The coronavirus pandemic has put immense pressure on healthcare systems all over the world and has challenged the mental health of frontline workers, who walk a fine line between life and death every single day.T he novel coronavirus has taken the world by storm. Everything we know has been transformed entirely, and every day we step out of the house we now tread carefully and manoeuvre cautiously, trying to adapt to this ‘new normal’ where a handshake or a hug can carry more danger than one would have thought possible.
The coronavirus 2019 (covid-19) was first identified in the town of Wuhan, China in December 2019 and quickly engulfed the rest of the world. The World Health Organisation (WHO) declared this virus a global pandemic in March – governments had to respond accordingly, and life as we knew it was a thing of the past.
The virus was swift and impartial in its conquest, forcing us to adjust quickly and normalise habits that would otherwise be foreign to us. The pandemic has shone a light on healthcare systems all across the world. Some systems have shown exemplary direction, while others have buckled under the pressure as seen in countries such as America, Mexico and India.
Within every healthcare system there is a team of people – human beings who are as afraid of the virus as we are, yet wake up every day to treat, look after and, in some instances, save the lives of those who are sick with covid-19.
A closer look at the essential worker
The term ‘frontline healthcare worker’ covers all types of health workers such as nurses, midwives, community health workers, doctors and pharmacists – all who provide care directly to their communities. Due to their close contact with infected individuals, healthcare workers are at high risk of infection, which could lead to further spread to patients, friends and family.
The mental well-being of healthcare workers has been the topic of discussion across all spheres of society. Their lived fear is something we, as onlookers, don’t wish to even imagine. Fear of catching the virus, witnessing countless deaths on a daily basis, treating critical patients but being afraid of them, are only a few of the stresses healthcare workers have had to grapple with and overcome every day, since the virus started spreading.
In the Kingdom of Eswatini, the prime minister invoked section 29 of the Disaster Management Act (2006) and declared a National Emergency on March 17, and thereafter the country entered a five-week partial lockdown. The lockdown was partial to ensure economic survival for the small nation. As of November 1, the Kingdom has recorded 5 925 covid-19 cases and 117 deaths.
A brief introduction
Nurses Vesta Makadzange (40) and Tadessu Kebede (48) took time to speak to Wits Vuvuzela about what their experience of the pandemic has been like at Manzini Clinic, named after the most populated region of the country and the epicentre of the virus since April this year.
Both women are veteran nurses, with over 20 years of nursing experience, yet neither of them was entirely prepared for the anxieties the pandemic would bring with it.
“When the virus started spreading overseas, everyone was scared – front liners included,” Makadzange remarked.
Makadzange started nursing in Zimbabwe, her home country, and moved to Eswatini with her husband over 10 years ago. Kebede is originally from Ethiopia and has been in Eswatini for 25 years.
Makadzange details her daily activities, which start with a daily report from the night-shift nurses at 07:00, followed by an outfit change into scrubs, including the required personal protective equipment (PPE). She will then greet patients, administer medication, perform sponge baths on bed-ridden patients and accompany others to the bathroom because they are too weak to go themselves, among other things.
Towards the evening, she will write up a report for the night-shift nurses coming in, reporting on any changes, admissions or deaths that happened throughout the day, and by 19:00 she is checked out and on her way home. A typical day in the life, you would assume.
However, with covid-19 roaming the streets, the days have not been as predictable. On any given day, in between these seemingly mundane activities, nurses morph into super humans. Some days, they are resuscitating patients who have suddenly stopped breathing, while others spend hours trying to stabilise a patient despite fearing over-exposure (nurses are advised to see patients at 30-minute intervals, to reduce the possibility of catching covid-19). On other days, nurses helplessly watch chronic patients pass on, and some might lose six patients in a day and struggle to sleep for nights on end.
These ‘in-betweens’ are the moments and memories that remain with healthcare workers: these are the events that will mark their experience of covid-19 and be part of their lives forever.
Fear of covid-19 in Eswatini was high. Many felt the country was not prepared for it. Remarking on her initial thoughts on the pandemic, Kebede said she had feared that the clinic would lack the capability to handle the virus.
“We hadn’t been trained; we didn’t have enough outfits [PPE – personal protective equipment]. Everything was happening very fast and our response had to be fast too,” she said.
Fortunately, the clinic managed to pull resources together and ensure that its staff was sufficiently protected against infection. This was assisted by the clinic being private. However, for other healthcare workers in public hospitals across the country the process was not as swift.
Poor resources can affect the mental-health of healthcare workers
In April the Swaziland Democratic Nurses’ Union (SWADNU) held a protest and filed a lawsuit against the government for failing to provide adequate PPE for healthcare workers across Eswatini. The union felt that government was infringing on their rights as dictated in the Occupational Health and Safety Act (OHS). The act states that every employer has a duty to provide “adequate and appropriate personal protective appliances, equipment and clothing” to its employees who work under conditions that can affect their safety and health negatively.
The national newspaper, Times of Swaziland, reported that the ministers concerned said these allegations were baseless because the National Emergency Act waives the duties laid out in the OHS act.
Research done by the Human Sciences Research Council (HSRC) shows that inadequate PPE can cause anxiety and stress levels to peak among healthcare workers, which can breed other anxieties like catching the virus, or unknowingly spreading it to loved ones or even patients.
