestis and the Plague – Genomic Analysis Lancet 14 April 2014 

11Bassareo – Learning from the past in Covid-19 Era – Post Grad Med J 114:633 

Images

1Souza, Philip De, The Peloponnesian War, 431-404 BC., (Oxford: Osprey, 2002). 

Tarrant County COVID-19 Activity – 03/30/21


COVID-19 Positive cases: 250,646

COVID-19 related deaths: 3284

Recovered COVID-19 cases: 242,147

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Tuesday, March 30, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Tarrant County COVID-19 Activity – 03/25/21

COVID-19 Positive cases: 249,821

COVID-19 related deaths: 3240

Recovered COVID-19 cases: 240,498

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, March 25, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

Stop Six neighborhood gets expanded access to COVID-19 vaccine

A vaccine distribution site is now open at the Brighter Outlook Center at Ebenezer Baptist Church, 4910 Dunbar St. in Stop Six.

This vaccination site is a partnership between Tarrant County, Tarrant County Public Health, and the University of North Texas Health Science Center to bring vaccinations to underserved communities. In addition to vaccines, the clinic will provide outreach and education to the Stop Six community.

To access the vaccinations, people must be registered through the Tarrant County Public Health Department. Those without internet access can call the hotline at 817-248-6299.

To assist residents in underserved neighborhoods with the registration process, there will be a pop-up vaccine registration event through March 25 at Tarrant County College South Campus, 5301 Circle Drive, in the Music Building. The event is open from 3-7 p.m. and is sponsored by Tarrant County Commissioner Roy Brooks.

The Texas Department of State Health Services announced this week that all adults will be eligible to receive a COVID-19 vaccine in Texas beginning March 29.

Additional clinics coming to underserved areas

The University of North Texas Health Science Center at Fort Worth has contracted with OptumServe, a national health care services business, to help expand access to the COVID-19 vaccine into underserved and hard-to-reach neighborhoods in Tarrant County. Besides the Stop Six clinic, additional sites in north and west Fort Worth also are under consideration.

“OptumServe has a proven track record in end-to-end COVID-19 vaccine administration,” said Dr. Sylvia Trent-Adams, HSC chief strategy officer. “Together, we will take a data-driven approach to expanding access to the vaccine in hard-to-reach communities and, importantly, build a relationship of trust and understanding with the people who live there.”

The contract is part of an agreement between HSC and Tarrant County to expand access to the vaccine and overcome vaccine hesitancy. HSC recently unveiled to Tarrant County Commissioners a plan to identity potential vaccination sites, promote registration and provide information to people who may be reluctant to get vaccinated. HSC also is forming partnerships with community leaders familiar with those neighborhoods to serve as voices of trust and build relationships.

Vaccine assistant positions open

Fort Worth will begin hiring part-time vaccine site assistants to staff community clinics. Pay is $15 per hour, and the assistants will work for up to 10 months.

Up to 100 positions are available. These positions will not administer vaccines. These positions will support all other roles, which may include registration, recordkeeping, customer service, site cleanliness and general vaccination site support.

Vaccine site assistants will be assigned to clinics at the Bob Bolen Public Safety Complex or Farrington Field in support of COVID-19 operations and will be expected to maintain a work schedule of at least 20 hours a week with the opportunity to work up to 40 hours per week. Assistants fluent in Spanish are preferred.

Apply for the vaccine assistant position online. 

Tarrant County COVID-19 Activity – 03/23/21

COVID-19 Positive cases: 249,418

COVID-19 related deaths: 3226

Recovered COVID-19 cases: 239,433

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Tuesday, March 23, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

With vaccine supply increasing, use online portal to make appointments

COVID-19 vaccination clinics are being added at additional locations across Tarrant County, and officials are encouraging residents to register online for an appointment.

Tarrant County Public Health maintains an online portal that allows eligible residents to easily register for a no-cost vaccine for residents with or without health insurance. Tarrant County Public Health will determine if you qualify for a vaccination and then send an email, text message or phone message regarding upcoming appointments.

