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Cassandra Rollins' daughter was still conscious when the ambulance took her away.

Shalondra Rollins, 38, was struggling to breathe as covid overwhelmed her lungs. But before the doors closed, clomid and success rate she asked for her cellphone, so she could call her family from the hospital.

It was April 7, 2020 — the last time Rollins would see her daughter or hear her voice.

The hospital rang an hour later to say she was gone. A chaplain later told Rollins that Shalondra had died on a gurney in the hallway. Rollins was left to break the news to Shalondra's children, ages 13 and 15.

More than a year later, Rollins said, the grief is unrelenting.

Rollins has suffered panic attacks and depression that make it hard to get out of bed. She often startles when the phone rings, fearing that someone else is hurt or dead. If her other daughters don't pick up when she calls, Rollins phones their neighbors to check on them.

"You would think that as time passes it would get better," said Rollins, 57, of Jackson, Mississippi. "Sometimes, it is even harder. … This wound right here, time don't heal it."

With nearly 600,000 in the U.S. lost to covid-19 — now a leading cause of death — researchers estimate that more than 5 million Americans are in mourning, including more than 43,000 children who have lost a parent.

The pandemic — and the political battles and economic devastation that have accompanied it — have inflicted unique forms of torment on mourners, making it harder to move ahead with their lives than with a typical loss, said sociologist Holly Prigerson, co-director of the Cornell Center for Research on End-of-Life Care.

The scale and complexity of pandemic-related grief have created a public health burden that could deplete Americans' physical and mental health for years, leading to more depression, substance misuse, suicidal thinking, sleep disturbances, heart disease, cancer, high blood pressure and impaired immune function.

"Unequivocally, grief is a public health issue," said Prigerson, who lost her mother to covid in January. "You could call it the grief pandemic."

Like many other mourners, Rollins has struggled with feelings of guilt, regret and helplessness — for the loss of her daughter as well as Rollins' only son, Tyler, who died by suicide seven months earlier.

"I was there to see my mom close her eyes and leave this world," said Rollins, who was first interviewed by KHN a year ago in a story about covid's disproportionate effects on communities of color. "The hardest part is that my kids died alone. If it weren't for this covid, I could have been right there with her" in the ambulance and emergency room. "I could have held her hand."

The pandemic has prevented many families from gathering and holding funerals, even after deaths caused by conditions other than covid. Prigerson's research shows that families of patients who die in hospital intensive care units are seven times more likely to develop post-traumatic stress disorder than loved ones of people who die in home hospice.

The polarized political climate has even pitted some family members against one another, with some insisting that the pandemic is a hoax and that loved ones must have died from influenza, rather than covid. People in grief say they're angry at relatives, neighbors and fellow Americans who failed to take the coronavirus seriously, or who still don't appreciate how many people have suffered.

"People holler about not being able to have a birthday party," Rollins said. "We couldn't even have a funeral."

Indeed, the optimism generated by vaccines and falling infection rates has blinded many Americans to the deep sorrow and depression of those around them. Some mourners say they will continue wearing their face masks — even in places where mandates have been removed — as a memorial to those lost.

"People say, 'I can't wait until life gets back to normal,'" said Heidi Diaz Goff, 30, of the Los Angeles area, who lost her 72-year-old father to covid. "My life will never be normal again."

Many of those grieving say celebrating the end of the pandemic feels not just premature, but insulting to their loved ones' memories.

"Grief is invisible in many ways," said Tashel Bordere, a University of Missouri assistant professor of human development and family science who studies bereavement, particularly in the Black community. "When a loss is invisible and people can't see it, they may not say 'I'm sorry for your loss,' because they don't know it's occurred."

"You would think that as time passes it would get better. Sometimes, it is even harder. … This wound right here, time don't heal it."

                                                                        Cassandra Rollins, of Jackson, Mississippi

Communities of color, which have experienced disproportionately higher rates of death and job loss from covid, are now carrying a heavier burden.

Black children are more likely than white children to lose a parent to covid. Even before the pandemic, the combination of higher infant and maternal mortality rates, a greater incidence of chronic disease and shorter life expectancies made Black people more likely than others to be grieving a close family member at any point in their lives.

Rollins said everyone she knows has lost someone to covid.

"You wake up every morning, and it's another day they're not here," Rollins said. "You go to bed at night, and it's the same thing."

A lifetime of loss

Rollins has been battered by hardships and loss since childhood.

She was the youngest of 11 children raised in the segregated South. Rollins was 5 years old when her older sister Cora, whom she called "Coral," was stabbed to death at a nightclub, according to news reports. Although Cora's husband was charged with murder, he was set free after a mistrial.

Rollins gave birth to Shalondra at age 17, and the two were especially close. "We grew up together," Rollins said.

Just a few months after Shalondra was born, Rollins' older sister Christine was fatally shot during an argument with another woman. Rollins and her mother helped raise two of the children Christine left behind.

Heartbreak is all too common in the Black community, Bordere said. The accumulated trauma — from violence to chronic illness and racial discrimination — can have a weathering effect, making it harder for people to recover.