South Africa has dealt with similar difficulties in terms of PPE procurement. In the earlier stages of the pandemic the HSRC created a survey for healthcare workers to review their preparedness and expectations towards the then coming storm. More than 7 600 healthcare professionals participated in the survey.
Mental health statistics among healthcare workers
Under the theme of health and well-being, the results show that nearly half the nurse practitioners were extremely concerned for their personal health, while three in five reported being concerned about passing infection to family members. A quarter of nurse practitioners experienced severe psychological distress, and health professionals working in public hospitals were seen to be experiencing higher levels of psychological distress, compared to those working in the private sector.
Overall, the HSRC found that nurses had higher personal risk perception (a general perception one holds of the severity of/their vulnerability to a health threat), causing poor mental health and affecting the health workforce’s capabilities, staff performance and morale.
Clinical psychologist, Garret Barnwell, says psychological distress is often caused through structural issues: “Things like PPE, access to adequate diagnostics, treatments and staffing, clear protocols, good team communications, all help to create a facilitating environment for staff.”
Dove Medical Press, a publisher of scientific and medical journals, published an article on the implications of covid-19 for sub-Saharan Africa and found that the impact of covid-19 could be immense, due to weak healthcare systems.
As observed during the Ebola epidemic of 2014-2016, the psychological effects of an epidemic can be far-reaching and can lead to an increase in depression, anxiety and post-traumatic stress disorders. From their findings, writers Bazghina-werq Semo and Souci Mogga Frissa say that mental health and psychosocial support services need to be integrated into the pandemic response, and coordinated nationally.
Echoing this idea, HSRC researcher Professor Sibusiso Sifunda says the primary concern reflected in the results of the survey was mental health and finding ways to protect the well-being of all workers.
“We measured a high level of burnout and poor mental health, even at that early stage,” he explained. “There existed a lot of fear around catching the virus and bringing it back to your family.”
This fear became a reality for both Makadzange and Kebede, when they caught covid-19.
Makadzange believes she caught it after resuscitating a patient.
“There were about five of us in the room with her, she’d started gasping and all of a sudden she just stopped breathing. We started doing CPR, giving her oxygen and trying to put her on a ventilator. The exposure during this process is quite great.”
Having spent over three hours in the room, much longer than the advised 30 minutes, all but one of them tested positive for covid-19 in the following weeks.
Fortunately for Makadzange, she was able to isolate and recover in her home after 14 days without spreading the virus to her husband and three sons.
However, Kebede’s recovery took over a month and she had to be hospitalised for a week. Having worked most shifts in the emergency room and being exposed to numerous covid-19 patients on a daily basis, she was not quite sure where she caught the infection.
“I started having flu symptoms and decided to isolate myself because of my family – my kids and my husband – and the patient too. I didn’t want to put anyone at risk while I waited for my results,” she said.
The mother of three describes the hospital as being very lonely.
“There’s a lot of fear,” she stated. “All the symptoms come at night. People would scream at night, everything is dark…”
“One feels dazed. It’s like your body was not yours,” she described.
“Everything is scary… Every day you see, it’s like death is coming.”
Manzini Clinic offers all their staff members counselling after they contract covid-19, a noble gesture, even if it doesn’t stretch out to those healthcare workers who continue to witness innumerable deaths and are accumulating trauma despite remaining healthy.
Sifunda feels the pandemic has proved to many African countries that the healthcare system can be prioritised and can thrive when money is allocated correctly.
“It has also shed light on the need for systems that look after healthcare workers. Traditionally, it [the system] has been a model where a healthcare worker is assumed to be okay and healthy enough to look after patients. This has changed.”
“Healthcare workers aren’t usually afraid of catching disease from patients, but now they have to worry about themselves and this is something new.”
Sifunda says national responses will have to design new ways to support healthcare workers and ensure that health and wellness programmes are proactive, leaving behind the passive approach that existed before covid-19.
Writers Bazghina-werq Semo and Souci Mogga Frissa say that countries in sub-Saharan Africa could learn from countries abroad and establish adequate services to address mental health.
These lessons consist of identifying high risk groups early on and providing them with targeted interventions to help get ahead of the problem, and routine screening of mental health problems.
Barnwell says it is important not to attribute psychological distress to individual issues: this calls for regular check-ins with team members and monitoring their current mental states. Lastly, the mental health of healthcare staff can be preserved by prioritising shorter work days, adequate provision of PPE and satisfactory training in infection control.
Both Nurse Makadzange and Nurse Kebede agree that their job cannot be done without passion – the crucial trait that causes you to continuously place a patient’s needs before your own, no matter what the cost.
Makadzange: “There’s a point where you need to remember the oath you made to take care of the patients. Whether you’re going to die as well or get infected, there’s a moment where you don’t have a choice. You just have to do it.”
FEATURED IMAGE: The covid-19 pandemic has put immense pressure on healthcare workers all around the world. Their exposure to the tragedies caused by the virus have led to a strong emphasis on mental-health in hospitals to ensure medical staff do not experience burnout, depression and other symptoms of poor mental health. Photo: Vetiwe Mamba.