Late on a Friday night in May 2020, Hester Juries, 60, and her husband, Willie, 59, were huddled in their favourite spot — the couch in front of the television in their house in Delft, outside Cape Town. It had been a horrible week. 

On most evenings, Willie would inch close enough to rest his head on Hester’s shoulder at which point there’d be no hope of the pair staying awake for much longer. 

“You two even snore in unison,” their daughter and three grandchildren, who live with them, would tease.  

But this night was different. 

Hester was just starting to doze off when Willie complained that he was struggling to breathe. It was just past midnight. 

Her heart was racing. 

Breathlessness is one of the symptoms of Covid-19. All but one of the Juries – a year-old baby boy – had tested positive for the virus just three days earlier. 

They rushed to their local clinic, but there was no space in the Covid-19 ward. The nurses said they should come back if Willie’s symptoms got worse. Willie started wheezing almost as soon as they stepped inside their house. 

By 3am, they’re back at the clinic. There were still no open beds so the couple  was forced to sit in the biting Cape wind for four hours. Willie had been given a drip, but his breathing was becoming all the more panicked. Hester pleaded, crying: “My husband is suffering, please help us.” 

When her husband was finally admitted, Hester elbowed her way into the facility, demanding a chance to tell him to be strong and to listen to the doctors. On her way back home, Hester was beside herself with stress. 

Sobbing, she told her daughter on the phone: “When is this year going to end?” 

Loss upon loss: Preparing for a wave of grief in SA 

All of us are suffering multiple losses – every day, says social worker and bereavement expert Nelia Drenth. She was speaking on a webinar hosted by The Association of Palliative Care Practitioners of South Africa in June 2020. 

People around the world are grieving the loss of their day-to-day lives and the plans they made. They’re also living in expectation of what they might come to lose whether it’s their income, their health or their loved ones. 

In South Africa, the virus is spreading rapidly and the death toll is climbing. “People might feel the virus coming closer,” Drenth argues. “For some, death will become more personal.”

 Like death, bereavement is a part of life, she says. It’s a natural adjustment period everyone will go through as they learn to live with the loss of something – or someone – valuable. 

But the Covid-19 pandemic is changing everything – including the way we die and grieve. 

The disruption could mean people may take a bit longer to adjust, Drenth says, as people battle the chronic uncertainty of life with Covid-19, for which there is currently no cure. She explains: “Grief is always complex, but for most people it is not overwhelming in the end.” 

In some cases, however, people can become flooded with an endless desolation that doesn’t get better. Those instances are referred to as “complicated grief” and affect between 10% and 20% of bereaved people, studies have shown.  

While some experts say it’s still too soon to measure whether Covid-19 could lead to a spike in cases of complicated grief, evidence from previous crises reveal it might be worth thinking about the psychological implications of the pandemic as South Africa battles unprecedented poverty, joblessness and hunger with very few mental health professionals to help ease the panic. 

Jokes, juice and a change of pyjamas 

In her living room in Delft, Hester Juries’ cellphone rang. 

It was Tuesday – three days before, she and her husband, Willie had sat shivering outside their local clinic – when the lab technician called with the family’s Covid-19 test results. 

By that time, Hester’s daughter, Marlene, had been in hospital with Covid-19 for about a week. But the doctors said she was doing well. A few days earlier, the 36-year-old mother of three had phoned from her hospital bed for a chat.

She had asked her mother to bring a change of pyjamas to the hospital and even demanded some juice and snacks in her playful, very Marlene way. 

“She sounded like herself again,” Juries told Bhekisisa on the phone from Delft in July 2020.  

Marlene’s care package was ready to be delivered, but Hester decided not to go to the hospital since it seemed likely her daughter would be coming home soon. She isn’t sure how much time passed between the call about her family’s Covid-19 test results and a second call from Marlene’s doctor at Tygerberg Hospital. 

It felt like seconds. 

Hester struggles to get the next sentence out: “They called to say that Marlene had died.” 

‘The fear doesn’t end’

I forgive you. I love you. Goodbye. These are the three things people want to be able to say when somebody they love is dying, says Drenth. The Covid-19 pandemic and the regulations, and restrictions put in place to stop it robs people of that chance. 

When somebody loses a loved one, psychologists often use a five-step model to help explain the whirlpool of emotions people might face. Denial, anger, bargaining, depression and acceptance, it goes. But the emotions don’t necessarily come one after the other – or one at a time, explains Zamo Mbele, a clinical psychologist in Johannesburg and director at mental health advocacy nonprofit, the South African Depression and Anxiety Group.

These days, Mbele says, there are so many factors that could inflame the kind of grief people experience, often leading to a more complicated grieving process. People might wonder if they could have done more. They may be angry with the family member who exposed everyone to the virus, or at the country’s health system, he says. What’s more, many people have been far away from their family for four months. “If only I had spent their last moments with them,” they might think.

Even if they had been near the hospital in which the patient was admitted, they would not have been allowed to visit. 

