Healthcare workers: “We are living in the shadows of death”

Health workers believe they work under the shadow of death.

Frontline healthcare workers have been the hardest hit during the COVID-19 wave.
It’s been over a year since COVID-19 first hit South Africa. Since then, many people have been living in constant fear and many have lost loved ones. Frontline healthcare workers had no choice but to face their fears if they were to keep doing the life-saving work they were trained for. Amy Green, for Spotlight and Health-e-News, and colleagues explore the emotional toll that South Africa’s third wave of COVID-19 is taking on healthcare workers.
It’s been over a year since COVID-19 first hit South Africa. Since then, almost everyone has been living in fear. But frontline healthcare workers are hit hardest, placing themselves last to save the lives of others. Frontline healthcare workers have been taking considerable strain, especially during the third wave. They work long hours, often without the resources causing them physical and especially emotional harm.
“I dread going [to] work on Mondays. The sight of dead bodies being wheeled out of a ward on a stretcher just kills the spirit and breaks one down. It’s very depressing,” says 30-year-old Mandisa Majavu*.
As a psychologist, Majavu’s very job is to counsel the bereaved and others, including fellow healthcare workers, but the COVID-19 death toll associated with the third wave of infections is taking its toll on her too. Although a counsellor, she, perhaps, also needs to be counselled.
“Two weeks ago, on two different days, I noticed five bodies being wheeled out of a ward. As one who should make others feel stronger and instill faith in them, you find yourself overwhelmed. Remember, we are also only human,” she says.
The physical harm of COVID-19 is well-established, but the psychological toll is much harder to quantify, yet the harm is significant and is a threat to individuals and society.

Frontline healthcare workers are hit hardest, placing themselves last to save the lives of others.

Majavu says that healthcare workers working during this time need to be “very strong emotionally” and that, working as a psychologist particularly, “is really tough, but we have to do it”.
“I have never read the Bible before like I am now,” she says. Majavu works at Livingstone Hospital in Gqeberha where the third wave officially broke out over a month ago. On 6 July 2021, provincial Health MEC Nomakhosazana Meth announced the province’s biggest metro, Nelson Mandela Bay (in which Gqeberha is located), had been hit by a third wave of COVID-19 infections. According to the MEC, the rest of the province was only hit by the third wave two weeks ago.
As clinical psychologist Dr. JD du Toit recently summed up in an op-ed: “South Africa is currently experiencing what is probably one of its most stressful periods in recent history. As part of the global village, along with the rest of the world, we are experiencing an ongoing pandemic, the likes of which have not been seen for over 100 years.
If our state psychologists are in trouble, what does it say about the emotional and mental state of the country’s other frontline healthcare workers?
Sheila Nkgapele (49), who has been a nurse for 24 years, says that “death is common” in her line of duty. “But nowadays it’s horrific. You see dead and dying people several times during your working hours. It is traumatic because some of them are your colleagues or people you know. Every time you ask: Am I infected?” says Nkgapele who works at Pietersburg Hospital in Polokwane, Limpopo.
Not only do healthcare workers on the frontline have to worry about their own health, and risking the health of their families because of work-based exposure, but experiencing so much death can lead to a worrying condition called compassion fatigue.
This is according to Professor Gareth Stevens, who is both a clinical psychologist and Dean of the Faculty for Humanities at the University of the Witwatersrand (Wits). “Compassion fatigue is essentially when, with death being so frequent, we become somewhat desensitised to it. Being compassion fatigued means there are higher levels of burnout,” he says.
According to a 2016 systematic review on compassion fatigue published in the International Journal of Environmental Research and Public Health, compassion fatigue can be caused by any traumatising situation and poses a serious threat of burnout. Burnout is “a state of physical and mental exhaustion caused by a depleted ability to cope with one’s everyday environment”.
Stevens says that “healthcare workers are foremost human beings” and, directly because of COVID-19, “they are like other humans struggling with mental health issues at this moment.