Quantities of the coronavirus vaccine are expected to increase over the coming weeks as manufacturing and distribution ramp up. Residents are encouraged to preregister on the website now so that Tarrant County and its partners can better plan for and distribute the vaccine.

Currently, anyone 50 and older, as well as school and licensed child care personnel, are eligible to receive a vaccination. Anyone more than 18 years old with chronic health conditions is also eligible. The Texas Department of State Health Services has information on the criteria used for vaccination priority on their website. You can also find a list of other vaccination locations throughout the state on their website. It is anticipated that everyone will be eligible very soon, so even if you are not currently eligible, it’s acceptable to register now.

Fort Worth Health Officer and Code Compliance Director Brandon Bennett emphasized that people should not visit one of the clinic sites without an appointment. “By registering on the Tarrant County portal, it not only gets your name in the queue for the vaccine, it also helps us plan for future locations for vaccinations,” Bennett said.

People who show up without having used the online portal to make an appointment will be turned away, he said.

Learn more about the vaccine process in Tarrant County. The City of Fort Worth website provides additional information about the vaccination process and other providers in the community.

AMA President Joins TMAF Gala as Honorary Chair

Susan Rudd Bailey, MD, TMA past president and current American Medical Association president, will serve as honorary chair of the TMA Foundation’s virtual gala, Superheroes: Meeting the Challenge, which is scheduled for Friday, May 14, 2021, during TexMed 2021, TMA’s annual meeting. The gala helps make TMA’s population health, science, and quality of care programs possible.

“Clearly the COVID-19 pandemic has called on physicians like no other threat has in our lifetimes,” Dr. Bailey said. “It’s with great pleasure that I join the TMA Foundation gala to recognize and celebrate the courage physicians have shown because of their singular dedication to the health of their patients.”

Dr. Bailey is an allergist in private practice and has been with Fort Worth Allergy and Asthma Associates for more than 30 years. She has a long history of service in organized medicine, having served as TMA vice speaker and speaker and as board chair and president of the Tarrant County Medical Society.

“Please join me, the gala-co-chairs, and the TMAF board by attending this virtual gala, which comes at a time when we need to remain strong and follow where the science leads us. The continued strength and resolve of our physician heroes is needed to see us to the very end of this pandemic,” Dr. Bailey added.

TMAF’s gala will take place as a virtual event from 7 to 8:15 pm (CT) Friday, May 14, with a preshow from 6:30 to 7 pm. It will feature a silent auction, special messages to the health care superheroes in Texas, entertainment from Austin musicians, a party Box for guests and more.

 Purchase your table or tickets  or call (800) 880-1330, ext. 1664, or (512) 370-1664 today for more intormation.

Tarrant County COVID-19 Activity – 03/18/21

COVID-19 Positive cases: 248,317

COVID-19 related deaths: 3160

Recovered COVID-19 cases: 237,427

Data from Tarrant County Public Heath’s (TCPH) report of COVID-19 activity in Tarrant County, updated Thursday, March 18, 2021. Find more COVID-19 information from TCPH here.

*These data are provisional and are subject to change at any time.

Deaths and recovered cases are included in total COVID-19 positive cases.

TURNING 2021 – STARTING THE YEAR MENTALLY FIT

by Aekta Malhotra, MD, MS

Originally published in the January 2021 issue of the Dallas Medical Journal. Reprinted with permission.

There is a prospective optimism that a new year brings allowing a “start over” positivity that helps our collective need to shed and renew. Yet, before we burst out the Champagne, we should process how we got here as 2020 may well have been the most challenging year of our lives, with enough despair, wounds, and wisdom, such that we are Turning 2021, metaphorically speaking, of course.

