Funeral rites in the COVID-19 pandemic and grief: possible reverberationsa a This study is part of a thesis’ dissertation called “Processo de Luto diante da Ausência de Ritual Fúnebre na Pandemia da COVID-19: análise documental jornalismo online”, presented to the Graduate Program in Mental Health and Psychosocial Care at the Universidade Federal de Santa Catarina, in 2020, by Maria Eduarda Padilha Giamattey under the guidance of Joselma Tavares Frutuoso

Maria Eduarda Padilha Giamattey Joselma Tavares Frutuoso Maria Lígia dos Reis Bellaguarda Ivânia Jann Luna About the authors

Resumo

Objetivo

compreender a ausência de rituais fúnebres na pandemia de COVID-19 no processo de viver o luto das famílias brasileiras que perderam entes queridos por COVID-19.

Método

pesquisa qualitativa documental realizada em três jornais disponibilizados online. Foram analisadas 67 reportagens, divididas em duas categorias; a primeira trata dos sofrimentos psicológicos derivados do isolamento social, como ansiedade, depressão, solidão e medo; e a segunda trata das diferentes manifestações do luto e o efeito psicológico das perdas em meio à pandemia.

Resultado

a ritualização da morte é indissociável do processo de elaboração das perdas. A ausência de rituais fúnebres, aliada ao distanciamento social, repercute de forma desafiadora para a sociedade e para os profissionais da saúde mental. Estratégias não presenciais de demonstração de afeto e elaboração da perda podem amenizar o isolamento imposto pela pandemia.

Conclusões e implicações para a prática

o processo de viver humano é repleto de ritos de passagem e a ritualística na morte-morrer se mostra necessária para a vivência da despedida, da certeza do distanciamento ocorrido entre entes e família. Implica em modos resolutivos de registro emocional, mental e mesmo físico da expressão pública de sofrimento do enlutado e do não esquecimento do Ser à morte. Impacta na prática assistencial para o acolhimento, orientação e elaboração das perdas para a manutenção de vida saudável das pessoas enlutadas, o que propõe argumentos teórico-reflexivos no cuidado em saúde mental e na guarida de pessoas enlutadas decorrentes da pandemia.

Palavras-chave:
Luto; Rituais Fúnebres; Infecções por Coronavirus; Morte; Psicologia

Resumen

Objetivo

comprender la ausencia de rituales funerarios en el proceso de dolor de las familias brasileñas que perdieron a sus seres queridos por COVID-19.

Método

una investigación documental cualitativa realizada en tres periódicos disponibles en línea. Se analizaron 67 informes, divididos en dos categorías; el primero trata sobre el sufrimiento psicológico derivado del aislamiento social, como la ansiedad, la depresión, la soledad y el miedo; y el segundo trata de las diferentes manifestaciones del dolor y el efecto psicológico de las pérdidas en medio de la pandemia.

Resultado

la ritualización de la muerte es inseparable del proceso de elaboración de las pérdidas. La ausencia de rituales funerarios combinada con la dictadura social puede tener un impacto desafiante en la sociedad y los profesionales de la salud mental. Las estrategias no presenciales para mostrar afecto y explicar la pérdida pueden aliviar el aislamiento impuesto por la pandemia.

Conclusiones e implicaciones para la práctica

el proceso del vivir humano está lleno de ritos de paso y los rituales de la muerte-morir resultan necesarios para la experiencia de la despedida, de la certeza de la distancia entre los seres queridos y la familia. Implica resolver modos de registro emocional, mental e incluso físico de la expresión pública del sufrimiento del doliente y del no olvido del Ser hasta la muerte. Incide en la práctica asistencial para la recepción, orientación y elaboración de las pérdidas para el mantenimiento de una vida sana de las personas en dolor, el cual propone argumentos teórico-reflexivos en la atención de la salud mental y en el refugio de personas en dolor producto de la pandemia.

Palabras clave:
Aflicción; Ritos Fúnebres; Infecciones por Coronavirus; Muerte; Psicología

Abstract

Objective

to understand the absence of funeral rituals in the process of living the grief process of Brazilian families who lost loved ones by COVID-19.

Method

this is a qualitative documental research carried out in three newspapers available online. Sixty-seven reports were analyzed, divided into two categories; the first deals with psychological suffering derived from social isolation, such as anxiety, depression, loneliness and fear; and the second deals with the different manifestations of grief and the psychological effect of losses amidst the pandemic.

Result:

the ritualization of death is inseparable from the process of elaboration of the losses. The absence of funeral rituals combined with social dictatorship can have a challenging impact on society and mental healthcare professionals. Non-presential strategies for showing affection and elaborating the loss can ease the isolation imposed by the pandemic.

Conclusions and implications for practice

the human living process is full of rites of passage and death-dying rituals prove to be necessary for the experience of farewell, of the certainty of the distance between loved ones and family. It implies resolving modes of emotional, mental and even physical recording of the public expression of griever’s suffering and not forgetting the Being’s to death. It impacts care practice for reception, guidance and elaboration of losses for the maintenance of a healthy life for grievers, which proposes theoretical-reflective arguments in mental healthcare and in the shelter of grievers resulting from the pandemic.