Family members who lose their loved ones in an intensive care unit are at a higher risk of complicated grief, studies have shown. The same goes for people who couldn’t say goodbye.

And the perception that a loved one struggled to breathe when they passed on can also cause trauma for family members that stretches for months after they died. 

To make matters worse, people would normally have time to deal with all this and to settle into their grieving process. Now, the next loss seems imminent, Mbele says. He explains: “The fear just doesn’t go away.” 

Could all this lead to a wave of complicated grief? 

What makes this so difficult to predict is that all the factors that lead to complicated grief have been evaluated when they happen one at a time, but they’ve “never been seen combined into one, unprecedented disaster – happening on a global scale”, write authors of a paper published in the journal Frontiers in Psychiatry in May 2020. 

The researchers, whose research was based on US families, tried to do the maths nonetheless. Their thinking is this: If each person who dies leaves five others bereaved, and a tenth of those are at risk of developing complicated grief, there could soon be as many complicated grief cases as there are Covid-19 deaths. 

In South Africa, for example, more than 6,000 people have succumbed to the infection, so there could be at least 30,000 people in mourning and 3,000 who could experience complicated grief. 

While Drenth argues it’s too early to know, Mbele warns there simply isn’t enough support for everyone dealing with grief – complicated or otherwise. 

South Africa has fewer than one psychologist for every 100,000 public sector patients, a 2019 study published in Health Policy and Planning reveals. The data was gathered from the health department’s payroll database.  

This staff shortage has contributed to a huge treatment gap for mental illness. The researchers estimate that as many as 92% of public sector patients in South Africa who need care for mental disorders, epilepsy and intellectual disability don’t get it.  

What’s more, the authors warn of a “critical shortage” of child psychiatrists with only the Free State, Gauteng and the Western Cape reporting any of these specialists in the public sector. And children are a group that grief experts are particularly worried about as the deaths from Covid-19 threaten to topple family structures – again. 

Joan Marston, the former head of the International Children’s Palliative Care Network, helped care for families devastated by South Africa’s HIV epidemic in the 1990s. As a result, she’s worked in South Africa’s hospices for nearly three decades. 

Statistics South Africa estimates nearly two-thirds of the country’s orphans lost their parents to the virus. So much so, that HIV was nicknamed “grandmother’s burden” as thousands of elderly women took on the care of their grandchildren after burying their children, writes Howard Phillips in his 2012 book Plague, Pox and Pandemics. 

Now, Marston worries that those grandmothers are also the most likely to be impacted by Covid-19. She explains: “That granny generation saved us with HIV, we’re going to need a lot of care for young people if we lose them.” 

Back in Delft, Hester Juries is exhausted. She was up all night, trying to get her husband help for severe Covid-19 symptoms. She had been grieving for a long time. It had been three days since she lost her daughter to Covid-19 — after her grandson was fatally shot in June 2019, causing her eldest daughter to take her own life three months later. 

She flopped into bed to sleep, but couldn’t. She was too worried for her husband, so she woke up within two hours. Sitting outside with a cup of tea, her phone rang again, the tinny ringtone by now sending fear shooting through her body. 

Hester’s voice is heavy with emotion. “That’s all I can remember about that day.” Willie died just 12 hours after his breath first started racing.

The place where lost things go: Covid-19 burials bring little solace 

Willie and Marlene Juries were buried in the same grave in a small, joint funeral in Durbanville in Cape Town’s northern suburbs. The Covid-19 pandemic has deprived the Juries of the rituals that would usually have brought some solace. Hester was not allowed to identify their bodies, nor bring them home or to church for a service. Per government guidelines, the undertaker took the bodies straight from the morgue to the graveyard. 

“You don’t even know if it’s your people that are in the casket. It’s so painful,” she sighs.

The government’s burial regulations have been tough on undertakers too. Monageng Legae, the spokesperson for the South African Funeral Practitioners’ Association (Safpa) in Gauteng, which represents over 750 funeral directors, says he’s overwhelmed. “We’re burying people every day of the week,” he says. 

Although burials have almost doubled for Legae’s organisation, it hasn’t been a particularly lucrative time. Personal protective equipment for mourners and staff are for the undertaker’s account, since many families could not take on any extra costs.

And, in an attempt to help bereaved families to get some closure, many Safpa members have started to buy transparent body bags, so that one or two family members can identify the body if it’s necessary.

Many of Legae’s staff worry they’re offending their bereaved customers when they handle their loved one’s coffin with gloves, as if they are unclean, he says. Every death has to be handled as an asymptomatic case, so even families who lose a loved one to say, cancer, and not Covid-19, will be forced to give up some of their burial rituals. 

But it’s not just funeral rites that have been interrupted by the pandemic — sometimes, it’s the entire ceremony. In the public sector, hospital’s mortuaries are so full, it can take a while to find the right body, Legae says. 

