COVID-19 fatigue wilting frontline workers
As India’s pandemic case numbers inch towards the seven million mark, healthcare workers are feeling burnt out with unprecedented work load, anxiety and uncertainty.
doi:10.1038/nindia.2020.156 Published online 5 October 2020
G. M. V. Kasiram dons his light blue head-to-toe personal protective equipment to enter a COVID-19 ward. The pulmonologist wants to keep his work hours efficient.
“The more time you’re exposed to the virus, the more the risk of infection,” Kasiram, an assistant professor of pulmonology in a COVID-19 hospital in the southern Indian state of Andhra Pradesh, says.
In mid-April 2020, Kasiram was appointed to the Government General Hospital in Vijayawada through a special recruitment drive. What started as one doctor attending to about 25 COVID-19 patients a day shot up to about 80 patients, six months into the pandemic. Patients from remote districts of the state are routinely wheeled into the hospital in ‘serious, unstable condition’, their breaths flickering. Physicians, nurses, assistants, technicians, hospital administrators and volunteers are increasingly exposed to high viral loads. Kasiram suspects that the virus hangs in his ward like fine dust. “Chances are many of us doctors have quietly had the novel coronavirus already but remained asymptomatic,” he says.
As new admissions and deaths due to COVID-19 spike in the hospital, Kasiram and his colleagues feel increasingly helpless. “Despite efforts round the clock, we just cannot manage the patients, or save many of them.”
Kasiram says he has experienced several stages of mental unrest in the last six months – severe stress, overwhelming frustration and a feeling of inadequacy to handle emergencies, and is “at the end of his tether” now. He constantly worries for himself and his family, his colleagues and his patients. Their despair-filled conversations are almost always about how and when the pandemic might end. “We are spent, we are lost.”
Kongara Soumya, a postgraduate pulmonology student finds the long months of continuous COVID-19 duty “psychologically exhausting”. Soumya has been attending to COVID-19 patients since March 2020 at the Infectious Diseases Hospital in Guntur, Andhra Pradesh. She and other postgraduate students put in anything between 24 to 36 hours at a stretch in the wards.
When one of Soumya’s colleagues got infected with the novel coronavirus in April, they were all quarantined. “We suffered like hell.” Neighbours started putting pressure on her family to dissuade her from COVID-care. After months of exposure to the virus, Soumya says she and her colleagues have decided to make peace with it.“Now, we have adjusted.”
Her regular postgraduate classes have come to a halt and when the pandemic ends, getting up to speed with studies is going to be another big challenge, Soumya says.
Globally, around 7,000 healthcare workers have died due to COVID-19, according to an estimate released in early September 2020 by Amnesty International. The Indian Medical Association (IMA) says about 573 frontline workers died of COVID-19 in the country till mid September 2020 and over 87,000 were infected with the virus.
“Data on the number of healthcare workers who are infected by COVID-19 or number of such persons who have lost lives during COVID duty is not maintained at central level by Ministry of Health," India's junior minister for health Ashwini Choubey told the lower house of Parliament in September. The IMA slammed the government's "hypocrisy of calling them corona warriors on one hand and denying them and their families the status and benefits of martyrdom."
India failed to use its early advantage of a prolonged nationwide lock down to increase the capacity of its healthcare system and break the viral chain of transmission, says Soumyadeep Bhaumik, a research fellow at The George Institute for Global Health, India. “Transmission has not stopped and we are still struggling with capacity.”
Uncertainty fuelling despair
The country’s frontline public healthcare personnel are grossly overworked and fatigued, with no respite in sight. “More than anything else, the uncertainty over when this will end is frustrating,” says Nuggehalli Srinivas Prashanth, an assistant director of research at the Institute of Public Health in Bengaluru. Prashanth lives in south-eastern Karnataka's Biligirirangana Hills, 175 kilometres from Bengaluru, and works with the Soliga tribal community.
While the number of COVID-19 cases in Bengaluru is close to 0.6 million, the tribal community reported just a single case by September 2020. “In the same country, there are thousands of neighbourhoods, locations and geographies, all at different stages of the (infection) cycle,” he adds, "and that is making it very difficult to mount a collective societal or healthcare response.”
Prashanth points to the irony that while some government doctors involved in COVID-19 care are overworked, many in private hospitals may not be have been involved in pandemic care despite their willingness. The public health community has not been sufficiently involved in the country’s emergency response, he feels.
Soumitra Pathare, a consultant psychiatrist and director of the Centre for Mental Health Law and Policy at the Indian Law Society in Pune, says the long duration of the pandemic has turned life into a battle of survival even for the working class, more so for health workers.
“If you are not well off and your job is at risk, the anxiety and fear comes from the uncertainty -- you don’t know what’s going to happen to your livelihood, your family.”
Easing the burden
Pathare says frontline health workers’ fatigue is largely due to systemic issues such as shortage of beds, PPEs or oxygen units, having to triage patients for ventilators, poor administrative support, punishing schedules and salary-cuts for COVID-19 affected healthcare workers – all of this is weighing down heavily on their minds. “What can a doctor or a nurse do about these?”
Frontline workers also face the brunt of public anger when things go wrong. “Treating patients does not stress them out, a lot of their stress comes from issues they have no control over,” Pathare says.
Healthcare workers have been protesting in many hospitals across the country for not being paid their salaries for months. "They have been working outside their comfort zones and are exposed to such high levels of risk," says Balasubramaniam Ramana, a surgeon with the Calcutta Medical Research Institute (CMRI) in Kolkata. "Instead of being paid extra for this, they aren't even being paid regular salaries." Widespread violence and negative media coverage about doctors in private medical centres also leaves deep psychological scars on them, he adds. A number of suicides by healthcare workers during the ongoing pandemic point to this grim reality.
The government's messaging around the pandemic has not prepared people for a long haul, Pathare says. “Messaging has always been for quick dashes, not for a marathon. This kind of messaging hasn’t helped anybody.”
Compliance fatigue has also set in among the general public, who are openly flouting mask and physical distancing advice, Pathare says. India's health minister Harsh Vardhan, however, chose to describe such non-adherence as 'prevention fatigue' rather than complacency. “People tire out when they have to constantly take precautions. My message to everyone is that we must all diligently take precautions”, especially during the ensuing festival season, he said during an interaction with social media users recently.
Before the ‘fatigue phase’ in the life of a pandemic, a country should ideally enter a phase of confidence in its capacity to handle it, Prashanth says. “But that doesn’t seem to have happened.”
Creating an army of healthcare workers dedicated to extensive contact tracing could still help reduce transmission thereby taking off some of the load on the hospitals and medical professionals, Bhaumik says. Restricted work hours and due compensation would help restore the dignity of the healthcare workers, according to Ramana. "The fatigue is daunting — our actions as a country need to match our words."