Keywords:
Bereavement; Funeral Rites; Coronavirus Infections; Death; Psychology

INTRODUCTION

In the year 2020, the world found itself facing a common enemy: the disease caused by the SARS-CoV-2 virus, short for Coronavirus Disease, which would soon be called just COVID-1911 Li H, Liu L, Zhang D, Xu J, Dai H, Tang N et al. SARS-CoV-2 and viral sepsis: observations and hypotheses. Lancet. 2020;395(10235):1517-20. http://dx.doi.org/10.1016/S0140-6736(20)30920-X. PMid:32311318.
http://dx.doi.org/10.1016/S0140-6736(20)...
. Initially reported in Wuhan Province, China, in December 2019, the disease was characterized by the World Health Organization (WHO) as a public health emergency of international concern on January 30, 2020, when all 34 provinces of the country reported cases of the disease and the total number of infected already exceeded the number reached by Severe Acute Respiratory Syndrome (SARS) in 200322 Ho C, Chee C, Ho R. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Annals of the Academy of Medicine. 2020;49(1):1-3. PMid:32200399.. On March 11, 2020, given the rapid growth in the number of people infected and deaths by COVID-19 in different countries, the WHO started to declare the situation as a pandemic33 Organização Mundial da Saúde. WHO Director-General's opening remarks at the media briefing on COVID-19 [Internet]. 2020 [citado 2021 maio 7]. Disponível em: https://www.who.int/director-general/speeches/detail/who-director-general-s-opening-remarks-at-the-media-briefing-on-covid-19---11-march-2020
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The current generation, in any range of human development, has never experienced something similar and with such brutal lethality in a short period of time, referring to the Spanish Flu, which lasted from 1918 to 1920 and infected around 100 million people worldwide and led to the death of between 17 and 50 million lives, making this one of the deadliest epidemics in history. Collateral damage and mortality from the COVID-19 pandemic overturned this argument44 Spreeuwenberg P, Kroneman M, Paget J. Reassessing the global mortality burden of the 1918 influenza pandemic. Am J Epidemiol. 2018;187(12):2561-7. http://dx.doi.org/10.1093/aje/kwy191. PMid:30202996.
http://dx.doi.org/10.1093/aje/kwy191...
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Global measures of social distancing were immediate measures to try to prevent the rapid spread of the disease and the preservation of health systems to meet the growing demand for hospital beds. The recovery of the acute symptoms of COVID-19, in a hospital environment, may require several days or months of hospitalization. Therefore, social distancing measures are not intended only to stop the transmission of COVID-19 virus, but to flatten the contagion curve so that hospital beds do not reach maximum capacity, which would lead to a collapse in the country’s health system.

Different approaches were used to fight COVID-19 infection, including those promoted by Telemedicine, namely: having a diagnosis faster and start treatment and follow-up at home, avoiding overloading hospitals; minimizing the movement of people in public environments through telephone contact; preventing the risk of contagion, avoiding direct physical contact; reducing costs with personal protective equipment; and even distance training of healthcare professionals; in addition, providing regular updates on the evolution of the pandemic55 Vidal-Alaball J, Acosta-Roja R, Pastor Hernández N, Sanchez Luque U, Morrison D, Narejos Pérez S et al. Telemedicine in the face of the COVID-19 pandemic. Aten Primaria. 2020;52(6):418-22. http://dx.doi.org/10.1016/j.aprim.2020.04.003. PMid:32402477.
http://dx.doi.org/10.1016/j.aprim.2020.0...
. These are measures that favor social distancing, at the same time that they work for the benefit of the population that needs more concrete and adequate support and information.

For a time, Brazilian states managed to create and adhere to restrictive agglomeration measures. Such measures were temporary suspension of schools, universities, public transport, prohibition of any activity involving agglomerations of more than ten people, isolation of suspected cases, mandatory use of masks and temperature control in public and closed environments, such as shopping malls, gyms and supermarkets66 Aquino EML, Silveira IH, Pescarini JM, Aquino R, Souza-Filho JA, Rocha AS et al. Social distancing measures to control the COVID-19 pandemic: potential impacts and challenges in Brazil. Cien Saude Colet. 2020 Jun;25(Supl. 1):2423-46. http://dx.doi.org/10.1590/1413-81232020256.1.10502020.
http://dx.doi.org/10.1590/1413-812320202...
. However, with the absence of public, governmental and financial strengthening of these measures, they were diluted over time, added to the collapse of health services, increase in the number of deaths and exacerbated contagion throughout the country77 Santos TBS, Andrade LR, Vieira SL, Duarte JA, Martins JS, Rosado LB et al. Hospital contingency in coping with COVID-19 in Brazil: governmental problems and alternatives. Cien Saude Colet. 2021 Apr;26(4):1407-18. http://dx.doi.org/10.1590/1413-81232021264.43472020.
http://dx.doi.org/10.1590/1413-812320212...
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The pandemic caused by the new coronavirus is not only an epidemiological crisis, it is also a psychological one. The politicization of COVID-19, the messages about masks, and the impact of social distancing on mental health have made clear how important psychology is during a pandemic. Regardless of exposure to the disease, the current situation can cause feelings such as stress, anxiety, sadness, helplessness, anger and impotence, among others88 American Psychological Association. Social science and the COVID-19 vaccines [Internet]. 2021 [citado 2021 maio 7]. Disponível em: https://www.apa.org/monitor/2021/03/covid-19-vaccines
https://www.apa.org/monitor/2021/03/covi...
. Research has already revealed the deep and broad spectrum of psychological impacts that epidemics can inflict on people, ranging from the triggering of new clinical conditions of psychological distress in those who previously had no history to the worsening of the conditions of those who already had some condition of psychological distress22 Ho C, Chee C, Ho R. Mental health strategies to combat the psychological impact of COVID-19 beyond paranoia and panic. Annals of the Academy of Medicine. 2020;49(1):1-3. PMid:32200399..