We have been in the grips of a worldwide pandemic that has upended our personal and professional lives. Our nation’s soul lays bare amidst a fight for racial equality. As the pandemic rages on, our mental health has continued to take a hit. The chronic exposure to stress is causing a variety of issues. The uncertainty, lack of sense of control, and alteration in our values and routines have given way to anxiety. The successive, unexpected changes brought on by the pandemic have also been underscored by a series of losses—our jobs, how we work, our children’s routines, travel, finances, gathering with family and friends, and simple pleasures like eating out and entertainment. This sense of loss over life as we knew it has been a chief driver of depression. When attempting to suppress severe wildfire, there is a possibility for firefighting crews to be overrun by wildfire, known as entrapment and burnover. There are many metaphors that come to mind when we consider the toll of 2020 on our mental fitness. Move over burnout. We are suffering from burnover.

Turning 2021 might not feel like a moment to see the glass as half full, but a critical step towards restoring mental fitness, and a favorite tool in the psychiatrist’s toolbox, is perspective taking. This is not meant to minimize the harsh reality of an incredibly difficult 2020 with Pollyannaish optimism. Many of us have lost loved ones, friends, and colleagues. We are sad, frustrated, and exhausted. But as we reflect on 2020, taking stock of the losses and triumphs, there were unmissable silver linings:

Creativity
Amidst the suffering, we witnessed heights of human spirit and ingenuity. Rising to the clinical and logistical challenges, we put on our problem-solving caps to make the most of a limited supply of Personal Protective Equipment (PPE), ventilators, and medications. When our hospitals reached capacity, we built makeshift hospitals and converted concert centers into giant negative-pressure rooms. We served our patients to the best of our abilities, embracing the steep learning curve and ever-changing guidelines and information on COVID-19. We held our patients’ hands to give them a dignified sendoff when their loved ones could not be there in their last moments. Our creativity wasn’t just limited to our professional lives; In addition to doctor, we added teacher, caregiver, coach, and other roles to our credit.


Technology
We went virtual. Sure, we went from one online meeting to the next and had to scramble for a bathroom break, but we found a great way to safely connect with our patients, parents, friends, and each other. When we ached for culture, we brought Hamilton, the Metropolitan Opera, and concerts streaming home. We virtually toured cities and world class museums, studying art masterpieces, closely zooming in and out.

We flexed our tech muscles and found other convenient ways to bring the comfort of nourishment and shopping for essentials to our doorsteps. It took a few months to get the hang of it, but we joined online gyms and live workout classes from home.

Our internet bandwidth made it possible to meet the combined needs of work from home, telemedicine, online school, and a dozen devices streaming online platforms simultaneously. We concurrently admired and doom-scrolled the Institutional and governmental COVID-19 data repositories. Most importantly, we had real time information about this pandemic on our fingertips, (at times—perhaps too much information).

Community
We learned that gratitude and grief can coexist. Our circles got smaller by necessity and we became intentional about our connections, out of which came bonus time with family and pets (and plants). Without our usual external outlets and distractions, we turned inwards and made time for introspection. We came upon unexpected opportunities for nourishment—we took up new (and old) hobbies, games, books, podcasts, yoga. We made a commitment to support struggling local and small businesses. Even if the presidential election of 2020 delivered a powerful referendum on how divided we stand, we found ways to unite over popular fads and shows. We developed new coping skills, and when these were not sufficient, we leaned on our colleagues, family, and friends for support. Meanwhile, our scientific community also embraced the challenge of 2020 with a promise of a vaccine, which has been developed in record time.

Priorities
There’s nothing quite like a pandemic to make us reevaluate our priorities. As physicians, we (finally) learned to say no as self-care became more critical than ever. We watched a third of the country burn in wildfires and came to appreciate the profound impact of our choices on our environment. A discussion about Turning 2021 would be entirely remiss without acknowledging the pandemic of racial oppression thrust into the forefront in 2020. The intersectionality of COVID-19 pandemic and social determinants of health has been underscored by the disproportionate and devastating impact of the pandemic on black, latinx, and indigenous people of our nation. So, we committed ourselves to the task of self-examination and intentional antiracism. Out of activism came a commitment to change for the better with more progress on equity and justice.

