ROANOKE, Va. - Respiratory therapist Alva Daniels fought in covid hot spots throughout the pandemic, but it was only in recent months that the strain began to show.
He started calling his wife from the hospital bathroom, crying, when he lost a patient. "We can't save them. All we do is bag 'em and tag 'em," he told a friend. Then, as coronavirus cases fueled by the delta variant rose over the summer, he told his wife: "Things are getting bad again and we don't have enough people to fight it. If something happens to me - if I die - I want to be buried next to my mom."
Alicia McAllister-Daniels, a nurse, thought her husband was talking about a breakthrough case of covid-19. Instead, Daniels, 38, died by suicide just five days later, his body found in a wooded area near the apartment in Fredericksburg where he was living while on a travel assignment.
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As the omicron variant threatens to bring a punishing fifth wave this winter, the country faces an unprecedented mental health crisis brought on by the nearly two-year pandemic. Hospitals and health-care facilities are woefully understaffed as capacity peaks once again - and workers, emotionally battered, burned out and suffering from post-traumatic stress disorder, are leaving the field in droves. Efforts to help them have taken on a new urgency, with Congress expected to pass landmark legislation in coming weeks aimed at reducing and preventing suicide and burnout and addressing the mental health needs of health-care workers.
Alva was an easygoing guy who liked nothing better than strumming his guitar by a campfire. And he was used to working under pressure. Before the pandemic, he had worked on a transport team ferrying critically ill children. His death shocked his large community of family and friends in Roanoke and southwestern Virginia and left many - including his wife of less than a year - wondering if they could have done more, if there were warning signs they missed.
"I should be a newlywed," Alicia said. "Now I'm a widow."
Alicia McAllister-Daniels takes in the view from her office at Carilion Children's Hospital in Roanoke, where she works as a nurse, on Dec. 13. When she needed time off after the death of her husband, the hospital was very supportive.
The elder Alva Daniels sits on the edge of the bed where his son used to sleep in the basement of his house in Jonesville, Va., starting at age 14 and later on visits home. On the wall are his son's graduation gowns from junior high, high school and college.
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O ne day in early December, Alicia was in True Craft Tattoo in downtown Roanoke, talking with owner Jason Setchel about the design she wanted tattooed on her left arm to memorialize Alva.
It was part of the grieving plan she'd created for herself in recent weeks, a way of getting through not just the first holiday without her husband, but also the cruel darkness of January and February to come. She managed a staff of 180 nurses and health-care workers at Carilion Children's Hospital in Roanoke, and now she turned her planning and organizational talents on herself: There would be a tattoo, or maybe tattoos, plural. Grief yoga. Reading notes from well-wishers she'd saved and not yet looked at.
Alicia showed Setchel samples for her tattoo design: a song lyric to encircle her wrist that would incorporate a semicolon - a symbol of suicide prevention - and end with a loop (or maybe a star) on her radial artery, the point on the body where Alva had checked the blood oxygen levels of hundreds of patients over the years.
If she could tolerate this one, she told Setchel, she'd come back for more.
"Part of my therapy plan is to get some tattoos and have somebody inflict physical pain on me so I'm not in emotional pain," she said.
She had met Alva at the hospital over a decade ago when she was an intensive care nurse and he was a newly minted pediatric respiratory therapist who would later join the high-flying transport team. "Nobody touches my kids unless they know what they're doing," she told him when they met. He just laughed.
Later, when anybody asked what he'd been up to, he'd always say lightly, "just saving babies."
She was divorced and six years older, and neither was looking for anything serious. They spent time hiking, playing music and traveling to festivals in their 31-foot camper named Millie. They joked that if they were still together in 10 years they'd get married, "and then we'd laugh and laugh and laugh," she recalled. The pandemic was raging on their 10-year dating anniversary in October 2020. They eloped to Asheville, N.C.
In 2019, Alva took a new job as a traveling respiratory therapist, taking assignments at hospitals within driving distance of Roanoke, so he could go home on breaks. He ended up at Holston Valley Medical Center in Kingsport, Tenn., not far from the town in southwestern Virginia where he had grown up in a log home on the top of a mountain, and where his father, also named Alva, still lived.
The elder Alva had been a lineman for coal companies, and his mother, Connie Gayle, was a nurse who taught him how to play the guitar. She was ill with her own respiratory issues when he left for college in 2001, and when she died a year later, "he never forgave himself," his father said.
Alva returned often to visit, finding the family mountain a place of solace - riding the tractor, walking the fields, devouring his stepmother's pinto beans and cornbread, and shooting targets with his handgun. "This is where I am the happiest," he told Alicia during one visit, when they were curled up in his childhood bedroom, their Great Dane named Avett slumbering nearby.
But last year's winter surge filled them both with dread, Alicia recalled. The loss of one covid patient in particular flattened him, she said. The man had loved watermelon, so Alva had searched all over town for the out-of-season fruit so the patient could taste it one more time before he was put on a ventilator. When he told Alicia about it, she said, "Oh my God, babe, I'm glad it was you who was there with him."
In January, Alva's primary care doctor prescribed the antidepressant Lexapro for him, but he was slower to seek professional help. His company did not provide counseling services for contract employees, an issue itself, and he feared - incorrectly - that he would cause Alicia problems at work if he sought help through her employee assistance program.
Studies have shown that doctors and nurses were already almost twice as likely to die by suicide as people in other professions, even before the pandemic began. Its unrelenting barrage has put them more at risk, according to Corey Feist, president of the Dr. Lorna Breen Heroes' Foundation, a mental health advocacy group founded in honor of his sister-in-law, Lorna Breen, a New York doctor who died by suicide early in the pandemic. The foundation has worked with about a dozen families who have lost family members who work in health care to suicide in the past year, he said.