His own mortuary at Sapema Funeral Services in Soweto outside Johannesburg is chock-a-block as well. He and many of his colleagues have been forced to make a plan and fast, turning large fridges into make-shift mortuaries, for example. 

Then there’s the administrative hang-ups: Safpa members have had to wait days for burial orders from home affairs, forcing families to postpone funerals. 

For Hester Juries, it was terrible not to be able to stand close to her loved ones’ graves. Even the devotions spoken over their graves by the handful of funeral-goers were a far cry from the choral hymns that defined the funerals of Hester’s community in the pre-Covid-19 era. She explains: 

“Our people, the Griquas, we usually bury our loved ones with songs of praise. Now, it feels like you are throwing your people away.”

South Africa’s mass graves – dug nearly a century apart 

In June 2020, images of yellow bulldozers preparing mass graves around Gauteng filled screens around the country. But mass graves have been dug in South Africa before, it just wasn’t televised.

In 1918, a global pandemic of highly infectious influenza, known as the Spanish Flu, wiped out 6% of the entire population in just six weeks, writes Howard Phillips. 

“Tens of thousands of wives and husbands turned into widows or widowers virtually overnight, hundreds of thousands of orphans created at a stroke.” 

Cities around the country were overwhelmed by a rising tide of corpses. Families in Cape Town pushed their loved ones to the cemetery in wheelbarrows and trolleys, Philips’ research reveals.  

In Kimberley, over 100 miners were buried every day between 2pm and 4pm — regardless of their religion. Twenty-five bodies at a time, with no more than a blanket and a thin layer of soil between them.

Now, a century later, the gravediggers preparing the resting places for Covid-19 deaths are taking strain as well. 

Pitso Maleka and his team of more than 1,000 gravediggers have the contract to dig and close graves for the City of Johannesburg for 2020. Maleka runs Pitso’s Grave Closure in Soweto. 

He estimates they’re digging about four times more graves than they would in a normal year. Maleka’s job has taken on a darker meaning of late. “It’s terrifying,” he explains. “What if I’m digging my own grave?” 

Grief counsellors help families cope 

For nearly four decades, Hester Juries woke up to a pair of polished shoes for work, a glass of water and a washbasin with hot water. Every day, Willie made sure of it. They first met at a school dance, where they spent the night dancing to the blues – and were inseparable ever since. 

Now, she wakes up alone with her grandchildren crying for their mother. After Willie’s funeral, none of Hester’s family could come to visit, leaving her to care for, among others, a granddaughter who stopped speaking from grief for her mother, and a son struggling with the sudden death of his father and threatening to end his life.

All the while trying to explain to a baby boy why he can’t have a hug from Ouma. “None of us are really coping,” she says. “It’s hell.” 

About a week ago, Hester got a call from a counsellor, who works for the Western Cape health department. The department is trying to mitigate a possible wave of sadness and grief by linking families to mental health support. 

Back in April 2020, the department rolled out a palliative care action plan and online training sessions for health workers, says Juanita Arendse, the director for health services in the Cape Town metro. 

In that city, 161 people attended courses to provide spiritual support. More than 180 workers received training in dealing with bereavement and grief. Also part of the workshop session were lessons on how to help families with closure and how to deliver bad news. “We knew we would need a hell of a lot more help than that,” Arendse says.

So she and her team set up a “Covid-19 volunteer database” made up of social workers, psychologists and mental health nurses to which they could refer patients or family members dealing with the emotional fallout of Covid-19. Also on the list were faith-based organisations and volunteers. 

These names all go onto an app that the department uses to co-ordinate which people are linked to which counsellors. “We try to find a good match based on age, language, religion and gender.” 

The counsellors are available to Covid-19 patients and family, people in quarantine and isolation, or anyone grieving the loss of someone to the virus. 

Initially, very few people were referred for counselling, the department’s records show. Only 10 people got help in April and May 2020, but that figure quadrupled by June. Of the 46 people that were linked to counsellors, 70% were grieving the loss of a loved one. 

While there are enough counsellors to meet the current demand, Arendse anticipates the department may struggle to find enough trained volunteers and staff to help as the death toll continues to rise. 

Joan Marston argues that the government could be making more use of the existing hospice network in the country since its employees are all trained in bereavement support. Supporting bereaved people well pays off in the long run. If you can prevent complicated grief, she says, you can make sure people are able to work and look after their families properly, saving the economy and health service money. “By putting these interventions in now, you’re going to prevent healthcare costs in the future.” 

The national health department did not respond to Bhekisisa’s requests for comment. 

Hester Juries says she feels optimistic about the counselling, she’s had one session so far. She takes comfort in her job as a hospice carer, where she can give her patients the gentle death her family members couldn’t have. 

Nonetheless, her voice cracks when she recalls those first few weeks of grief. “You feel so alone, so bitterly alone.” DM/MC

 This story was produced by the Bhekisisa Centre for Health Journalism. Subscribe to the newsletter.