If 2020 was the ultimate exercise in improv, we gave a performance worthy of cheers and ovation. Even so, 2020 was especially stressful for doctors as we were stretched beyond our capacities in all spheres of our life, all at once, and for far too long. Published research on the impact of the pandemic on health care workers in the U.S. is limited at this point, but the data from China, Italy, France, and other countries impacted by COVID-19 earlier on in 2020 are telling. As a volunteer psychiatrist for the Physician Support Line, a free and confidential peer phone support helpline for struggling physicians and medical students, I have heard countless stories of physicians and medical students, I have heard countless stories of physicians who endured a risky, exhausting, and demoralizing milieu for much longer than the human body and mind were meant to tolerate—all the elements of not just burnout, but anxiety, depression, post-traumatic stress disorder (PTSD), substance use, and much more.

In his seminal book on trauma and its effects, The Body Keeps the Score: Brain, Mind, and Body in the Treatment of Trauma, Dr. Bessel van der Kolk discusses how trauma and chronic stress rearrange the brain’s wiring— specifically areas dedicated to pleasure, engagement, control, and trust—in a process known as neuroplasticity. The human response to psychological stress is one of the most important public health problems, and doctors are especially susceptible to it because of the nature of our work and the long hours, only compounded by the pandemic. Many of us are Turning 2021 psychologically wounded, exhausted, and mentally exhausted.

Taking stock of 2020, Turning 2021 mentally fit might seem like a lofty goal. Fortunately, there are evidence-based strategies that can help us ameliorate the impact of chronic stress as we pursue our goal of mental fitness in 2021.

Recalibrate “normal”
We have endured a collective trauma in 2020 that has given way to a crisis of meaning. The chronic stress might make you feel irritated, impatient, angry, sad, and you might experience feelings of disconnection, difficulty concentrating, and a range of other cognitive effects. You might also be navigating anxiety, depression, or fatigue. These are all perfectly human, adaptive responses during such a difficult time.

   ●  Welcome and honor the full spectrum of emotions that make you human, because they are here to teach you important lessons about your triggers, coping skills, and current emotional state.


   ●  Practice Self-compassion – as physicians, we have several personality traits that lead us to pursue careers in medicine, including perfectionism and self-denial. While these traits can serve us well in doing our clinical work, they also give way to unrealistic personal and professional expectations, including denial of personal vulnerability. Some days your best IS enough. You are a doctor, but you’re also human. Acknowledge and accept your vulnerability.

   ●  Seek Help – part of recalibrating normal is to also normalize seeking help. Extraordinary stresses cannot be overcome with ordinary measures. Although we all have the ability within us to heal, we sometimes need support in the journey to self-realization and optimal mental fitness.

Reflect and release
Unprocessed traumatic memories and stress can become sticking points that cause our mental and physical processes to suffer. As such, it is imperative that we reflect inwards and take intentional steps towards improving our mental fitness. The journey to recovery can be slow, intentional, and at times, uncomfortable, yet, immeasurably rewarding. As with any form of recovery, the first step is acceptance.
   ●  Give yourself the permission to grieve the many losses of 2020, including loved ones, colleagues, and even your routines. This isn’t always at our forefront, but in addition to attachments to other people, we also develop powerful attachments to our work, things, and places.

We know that neuroplasticity and trauma go hand in hand. Just as traumatic events can forge neural pathways, so can positive and effective therapeutic experiences that help us cope and heal. The psychiatrist’s toolbox is equipped with evidence-based strategies to help you navigate this journey.

●  Psychotherapy – if anxiety is the worst use of the imagination, psychotherapy helps us reestablish psychological safety and dial down the trauma response. There are numerous evidence-based therapies to help address anxiety, depression, and burnover, such as Cognitive Behavioral Therapy, Acceptance and Commitment Therapy, psychodynamic psychotherapy, and Mindfulness-Based Stress Reduction. The undertaking of knowing oneself might be the most challenging yet rewarding experience of one’s life, with lasting results. In fact, suffering often brings with it the opportunity that drives emotional growth for a more mentally fit self. As with anything worthwhile, this process requires time and commitment.