"Everyone is exhausted, there's not enough workforce to take care of patients, the doctors are tired, the nurses are tired and the cohort that is taking care of covid patients are exhibiting symptoms of PTSD, which puts them at risk of suicide, alcoholism and divorce," Feist said. "It's like the military when you come back from war. This is 20-month tour of duty."
Medical professionals like Breen often put off seeking help because of the stigma attached, Feist said, although some states are moving to change strict disclosure requirements on job applications. Around 62 percent of health-care workers have said that covid-19 has had a negative impact on their mental health, according to a Washington Post-Kaiser Family Foundation poll from March, but only about 13 percent had received mental health services or medication because of that worry.
Alva just kept saying he had to stay strong, said Peggy Meder, a nurse and longtime friend of the couple from Norfolk. He had come home in the summer when his Tennessee contract was up, saying he was taking a break. But he was restless, unable to sleep or calm down. He went out and bought a $60,000 Ram truck, his dream vehicle. Worried friends were surprised when he took a new contract at another hospital, this time in Fredericksburg.
Meder ran into Alva in late July at a music festival in Floyd, Va., where he asked her if he could have a confidential talk. She led him to her campsite and the pair sat down on a couple of bean bag chairs, Alva grabbing her turquoise blue Fender guitar to play a few bars of the Old Crow Medicine Show song "Wagon Wheel."
Alva grew teary-eyed when he spoke of his work, Meder recalled.
"I don't know if I can do this. We're losing three to five people a shift," he told her. "All we can do is bag 'em and tag 'em." The hospital was so short-staffed that the doctors had been doing after-death care of patients themselves, he said.
Meder tried to comfort him, making him promise he'd see a counselor soon. They parted with a hug and a "good cry," she said.
About three weeks later, on Aug. 8, Alicia and Alva went to Washington for a Green Day concert at Nationals Park. They met up with friends, laughed and sang along with Billie Joe Armstrong under a cloudless summer night sky. But Alva grew contemplative in their hotel room afterward, Alicia recalled. He'd always said that if something happened to him he would never want to be on a ventilator more than two weeks. Now he was going a step further, telling Alicia he wanted to be buried next to his mom in the family plot in Kentucky's Harlan County, where he was born.
She was vaguely alarmed, but thought he was talking about plans for what might happen if he died of covid-19. "I clearly wasn't as concerned as I should have been," she said.
The next day, they parted ways, with Alva heading to Fredericksburg to his new contract job and Alicia back to Roanoke. They planned to reunite the following weekend. On Aug. 12, the two said good night as usual, via text message.
"Sleep sweet," he told her, as he always did.
Alicia awoke the next morning to a string of texts Alva had sent in the middle of the night, telling her it was too much and that he was going to end his life.
Alva Daniels's grave lies in a small cemetery in Evarts, Ky. Alva told his wife that he wanted to be buried next to his mother, and because his death was so unexpected, he was buried in the plot that had been reserved for his father. The senior Alva will eventually be buried to the right of the main headstone.
Alicia returns home after a walk with her Great Dane, Avett, on Dec. 11. She only recently began walking in her neighborhood again, as she had wanted to avoid engaging with people and being forced to talk about her new life as a widow.
C andles flickered in Alicia's living room and meditation music emanated from the sound system as she went through yoga poses in her online grief therapy workshop one recent Saturday - phase two of her grieving plan. Outside, George, the cat, slept on one of the pair of rocking chairs on the porch of her home overlooking the Blue Ridge Mountains. Inside, Avett, the Great Dane, was on the sofa with a watchful eye on her. Christmas lights glinted on a garland above, where she'd hung all the ornaments that reminded her of Alva - a tiny guitar, a miniature camper and a glittery helicopter that a family had given him one Christmas after he saved their daughter's life.
The instructor's soothing voice reverberated from the computer propped on a pillow in front of her: "I now invite you to move your body into the shape of your grief."
"I don't know how to do that," Alicia said to the dog. "What do you think?"
She moved down on the mat in a kind of fetal squat, before fiddling with her wedding ring for a while and then giving up, collapsing into child's pose. Alva would have thought this was silly, she thought later, although he was always supportive when she used her yoga classes for stress relief.
By now he'd been gone 17 weeks.
Earlier, she had told the online group during introductions that she hoped to use the therapy sessions, which would stretch into January, to be "intentional" about how about how she was handling her feelings through the holiday season.
"I prefer my grief to be linear and it is not and that makes me angry," she told them.
There's a baseline anger too - at Alva - that remains, but it's not as raw as it once was, she said after the session ended.
"I do think it will flare up, but it's more like sadness now - that he felt this was his only option," she said. "It's something everyone should spend some time thinking about: What does it really mean when we say, 'Check on your people?' I'm a nurse, we're smart health-care professionals, and we were talking about therapy and all the things we should have been talking about and it still didn't help."
She still had a few more steps of her grief project to go. She was going to finally sit down and read all the emails that friends had sent her recounting their favorite Alva stories. She also had the little smiley-face bowl her mother, Mina, had given her for her birthday in October. Her family had filled it with written messages of encouragement on folded scraps of paper. She was saving the bowl for the darkest part of winter. She planned to unwrap them slowly, savoring the messages one by one until spring comes.
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The Washington Post's Alice Crites and Emily Guskin contributed to this report.
If you or anyone you know are having thoughts of suicide, please call the National Suicide Prevention Lifeline at 1-800-273-8255 (TALK).