In a pandemic, we experience both the loss of human life and the loss of jobs, face-to-face social interactions and routines. In other words, we are experiencing different forms of contact with the meanings of death and grief on a large social scale, from the collective deprivation of living with people to the loss of one’s own health or that of loved ones, in case of contagion by the virus and the occurrence of death. Also noteworthy are the changes in lifestyles resulting from the destabilization of social references, such as work, healthcare, education, economics or social and family connections99 Souza JB, Heidemann ITSB, Geremia DS, Madureira VSF, Bitencourt JVOV, Tombini LHT. Pandemic and immigration: haitian families in facing COVID-19 in Brazil. Esc Anna Nery. 2020;24(spe):e20200242. http://dx.doi.org/10.1590/2177-9465-ean-2020-0242.
http://dx.doi.org/10.1590/2177-9465-ean-...
,1010 Brooks SK, Webster RK, Smith LE, Woodland L, Wessely S, Greenberg N et al. The psychological impact of quarantine and how to reduce it: rapid review of the evidence. Lancet. 2020;395(10227):912-20. http://dx.doi.org/10.1016/S0140-6736(20)30460-8. PMid:32112714.
http://dx.doi.org/10.1016/S0140-6736(20)...
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Death necessarily comes with grief and both are phenomena that happen to all human beings. As these are universal and unavoidable phenomena, we could think that they would be faced naturally. However, death occupies a place of exclusion in Western society, where the subject is not talked about, or else, when quoting it, words are used to replace and soften the real meaning such as: passage, rest, or else popular expressions now linked to religion and spirituality such as ‘passed away’, ‘is in a better place, ‘went to Heaven’, ‘is resting in peace’, among others1111 Menezes RA, Gomes EC. “Seu funeral, sua escolha”: rituais fúnebres na contemporaneidade. Rev Antropol. 2011;54(1):88-131. https://doi.org/10.11606/2179-0892.ra.2011.38585.
https://doi.org/10.11606/2179-0892.ra.20...
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After going through some or all of the phases of human development, death marks the end of a unique and individual process of development for each human being. The death of someone important awakens the primordial conflict of the grief process, experiencing the suffering of the loss and, at the same time, moving on1212 Papalia D, Olds SW, Feldman RD. Desenvolvimento humano. 10. ed. Porto Alegre: Artmed; 2009.. Such definition is present in a booklet entitled “Processo de luto na COVID-19”, produced during the pandemic by the Fundação Oswaldo Cruz1313 Fundação Oswaldo Cruz. Saúde mental e Atenção Psicossocial na Pandemia COVID-19: Processo de luto no contexto da COVID-19 [Internet]. 2020 [citado 2021 maio 7]. Disponível em: http://renastonline.ensp.fiocruz.br/recursos/saude-mental-atencao-psicossocial-pandemia-covid-19-processo-luto-contexto-covid-19
http://renastonline.ensp.fiocruz.br/recu...
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The meaning, explanations, rituals of passage between life and death and the grieving process vary according to each society and its cultural, cosmological and religious differences as well as the circumstances in which deaths occur. Each society is responsible for establishing acceptable cultural codes for the establishment of funeral rituals for their loved ones, which range from farewell ceremonies, tributes, even different ways of treating bodies, such as burial or cremation.13:2

Grief is understood as a natural process of response to a broken bond through the loss of someone or something significant in life1414 Franco MHP. Porque estudar o luto na atualidade? In: Franco MHP, organizador. Formação e rompimento de vínculos: o dilema das perdas na atualidade. 1. ed. São Paulo: Summus Editorial; 2010. p. 17-42.. In this sense, the practice of rituals is directly related to changes in the life cycle and we understand that individuals change as they go beyond the boundaries that delimit the passage from one position, states and status to the next. In addition to the immense variety of rituals existing in human life, there are forms that permeate the sense of community specific to each society, at the same time they reveal the way in which it is structured and restructured in light of the changes that occur in the course of life1515 Van Gennep A. Os ritos de passagem. 2. ed. Petrópolis: Vozes; 2011..

The pandemic came in an overwhelming way, trampling the organization and performance of funeral and farewell rituals of families and their consequences: funeral, cremation, burial, grief. An example of this can be seen in the opening of mass graves in cities most impacted by the pandemic due to the inability of funeral services to deal with the high number of deaths in a short time caused by COVID-19, generating a scenario of open-air collective burials. In addition to the fact that, in cities where the funeral service is still able to meet the demands of burials and funerals, the ease of contagion by the virus made it impossible for these events to take place with more than ten people present, lasting only an hour or less. New ways of saying goodbye to loved ones emerged; in some places, ‘virtual wakes’, prayers by app and online support groups: the ‘new’ grief during the pandemic as a way to emotionally bring people closer and allow them to say goodbye are being organized1616 Bitencourt JVOV, Meschial WC, Frizon G, Biffi P, Souza JB, Maestri E. Nurse’s protagonism in structuring and managing a specific unit for COVID-19. Texto Contexto Enferm. 2020;29:e20200213. http://dx.doi.org/10.1590/1980-265x-tce-2020-0213.
http://dx.doi.org/10.1590/1980-265x-tce-...
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Funeral rites coincide with the initial phase of grief. It is possible to see them as powerful spaces for the elaboration of the loss, contributing to the psychological well-being, because, even suffering from the loss, the ritual helps in the psychological organization of life without the loved one. In addition, the ritual itself is organized in such a way that farewell can be made together by everyone who has established some kind of affective bond with the people who have died1717 Bayard JP. Sentido oculto dos ritos mortuários: morrer é morrer? 1. ed. São Paulo: Paulus; 1996..

Although there is no theoretical gap regarding the importance of funeral rites in the grief process, we believe that the interface of this theme (prevention of funeral rites) and the specific context of the pandemic are a space-time to be investigated. This study highlights the opportunity to aggregate the study in real time as a potential for the development of the theme. Therefore, we present the objective of understanding the reverberations of the absence of a funeral ritual in the process of experiencing the grief of Brazilian families who lost a loved one by COVID-19.