Healthcare workers have higher levels of anxiety and depression at this point in part because of factors like social isolation, lockdown, extended working days, and lack of social cohesion,

“In some ways, we all have higher levels of anxiety and depression at this point in part because of factors like social isolation, lockdown, extended working days, lack of social cohesion, and this has been confirmed in several studies in both South Africa and the World,” he says.
For example, local mental health advocacy organisation the South African Depression and Anxiety Group (SADAG) received more calls from people struggling with their mental health during the first lockdown. The organisation then conducted a survey among over 1 200 participants to investigate the impact of COVID-19 and the associated lockdown. While 59% of people felt stressed before the lockdown, this increased to 65% during the lockdown. A further 55% experienced anxiety and panic, 46% experienced financial pressure, 12% had suicidal thoughts, and 6% of survey participants turned to substance use.
But because healthcare workers are actually witnessing the consequences of COVID-19, repeatedly and daily, the risks to their mental health – including burnout–may even be higher than that of the general population.
Burnout is a constant threat for many frontline healthcare workers. Many have had to work longer hours with fewer staff members as exposure to the virus means that many healthcare workers who become infected have to take time off to isolate themselves and get better.
And, of course, this doesn’t factor in the at least 391 healthcare workers who lost their lives to COVID-19.
Sister Lorraine Malamule who works in the sub-districts of the Emalahleni Municipality in Mpumalanga, says she has been significantly affected by the long working hours.
“Since there is a shortage of staff, mainly because some of our colleagues were infected with this deadly virus, we now have to work long hours. We hardly even get time to reboot or to spend with our families,” she says.
Stevens points out that, at this time, where one is less able to spend time with support structures like families, “is really the time where these support structures are needed most”

According to Professor Francois Venter from Ezitsha at Wits, the health system is already too stretched under the third wave for healthcare workers to take time off for burnout, on top of all the other resource limitations.
Kedibone Mchaise, a nurse in Thembisile Hani Local Municipality in Mpumalanga can personally attest to the dearth of resources that are both human and material.
“Many healthcare services that are required at health facilities are not there,” Mchaise says there are staff shortages which means there are not enough workers to test people for COVID-19. “There [are] not enough healthcare workers to vaccinate people… the lack of resources is doing us injustice,” she says.
Compassion fatigue “can affect standards of patient care, relationships with colleagues, or lead to more serious mental health conditions such as post-traumatic stress disorder (PTSD), anxiety, or depression”, noted the authors of the 2016 review. “These conditions are known to increase sickness absence, psychological injury claims, job turnover, and negatively impact productivity.”
Justice Lamola, a social worker working in a hospital in the Capricorn District of Limpopo, explains that the high death toll has made a significant impact on his own mental health and threatens his ability to do his job efficiently. “As daily infections and fatalities continue, I need debriefing sessions as well. It pains me when I conduct a debriefing session [with] a client while I know that I also suffer the same stress. I try hard not to show my wounded part because I want the people I help to heal. We are living in the shadows of death,” he says. “I try hard not to show my wounded part because I want the people I help to heal. We are living in the shadows of death.” Not only are frontline healthcare workers more at risk of developing long-term mental health issues in this environment, but they are less likely to provide quality care if compassion fatigued. According to the review, compassion fatigue “is characterized by exhaustion, anger and irritability, negative coping behaviours including alcohol and drug abuse, reduced ability to feel sympathy and empathy, a diminished sense of enjoyment or satisfaction with work, increased absenteeism, and an impaired ability to decide and care for patients.” Kegomoditswe Phetla is a woman and youth coordinator for the Mpumalanga Department of Health and confirms that quality has been compromised because of a combination of sheer numbers of infections and by an already under-resourced system.
“We are not able to render the quality of care that we are expected to, we are also not able to cover all patients. Patients are waiting for turns, [and are] affected because of the shortage of resources,” she says.
“We are seeing this domino effect of pressure on our health system at the moment where people are exposed to long working hours, fewer resources, burnout, and higher levels of compassion fatigue,” says Stevens.
Newly qualified community service nurse Mzamani Sithole* (32) says that it was a terrible time to come into the profession.
“Here in Mokopane Hospital [a regional hospital in Limpopo], I used to do my work diligently, knowing I am helping the sick as even [I] myself could be a patient. But now working in this pandemic has made me terrified knowing that [I] too could be infected, get sick, or maybe not survive. I work through a traumatic situation every day that, even when it is payday, I do not relish my salary,” he says.
This includes people without COVID-19 symptoms or exposure “demanding” to be tested, something which Lerato Mokoena*, a nurse at Itsoseng Community Healthcare Centre in the North West, can attest to first-hand.
“Every day we see more and more patients coming into the Centre demanding to have COVID-19 tests done even when there are clear signs that they have a normal cold, for example, after we have screened them. We are very busy at work since the third wave began, and this pandemic has caused a lot of physical and emotional strain,” she says.
*This article was commissioned and edited by Spotlight and written by Amy Greene. Green is the news editor at Health-e-News.

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