"It's hard to recover from any one experience, because every day there is another loss," Bordere said. "Grief impacts our ability to think. It impacts our energy levels. Grief doesn't just show up in tears. It shows up in fatigue, in working less."

Rollins hoped her children would overcome the obstacles of growing up Black in Mississippi. Shalondra earned an associate's degree in early childhood education and loved her job as an assistant teacher to kids with special needs. Shalondra, who had been a second mother to her younger siblings, also adopted a cousin's stepdaughter after the child's mother died, raising the girl alongside her two children.

Rollins' son, Tyler, enlisted in the Army after high school, hoping to follow in the footsteps of other men in the family who had military careers.

Yet the hardest losses of Rollins' life were still to come. In 2019, Tyler killed himself at age 20, leaving behind a wife and unborn child.

"When you see two Army men walking up to your door," Rollins said, "that's unexplainable."

Tyler's daughter was born the day Shalondra died.

"They called to tell me the baby was born, and I had to tell them about Shalondra," Rollins said. "I don't know how to celebrate."

Shalondra's death from covid changed her daughters' lives in multiple ways.

The girls lost their mother, but also the routines that might help mourners adjust to a catastrophic loss. The girls moved in with their grandmother, who lives in their school district. But they have not set foot in a classroom for more than a year, spending their days in virtual school, rather than with friends.

Shalondra's death eroded their financial security as well, by taking away her income. Rollins, who worked as a substitute teacher before the pandemic, hasn't had a job since local schools shut down. She owns her own home and receives unemployment insurance, she said, but money is tight.

Makalin Odie, 14, said her mother, as a teacher, would have made online learning easier. "It would be very different with my mom here."

The girls especially miss their mom on holidays.

"My mom always loved birthdays," said Alana Odie, 16. "I know that if my mom were here my 16th birthday would have been really special."

Asked what she loved most about her mother, Alana replied, "I miss everything about her."

Grief complicated by illness

The trauma also has taken a toll on Alana and Makalin's health. Both teens have begun taking medications for high blood pressure. Alana has been on diabetes medication since before her mom died.

Mental and physical health problems are common after a major loss. "The mental health consequences of the pandemic are real," Prigerson said. "There are going to be all sorts of ripple effects."

The stress of losing a loved one to covid increases the risk for prolonged grief disorder, also known as complicated grief, which can lead to serious illness, increase the risk of domestic violence and steer marriages and relationships to fall apart, said Ashton Verdery, an associate professor of sociology and demography at Penn State.

People who lose a spouse have a roughly 30% higher risk of death over the following year, a phenomenon known as the "the widowhood effect." Similar risks are seen in people who lose a child or sibling, Verdery said.

Grief can lead to "broken-heart syndrome," a temporary condition in which the heart's main pumping chamber changes shape, affecting its ability to pump blood effectively, Verdery said.

From final farewells to funerals, the pandemic has robbed mourners of nearly everything that helps people cope with catastrophic loss, while piling on additional insults, said the Rev. Alicia Parker, minister of comfort at New Covenant Church of Philadelphia.

"It may be harder for them for many years to come," Parker said. "We don't know the fallout yet, because we are still in the middle of it."

Rollins said she would have liked to arrange a big funeral for Shalondra. Because of restrictions on social gatherings, the family held a small graveside service instead.

Funerals are important cultural traditions, allowing loved ones to give and receive support for a shared loss, Parker said.

"When someone dies, people bring food for you, they talk about your loved one, the pastor may come to the house," Parker said. "People come from out of town. What happens when people can't come to your home and people can't support you? Calling on the phone is not the same."

While many people are afraid to acknowledge depression, because of the stigma of mental illness, mourners know they can cry and wail at a funeral without being judged, Parker said.

"What happens in the African American house stays in the house," Parker said. "There's a lot of things we don't talk about or share about."

Funerals play an important psychological role in helping mourners process their loss, Bordere said. The ritual helps mourners move from denying that a loved one is gone to accepting "a new normal in which they will continue their life in the physical absence of the cared-about person." In many cases, death from covid comes suddenly, depriving people of a chance to mentally prepare for loss. While some families were able to talk to loved ones through FaceTime or similar technologies, many others were unable to say goodbye.

Funerals and burial rites are especially important in the Black community and others that have been marginalized, Bordere said.

"You spare no expense at a Black funeral," Bordere said. "The broader culture may have devalued this person, but the funeral validates this person's worth in a society that constantly tries to dehumanize them."

In the early days of the pandemic, funeral directors afraid of spreading the coronavirus did not allow families to provide clothing for their loved ones' burials, Parker said. So beloved parents and grandparents were buried in whatever they died in, such as undershirts or hospital gowns.

"They bag them and double-bag them and put them in the ground," Parker said. "It is an indignity."

Coping with loss

Every day, something reminds Rollins of her losses.

April brought the first anniversary of Shalondra's death. May brought Teacher Appreciation Week.

Yet Rollins said the memory of her children keeps her going.

When she begins to cry and thinks she will never stop, one thought pulls her from the darkness: "I know they would want me to be happy. I try to live on that."