METHOD

The methodological approach is qualitative with documentary research. This choice was made due to the impossibility of collecting empirical data in person, due to the measures of social isolation. Qualitative research aims to understand in depth how phenomena happen, and not just quantify numbers and incidence1818 Araújo CM, Oliveira MCSL, Rossato M. O sujeito na pesquisa qualitativa: desafios da investigação dos processos de desenvolvimento. Psicol, Teor Pesqui. 2017;(33):e33316. https://dx.doi.org/10.1590/0102.3772e33316.
https://dx.doi.org/10.1590/0102.3772e333...
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This study is considered to be of a documentary nature. Documentary research is one in which the data obtained are strictly from documents, with the aim of extracting information contained therein, in order to understand a phenomenon1919 Kripka R, Scheller M, Bonotto DL. Pesquisa documental: considerações sobre conceitos e caraterísticas na pesquisa qualitativa. Atas [Internet]. 2015; [citado 2021 maio 7];2:243-7. Disponível em: https://proceedings.ciaiq.org/index.php/ciaiq2015/article/view/252/248
https://proceedings.ciaiq.org/index.php/...
,2020 Flick U. Introdução à pesquisa qualitativa. 3. ed. Porto Alegre: Artmed; 2009.. The documentary sources researched in this study were constituted by the journalistic media2121 Padilha MI, Bellaguarda MLR, Nelson S, Maia ARC, Costa R. O uso das fontes na condução da pesquisa histórica. Texto Contexto Enferm. 2017;26(4):e2760017. http://dx.doi.org/10.1590/0104-07072017002760017.
http://dx.doi.org/10.1590/0104-070720170...
. The journalistic media available online, with wide circulation and coverage in Brazil, Latin America and Ibero-America were listed. The first newspaper selected was the one that is considered one of the main print media in the country2222 Jesus DSV. O Brasil no BRICS, segundo a Folha de S. Paulo e O Globo (2011-2013). Aurora. 2014;20(7):51-81. https://doi.org/10.23925/1982-6672.
https://doi.org/10.23925/1982-6672...
, Folha de São Paulo, and the second newspaper is available exclusively online and in more than one language, covering Latin America and Latin America, El País. Considering that, in the pilot search, we found few reports in Folha de São Paulo, we decided to include a third Brazilian newspaper with online and print circulation, from Rio de Janeiro, the newspaper O Globo.

As a time frame, we opted for the period from March to May 2020. We justify this choice because the measures of social distancing were initiated in the country in March. Thus, we decided to limit data collection until May, in order to be able to collect a sufficient number of data for analysis and discussion of the main findings. Data were collected by the main researcher between March 17 and May 31, the time available for the search and selection of articles was an average of 540 hours.

To develop this study, a search was carried out in online databases of selected newspapers, with the following search words: death; burial; funeral; pandemic; grief; coronaviruses; family, with wide scope for the newspaper sessions. The obituary session was discarded, a priori, because it is predominantly directed to tributes and funeral places. The inclusion criteria were: adherence to the study theme, that is, reports that in their content brought information regarding the process of death, dying and (re)organization of funeral rites in the pandemic. We used the exclusion criteria: repeated reports, information without adherence to the theme or completely escaping from the theme despite containing keywords. The saturation point of this study followed the criteria of intensity and quality of approaches and interactions that emerged from the journalistic stories and the depth with the phenomenon of grief and funeral rites, in addition to the quantity and repetition of ideas. The search process ended with data saturation, with 67 reports resulting from the opinion of journalists and/or interviewees, as represented in Figure 1.

Figure 1
Synthesis flow of sources and research reports on the grief process in the absence of funeral rites in the COVID-19 pandemic. Prepared by the authors. Florianópolis, 2021.

The thematic analysis method of hermeneutic and dialectical content proposed by Minayo was used2323 Minayo MCS. O desafio do conhecimento: pesquisa qualitativa em saúde. 14. ed. São Paulo: Hucitec; 2014., starting with a detailed reading of selected reports, to identify the themes related to the psychological impacts generated by the absence of funeral rites during the pandemic; then, they were categorized into content to compose thematic analysis and discussion of data. The population’s subjectivation process about the psychological impact of COVID-19 was built with the content of the reports from the three selected newspapers.

Considering that this study is of a documentary nature and uses, as a source of data collection, documents of a public nature and freely accessible to the population in general, it is justified to carry out the study without submission to an Institutional Review Board. The justification was supported under the terms of Resolution 510 of April 7, 2016 and in accordance with Law 12,527/2011, since it is a research that uses public domain and access information.

RESULTS

From analysis, two categories emerged: “Funeral rites in the context of social isolation” and “Different manifestations of grief”.

Funeral rites in the context of social isolation

We illustrate this theme, pointing out some reports that bring the impact of the pandemic on the alarming number of deaths and the inability of cemeteries to sustain the new demand for burials, and what this might mean for families who need to bury their dead. “It’s not death numbers. They are people, stories, affections, sacred memories […] So many open graves, one next to the other, are the portrait of an overwhelming pandemic”.2424 Jiménez C. Cemitério em São Paulo: a foto que jamais gostaríamos de publicar. El País [Internet]. 2020 abr 2 [citado 2021 maio 17]. Disponível em: https://brasil.elpais.com/opiniao/2020-04-03/cemiterio-em-sao-paulo-a-foto-que-jamais-gostariamos-de-publicar.html
https://brasil.elpais.com/opiniao/2020-0...

The pandemic creates unusual situations, including deaths without funerals. How is it possible for us to remain oblivious to such an ancient, exclusively human rite of passage? In nature, no other being grieves their dead and reveres them at burial (O Globo, Rio de Janeiro (Brazil), 04/27/2020 - Article: Antigona and Antares)2525 Betto F. Antígona e Antares. O Globo [Internet]. 2020 abr 27 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/sociedade/artigo-antigona-antares-24395691
https://oglobo.globo.com/sociedade/artig...
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All cultures establish ceremonies and rituals to say goodbye to their dead. This is a necessary act so that people linked to the departed can express their pain, their appreciation, their solidarity in a verbal and non-verbal way. The wake and burial are classic rituals that give family and friends the opportunity to structure the loss and say goodbye to the one who is gone. Now, due to the pandemic, they are prohibited or limited to prevent the virus to spread, since the transmission of COVID-19 can last for up to 72 hours after death, and funerals are places of great contact and physical proximity. Below, we highlight some selected articles in which they show how wakes and burials are being conducted in order to contain the transmission of the virus:

Whether due to the lack of exams, the delay in the analysis or the absence of protocols for carrying out the tests, those who are dying of respiratory arrest or an “undetermined cause” are being buried under the same criteria as those who die from complications of the coronavirus. This means, among other things, that there is no chance of farewell. There is no wake —not only to avoid crowding, but also to avoid contact with the possibly infected body— and the burial is carried out with a sealed coffin. […] When my mother entered the room to recognize the body, inside the coffin it was cardboard, on the satin floor with flowers, as she had chosen. It was because of COVID-19 (El País, São Paulo (Brazil), 03/31/2020 - Undiagnosed deaths reinforce suspicions that coronavirus statistics in São Paulo are outdated)2626 Rossi M. Mortes sem diagnóstico reforçam suspeitas de que estatísticas de coronavírus em São Paulo estão defasadas. El País [Internet]. 2020 mar 31 [citado 2021 maio 17]. Disponível em: https://brasil.elpais.com/politica/2020-03-31/mortes-sem-diagnostico-levantam-suspeita-de-subnotificacao-de-casos-do-coronavirus-em-sao-paulo.html
https://brasil.elpais.com/politica/2020-...
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There are more deaths than expected, from a pandemic that abhors the entire world, and for which many cannot even say goodbye to partners, parents, uncles, friends, living the worst pain of their lives, without a break for the ritual of grief. Coffins are arriving in cemeteries closed, to prevent family members from risking contamination (El País, São Paulo (Brazil), 04/02/2020 - Cemetery in São Paulo. The photo we would never like to publish)2424 Jiménez C. Cemitério em São Paulo: a foto que jamais gostaríamos de publicar. El País [Internet]. 2020 abr 2 [citado 2021 maio 17]. Disponível em: https://brasil.elpais.com/opiniao/2020-04-03/cemiterio-em-sao-paulo-a-foto-que-jamais-gostariamos-de-publicar.html
https://brasil.elpais.com/opiniao/2020-0...
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When we think of funeral ritual, it is very possible that the image that comes to mind is the one that most aligns with our culture and belief. The reports below demonstrate the role that rituals play at the time of departure, while exposing the wide spectrum of different meanings and ways in which these rituals are lived depending on the culture of the people involved, reminding us that the funeral ritual is performed beyond the way that Western Judeo-Christian culture does.

Now, the virus robs us of everything that translates our ties of kinship and friendship: visiting the sick, comforting and encouraging him, preparing the body for the funeral, promoting the wake, fulfilling the burial or cremation rituals, see the coffin descend to the tomb, pray together for the deceased, and express condolences and embrace those most affected by the loss (O Globo, Rio de Janeiro (Brazil), 04/27/2020 - Article: Antigone and Antares)2525 Betto F. Antígona e Antares. O Globo [Internet]. 2020 abr 27 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/sociedade/artigo-antigona-antares-24395691
https://oglobo.globo.com/sociedade/artig...
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In several countries in Africa, the fight against COVID-19 has changed funeral traditions that mix rituals from local religions with Christian elements introduced by European colonization in the 19th century […] Funerals in Africa are communal, not individual. When someone dies, the whole community grieves and shares the sadness with the deceased’s family, says Sihawukele Ngubane, a professor at the University of Kwazulu-Natal, in South Africa (Folha de São Paulo, São Paulo (São Paulo), 05/16/2020 - In Africa, funerals are as important as weddings)2727 Perassolo J, Ferraro M. Na África, funerais são tão importantes quanto casamentos: a pandemia os esvaziou. Folha de São Paulo [Internet]. 2020 maio 16 [citado 2021 maio 17]. Disponível em: https://www1.folha.uol.com.br/mundo/2020/05/na-africa-funerais-sao-tao-importantes-quanto-casamentos-a-pandemia-os-esvaziou.shtml
https://www1.folha.uol.com.br/mundo/2020...
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Without being able to live these milestones in a culturally consistent way, which fulfill the function of emotional organizers for grief, there are more chances of complications in the process of elaborating the loss. Loss in the context of a pandemic becomes something experienced in solitude or withdrawal. The reports below exemplify this new experience:

Maurício (not his real name) lost his mother to COVID-19 at the end of March. She had access to treatment with chloroquine and a respirator, but did not improve. She was 56 years old and had no previous illness. “My father went alone to recognize the body in the hospital, alone to the cemetery and alone to the crematorium. They did not have a wake or any funeral ritual, but Maurício hopes to be able to do something when the pandemic passes, like a mass to celebrate her life” (Folha de São Paulo, São Paulo (São Paulo), 04/14/2020 - Coronavirus deprives families of important grief rituals)2828 Appel C. Coronavírus priva famílias de importantes rituais do luto. Folha de São Paulo [Internet]. 2020 abr 14 [citado 2021 maio 17]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/04/coronavirus-priva-familias-de-importantes-rituais-do-luto.shtml
https://www1.folha.uol.com.br/equilibrio...
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Now 25 years old, Leonardo [grave keeper at the São Francisco Xavier Cemetery, in Caju, Rio de Janeiro] […] He is not managing to get used to the solitude of the burials of the victims of COVID-19. It is difficult to work with a single relative of the deceased […] — The absence of family members is the saddest thing. Those who come to the funeral bring the suffering of the whole family. The risk of contamination changed everything. It’s something abnormal. (O Globo, Rio de Janeiro (Brazil), 05/14/2020 - Coronavirus: ‘The absence of family members is the saddest thing’, recounts the grave keeper of Caju about his new routine at the cemetery)2929 Ribeiro G. Coronavírus: 'Ausência de familiares é o mais triste' conta sepultador do Caju sobre sua nova rotina no cemitério. O Globo [Internet]. 2020 maio 14 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/rio/coronavirus-ausencia-de-familiares-o-mais-triste-conta-sepultador-do-caju-sobre-sua-nova-rotina-no-cemiterio-24425947
https://oglobo.globo.com/rio/coronavirus...
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The importance of the grieving process does not mean that it is mandatory. We cannot infer that grief needs to be lived so that people affected by the loss can go on with their lives and that those who did not go through the process are stagnant. We want to point out that the experience of the grieving process, in its most diverse forms and singularities, is important from the point of view of mental health. The article highlighted below predicts severe impacts on the mental health of the population deprived of these important rituals, highlighting what the absence or impossibility of readaptation may entail.