●  Medications and more – we enter the medical profession with many underlying vulnerabilities, including personal and family medical and psychiatric history, chronic stress from childhood, personality factors, social determinants of health, and much more. Moreover, the stress from medical training is associated with systemic inflammation, telomere shortening, and oxidative stress, findings which have often also been reported in major depression. Antidepressant medications, in particular, are associated with not just mood recovery but also recovery from oxidative stress on a cellular level. There are also several medication and non-medication augmentation strategies that can help you with your mental recovery. Most importantly, a good psychiatrist can blend psychiatric medication management and psychotherapy while empowering you with skills for self-management over time.

If the body keeps the score of chronic stress, then the symbiotic relationship between the mind and body becomes a critical target for recovery.

●  Mind-Body strategies – we all know the benefits of exercise as a healthy coping skill to build our mental and physical fitness. However, when we are exhausted, the last thing we might want to do is run laps around the neighborhood with a mask on. Fortunately, recovery from stress does not require us to train like an athlete. In fact, routine, less intense activities, such as walking a pet, doing the laundry and dishes, gardening, and washing your car can be just as effective and give you a sense of accomplishment. One of the best strategies to facilitate traumatic release from the body is to engage in an intentional, slow, and mindful activity like yoga, which you can easily access over the internet from the comfort of your living room.

If you’re suffering from burnover from another discussion about mindfulness, you’re not alone. I had similar skepticism about mindfulness when I first took the eight-week Mindfulness Based Stress Reduction (MBSR) course. In fact, around the third week, I recall being quite frustrated with the process of completing the same body-scan meditation every day for an hour or more, but I stuck with it. Around week six, a sense of calmness came over me. My movements and actions became more intentional and I felt less exhausted, without any change in the rigor of my clinical schedule. My relationship with nourishment also changed as I learned to chew my food instead of my thoughts, which saved me precious mental energy to devote to other aspects of my life. When I wavered from this intentionality, I returned back non-judgmentally to the task at hand. One of the greatest misconceptions about mindfulness is that it helps us fight distressing thoughts. Quite the contrary, mindfulness allows us to change our relationship to the distressing thoughts that are a part of living.

Reimagine “Work”
As physicians, our careers have been shaped by the expectation of conformity married to the assumption that resilience and professionalism are in endless supply, particularly during a pandemic. Fittingly then, 2020 has been the ultimate test of our professional status quo. While the long hours and medical culture might make it seem that your personal identity is inextricable from your professional one, this is a perfect recipe for burnover. Along with recalibrating normal, Turning 2021 mentally fit requires that we reimagine work as an extension of what we do, rather than us as an extension of who we are. You are a person with many gifts, values, dreams, and talents, and one of them just happens to be being a hard-working doctor. This could be a variety of things, including spirituality, advocacy, mentorship, leadership, and other activities outside of your profession. Also, as much as possible, release yourself from the myth and burden of multitasking. Focusing on one task at a time and being mindful of the task at hand will improve your concentration and help you to be more mentally fit. Spreading ourselves thin depletes our battery faster than working on tasks individually. Like any of your devices, the more programs you have running simultaneously, the harder it is on the system. It is the same for our body and mind.

Reclaim Joy
Mental fitness is not merely the capacity to endure, but also the capacity to recharge. Most of us forget the latter. Take the time to slow down and explore other aspects of life that fill your bucket and keep you mentally fit. Recreation, humor, daydreaming, connection with nature, your partner’s touch, and the simple act of doing absolutely nothing at all can all be ways to recharge your mind. Rather than spending your time on passive activities like binge watching shows, find a book or a podcast that teaches you something new. Monitor your screen time and disconnect digitally to give your mind a digital holiday. Be it while on a walk around the neighborhood or on your walk from the parking lot to your office—put down your phone, pull down your mask and stop to smell the roses. New experiences and new ways of doing old things can also set you on the path to mental fitness.

Most of all, remember that mental fitness is not a checkbox, it’s a moving goalpost practiced over time with intentionality. If at first you fail, get up and try again. And again. And again. Join me in the commitment to turn 2021 happy, healthy, and mentally fit!