According to Erika Pallottino, a psychologist specialized in grief support, trained in post-disaster emergency situations and founder of Instituto Entrelaços, the impossibility of accompanying patients in the hospital or of saying goodbye if the condition worsens creates a “traumatic trait that is sudden, unexpected death.” She says that specialists abroad give a perspective of ten years of impact of the pandemic on people’s mental health, much caused by the grief response (O Globo, Rio de Janeiro (Brazil), 05/25/2020 - Virtual wake, app prayers and online support groups: the ‘new’ grief during the coronavirus pandemic)3030 Tatsch C. Velório virtual, orações por aplicativo e grupos de apoio online: o 'novo' luto durante a pandemia do coronavírus. O Globo [Internet]. 2020 abr 25 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/sociedade/coronavirus/velorio-virtual-oracoes-por-aplicativo-grupos-de-apoio-online-novo-luto-durante-pandemia-do-coronavirus-24385878
https://oglobo.globo.com/sociedade/coron...
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In times of pandemic and absence of face-to-face funeral rituals, we identified virtual ceremonies as valid alternatives for the realization of this farewell stage, as well as a way to prevent possible disturbances arising from interrupted grief. The reports presented below show how this restructuring of something so deeply rooted in our society is being conducted.

The Morada da Paz cemetery, in Natal, has held virtual wakes since 2001, allowing farewells to be held from anywhere in the world. But this kind of online mass celebrated by Father Bianor is a novelty that came with the pandemic. “It arose from the need to stay at home to protect family members, the environment, and also to protect the celebrant” […] “They asked me if it would be possible to say a prayer, give a word of comfort, virtually” (El País, São Paulo (Brazil), 05/25/2020 - “The living room became a church”: online wakes in times of coronavirus)3131 Rossi M. “A sala de casa virou uma igreja”: velórios online em tempos de coronavírus. El País [Internet]. 2020 maio 25 [citado 2021 maio 17]. Disponível em: https://brasil.elpais.com/brasil/2020-05-25/a-sala-de-casa-virou-uma-igreja-velorios-online-em-tempos-de-coronavirus.html
https://brasil.elpais.com/brasil/2020-05...
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In this forced isolation due to the pandemic, the 65-year-old Spaniard [Father José Maria Ramirez, of the Congregação Legionários de Cristo, in the neighborhood of Gávea, Rio de Janeiro] has resorted, more than ever, to technology […] He has driven from two to three virtual burials per week by a meeting app. It was the way he found so that families can say goodbye to their loved ones in this lonely death caused by the coronavirus […] It’s hard not being able to say goodbye to someone you love, not hugging loved ones at that time. Each death has an infinite value. How to talk about statistics if a friend is leaving? How to forbid a child from attending his father’s funeral? (O Globo, Rio de Janeiro (Brazil), 31/05/2020 - Priest performs virtual burials for victims of COVID-19: ‘How to tell a child that he cannot go to his father’s funeral?’)3232 Fortuna M. Padre faz sepultamentos virtuais para vítimas de Covid-19: 'Como dizer a um filho que não pode ir ao funeral do pai?’. O Globo [Internet]. 2020 maio 31 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/cultura/padre-faz-sepultamentos-virtuais-para-vitimas-de-covid-19-como-dizer-um-filho-que-nao-pode-ir-ao-funeral-do-pai-24455253
https://oglobo.globo.com/cultura/padre-f...
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In this analysis, we highlight the importance of a funeral ritual for the experience and elaboration of the loss. Although there is no standard way of saying goodbye, especially in the face of a pandemic, we believe that it is also important to question in future research how the funeral ritual in the midst of the pandemic was experienced by those who do not have internet or access to means that can help them experience this farewell stage.

Different manifestations of grief

In this second category, we identified a total of twenty-two reports in the three newspapers surveyed, covering the most diverse types of losses. We emphasize that, throughout this research, we came across different types of grief and we will seek to address them here. When we address pandemic deaths, we are targeting families being mown down at once, only having to experience rapid restructuring. Grief can take broader forms that go beyond the actual deaths of loved ones, as highlighted below:

In a way, we've all lived through a kind of grief, to a greater or lesser degree, for the enormous social change we are facing. David Kessler claims this is natural. “We have micro and macro grief. Obviously the biggest is the death of someone we love, but we also experience minor grief when, for example, we lose our job or split up. We also grieve the world that no longer exists. A month ago the world we knew disappeared. People feel sad, heavy, they don't know why they cry, and I say it's grief” (O Globo, Rio de Janeiro (Brazil), 04/25/2020 - Virtual wake, app prayers and online support groups: the 'new' grief during the coronavirus pandemic)3030 Tatsch C. Velório virtual, orações por aplicativo e grupos de apoio online: o 'novo' luto durante a pandemia do coronavírus. O Globo [Internet]. 2020 abr 25 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/sociedade/coronavirus/velorio-virtual-oracoes-por-aplicativo-grupos-de-apoio-online-novo-luto-durante-pandemia-do-coronavirus-24385878
https://oglobo.globo.com/sociedade/coron...
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Death experiences become more personal as nearby communities or people are affected. The article below addresses, in addition to anticipatory grief, the way in which our griefs may be being ‘organized’ and experienced in this pandemic period and in the times to come:

Specialist in caring for those who are very close to the end of life, she [physician Ana Cláudia Quintana Arantes, geriatrician and specialist in palliative care] already predicts that humanity will go through three types of grief. In addition to actual grief, objective losses, it adds anticipatory grief - the realization that death is coming. “Besides, we’re going to grieve the lack of awareness. Many people will regret not having been careful before and will think ‘I could have stayed at home, I could have convinced people to stay at home’, she says. “There will be collective repentance too”, bets (El País, São Paulo (Brazil), 04/28/2020 - “We will grieve the lack of conscience. Many will regret not having stayed at home”)3333 Rossi M. Coronavírus: “Vamos ter um luto pela falta de consciência. Muitos vão se arrepender de não ter ficado em casa”. El País [Internet]. 2020 abr 28 [citado 2021 maio 17]. Disponível em: https://brasil.elpais.com/politica/2020-04-20/ana-claudia-quintana-arantes-havera-um-arrependimento-coletivo-tambem.html
https://brasil.elpais.com/politica/2020-...
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The pain of loss is always great, but in times of coronavirus it becomes greater. Among the victims’ relatives and friends, that tight hug that helps to comfort is lacking. […] In the 21 cemeteries of the capital, in addition to sadness, loneliness reigns. The same one that affects patients, who, hospitalized in complete isolation, struggle for life without even the right to a quick family visit to the ICU (O Globo, Rio de Janeiro (Brazil), 04/04/2020 - No wake and sealed coffins: coronaviruses impose isolation even in grief and change routine in cemeteries)3434 Amorim D. Sem velório e com caixões lacrados: coronavírus impõe isolamento até no luto e muda rotina em cemitérios. O Globo [Internet]. 2020 abr 4 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/rio/sem-velorio-com-caixoes-lacrados-coronavirus-impoe-isolamento-ate-no-luto-muda-rotina-em-cemiterios-1-24350944
https://oglobo.globo.com/rio/sem-velorio...
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We can’t even grieve. We will have to live it another time. The body could not even be taken to IML (Medical-Legal Institute), which replied that they no longer receive suspected cases of coronaviruses, only those of violent deaths — says journalist and teacher Raquel Lobão, Maria Luiza’s daughter-in-law (O Globo, Rio de Janeiro (Brazil), 03/31/2020 – ‘We can’t even grieve, says a relative of a 70-year-old woman who died of suspected coronavirus in Rocinha)3535 Nunes M. Nova Iguaçu decreta calamidade pública com 80% dos leitos hospitalares já ocupados. O Globo [Internet]. 2020 mar 31 [citado 2021 maio 17]. Disponível em: https://oglobo.globo.com/rio/nova-iguacu-decreta-calamidade-publica-com-80-dos-leitos-hospitalares-ja-ocupados-1-24341264
https://oglobo.globo.com/rio/nova-iguacu...
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The grief process in line with the absence of traditional rituals of body care and homage and its consequences is addressed in the following articles:

Psychologist and doctor in clinical psychology, Gabriela Casellato, partner and founder of 4 Estações Instituto de Psicologia, specialized in grief, is concerned about the consequences of deprivation of these moments. “The first impact is to live the grief stifled, isolated. This tends to impact the duration and intensity of grief. Another issue is the lack of concreteness, of the present body, which can create an ambiguous aspect in dealing with the loss. The person tends to have more difficulties in going on with life,” she says. “The grief of someone who has lost a loved one to the virus is even more difficult […] (Folha de São Paulo, São Paulo (Brazil), 04/14/2020 - Coronavirus deprives families of important grief rituals)2828 Appel C. Coronavírus priva famílias de importantes rituais do luto. Folha de São Paulo [Internet]. 2020 abr 14 [citado 2021 maio 17]. Disponível em: https://www1.folha.uol.com.br/equilibrioesaude/2020/04/coronavirus-priva-familias-de-importantes-rituais-do-luto.shtml
https://www1.folha.uol.com.br/equilibrio...
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We believe that the COVID-19 pandemic has the potential to catalyze the restructuring of current and emerging demands in mental health and the grief phenomenon in Brazil, being the first time in history that we experience the frequent occurrence of deaths in the most diverse social groups, leading us to believe that this can reverberate in the way death is faced and studied in the country.

DISCUSSION

Death-related rituals, such as funerals, spatially and temporally contextualize the experience, serving as an aid for the rearrangement of roles in the relationships and continuity of the life cycle. Furthermore, they can provide culturally consistent responses capable of providing the family with the sense of support they need to overcome the numbness and confusion that the loss can entail3636 Souza CP, Souza AM. Rituais fúnebres no processo do luto: significados e funções. Psicol, Teor Pesqui. 2019;35:e35412. http://dx.doi.org/10.1590/0102.3772e35412.
http://dx.doi.org/10.1590/0102.3772e3541...
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At a wake, the family has the opportunity to organize the ceremony in the way they think the departed person would like so that the ceremony makes sense for what the person was in life, in addition to being able to gather loved ones and have the opportunity of sharing the pain while relieving it. All these factors contributing to the construction of a ‘narrative of loss’ are suspended during the pandemic.

This initiative of funeral rites in the online modality is pointed out by the Fundação Oswaldo Cruz booklet as a remote farewell strategy in view of the impossibility of proximity. Because, in addition to filling the gaps in the tributes to the dead, it reintegrates, at least in part, the feeling of communion and sharing that this moment asks for, and can also help those who are still alive1414 Franco MHP. Porque estudar o luto na atualidade? In: Franco MHP, organizador. Formação e rompimento de vínculos: o dilema das perdas na atualidade. 1. ed. São Paulo: Summus Editorial; 2010. p. 17-42..

The funeral ceremony serves to honor the one who has gone, but the continuity of life takes place through the living. Thus, the ritual is beneficial to those who participate in it, creating in it a moment and feelings of complicity, compassion and renewal, connected with the sacred and socially demarcating the beginning of the necessary grief. Furthermore, investing in the organization of rituals, even in the online format, can alleviate possible conflicting feelings, this being a necessary moment for psychological development, as it has healthy contributions such as helping individuals to cope with the loss, socially allowing entry into the grief process, enabling them to express and share their suffering3636 Souza CP, Souza AM. Rituais fúnebres no processo do luto: significados e funções. Psicol, Teor Pesqui. 2019;35:e35412. http://dx.doi.org/10.1590/0102.3772e35412.
http://dx.doi.org/10.1590/0102.3772e3541...
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Grief is the response to the rupture of a significant affective bond, in which the dimension of grief, together with its meaning, is proportional to the bond between the bereaved person and the person who left. We understand grief as a subjective and singular experience, experienced in a unique and different way individually. This process constitutes an experience endowed with meaning, multi-determined and cultural. The grief process would be like occupying a world deserted by that absence. Little by little, we recompose this space, transforming ourselves into what was lost, which starts to live in us3737 Braz MS, Franco MHP. Profissionais paliativistas e suas contribuições na prevenção de luto complicado. Psicologia. 2017;37(1):90-105. http://dx.doi.org/10.1590/1982-3703001702016.
http://dx.doi.org/10.1590/1982-370300170...
. However, amidst so many losses, the organization of an emotional space to remember the deceased and internalize their absences ends up being compromised, while this point is considered important for those who lived to be able to continue their lives3838 Worden JW. Grief counseling and grief therapy: a handbook for the mental health practitioner. 5th ed. Nova York: Springer; 2018. http://dx.doi.org/10.1891/9780826134752.
http://dx.doi.org/10.1891/9780826134752...
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Anticipatory grief is traditionally a normal response that occurs with a patient or family facing a terminal diagnosis and usually favors emotional preparation. However, the pandemic has contributed to increasingly difficult circumstances and the potential for a configuration of amplified anticipatory grief3939 Wallace CL, Wladkowski SP, Gibson A, White P. Grief During the COVID-19 Pandemic: considerations for palliative care providers. J Pain Symptom Manage. 2020;60(1):e70-6. http://dx.doi.org/10.1016/j.jpainsymman.2020.04.012. PMid:32298748.
http://dx.doi.org/10.1016/j.jpainsymman....
. This ‘amplified grief’ condition is derived from daily awareness, through media vehicles and social networks, global maps of contagion and death toll that can contribute to the feeling that the virus is ‘coming close’, increasing suffering from anticipation.

The complexity of the COVID-19 pandemic context can impact the grief process in different ways. First, as mentioned above, we emphasize that anticipatory grief tends to be affected, because we are facing a scenario in which hospitalized patients can have a rapidly worsening condition, and may die before the family can make sense of the imminence of loss. In other cases, the patient survives after several days in hospital, while the family was already experiencing the anticipatory grief of possible death, as Intensive Care Units (ICUs) started to carry the symbolic weight of being the places that, once entered, it is not possible to leave there, you will no longer see the family and the family will no longer have contact with the person who was hospitalized4040 Crepaldi MA, Schmidt B, Noal DS, Bolze SDA, Gabarra LM. Terminalidade, morte e luto na pandemia de COVID-19: demandas psicológicas emergentes e implicações práticas. Estud Psicol. 2020;37:e200090. . As pointed out in the previous analysis, the feeling that the deceased received the funeral ritual he deserved or the possibility of giving and receiving comfort are important markers in the elaboration of losses due to death, and the absence of these aids can make the grief process even more challenging4141 Ingravallo F. Death in the era of the COVID-19 pandemic. Lancet Public Health. 2020;5(5):e258. http://dx.doi.org/10.1016/S2468-2667(20)30079-7. PMid:32247328.
http://dx.doi.org/10.1016/S2468-2667(20)...
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The understanding of grief as something that is in our past, present and future history highlights the concern with not considering grief as a disease or with turning it into a psychologically pathological experience, as it was treated in the beginning of studies on the subject1313 Fundação Oswaldo Cruz. Saúde mental e Atenção Psicossocial na Pandemia COVID-19: Processo de luto no contexto da COVID-19 [Internet]. 2020 [citado 2021 maio 7]. Disponível em: http://renastonline.ensp.fiocruz.br/recursos/saude-mental-atencao-psicossocial-pandemia-covid-19-processo-luto-contexto-covid-19
http://renastonline.ensp.fiocruz.br/recu...
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CONCLUSIONS AND IMPLICATIONS FOR PRACTICE

Grief amidst a pandemic is inevitable, as the disease affects all groups, regardless of who denies its severity or considers themselves unattainable for not believing in it. This study made it possible to understand ways of sensitizing and qualifying healthcare professionals for the care of people in relation to death and those who experience grief for these losses.

It is important to emphasize that death and grief, in addition to being experienced individually in a unique way, are also experienced in socially different ways, as, in Brazil, they mainly affect people in situations of social vulnerability. When one of the main guidelines for protection against contagion by COVID-19 is that agglomerations are avoided and that the cleaning of spaces and people is constant, we cannot dismiss the Brazilian reality in which thousands of people live in a situation of overcrowding in their own homes and with little or no access to basic sanitation and healthcare. The lost lives that pile up, mainly from disadvantaged, marginalized social strata, in which public authorities are absent to provide decent living conditions. Despite all the very beneficial efforts to welcome people in isolation in the midst of loss, it is still not possible to know what will be the consequences of the absences left in the processes for the elaboration of the loss which, as we pointed out, already starts before the death itself.

We believe that, in terms of implications for practice, this study contributes to socializing the seriousness of the effects that the pandemic has on our lives. The memory of suffering and loss remains for a long period even after the production of drug strategies, vaccine and the immunity of the population. Thus, this study brings theoretical reflections that are substantiated in practical application in mental health and in the reception of those undergoing grief processes resulting from the pandemic, post-pandemic reflexes. A very widespread discourse is the desire to ‘return to normality’, when, in fact, the previous normality cannot return after more than four hundred thousand dead Brazilians, and when you, dear reader, read this article, this reality will be confirmed by an even greater number of deaths. The limitations of this study are shown in the physical distance itself from bringing funeral rites to reality under the testimony of grieved people. What we can do is build care and adaptation strategies in the face of this new scenario, especially in the field of mental health. Perhaps we may be able to give voice, in this study, through interviews with family members, to the society victimized by grief, the pain and suffering of goodbye without the possibility of farewell.

  • a
    This study is part of a thesis’ dissertation called “Processo de Luto diante da Ausência de Ritual Fúnebre na Pandemia da COVID-19: análise documental jornalismo online”, presented to the Graduate Program in Mental Health and Psychosocial Care at the Universidade Federal de Santa Catarina, in 2020, by Maria Eduarda Padilha Giamattey under the guidance of Joselma Tavares Frutuoso

References

ASSOCIATED EDITOR

http://orcid.org/0000-0002-2547-9906

Antonio José Almeida Filho

SCIENTIFIC EDITOR

http://orcid.org/0000-0002-1522-9516

Ivone Evangelista Cabral

Publication Dates

  • Publication in this collection
    29 Sept 2021
  • Date of issue
    2022

History

  • Received
    17 May 2021
  • Accepted
    03 Aug 2021
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