A healthcare worker puts on personal protective equipment. (James Oatway)

During epidemics doctors face moral dilemmas forcing them to make decisions against their conscience — such as having to follow treatment guidelines designed to cope with limited resources. COVID-19 is no different.

COMMENT

Alarm bells went off in my head.

The national health department and government laboratory service had just instructed us to be more selective about who we tested.

But our COVID-19 cases were increasing daily at the Nontyatyambo Community Health Centre in Mdantsane in the Eastern Cape where I was working as a community service doctor. 

We were in a catch-22 situation.

The number of COVID-19 cases were steadily growing. But the country was running out of test kits and labs couldn’t keep up with the processing of the tests, which meant we had to ration the tests.  

I was worried.

The people I turned away for testing returned to their communities. Because they never had a test or test result, they mostly didn’t think it was important to stay at home and isolate themselves.  

And because there was no record of their COVID-19 status, they also weren’t on the list of people who would be traced — so their contacts and their contact contacts’ movement wouldn’t be traced either. If that one untested patient was positive, the person could potentially start a whole new outbreak in their area. 

I felt responsible and conflicted. I wanted to test everyone who came to the clinic, but it was against government guidelines. 

Over the past six months, this is just one of the moral dilemmas that my colleagues and I have had to battle with. 

There’s an actual name for this predicament — moral injury.

‘We’ve often had to go without protective gear because of corruption’  

Moral injury is defined as preventing or bearing witness to acts that transgress your own deeply held moral beliefs and expectations. 

For healthcare workers, this includes their oath to provide the best care possible for their patients — and to always make their patients’ needs their first priority.

My colleagues and I in Mdantsane — the second largest township in South Africa — are not alone in our struggles. 

[WATCH] Webinar on Moral injury & mental health: What COVID doctors can learn from HIV

The webinar was hosted in partnership with the Healthcare Workers Care Network and the United States government’s President’s Emergency Plan for Aids Relief, Pepfar. 

Across the world, researchers have been exploring the impact of COVID-19 on the mental health of healthcare workers. What are the psychological effects of such extreme working environments?  How vulnerable are health workers to the mental health effects of seeing colleagues dying from the pandemic? And what happens to workers’ psyche when they’re forced to make treatment decisions they morally disagree with? 

In South Africa, on top of taxing occupational environments and having to deal with loss and grief, health workers face the added pressure of having to ration stretched resources. Moreover, they have to face the consequences of corruption and the pilfering of state healthcare contracts on their daily work lives. 

The Office of the Auditor General in South Africa has been investigating how R500-billion in redirected resources, meant to be spent on the health response and the relief of social and economic distress caused by COVID-19, has been misused.  

On the frontline, this has meant that many of us who need the personal protective equipment most have had to put our lives at risk and go without while treating patients who have contracted the virus.

Most, if not all of my colleagues have been afraid of contracting SARS-Cov-2, the virus that causes COVID-19, and they’ve been terrified of the potential impact this could have on their families.

In a province such as the Eastern Cape, where the health system has been severely under- resourced and mismanaged for decades, adding an epidemic to the situation often drives health workers to breaking point.  

Burn-out leads to apathy towards patients — and a deep sense of guilt about it 

I’ve had several moral injury encounters over the last six months —  like the massive testing backlogs. 

At the beginning of the pandemic the turnaround time for test results was two days. But as the numbers started to rise, government facilities in the Eastern Cape had backlogs of as huge as 20 000 cases. This resulted in the turnaround time to receive test results sometimes being as long as four weeks. 

Some positive patients therefore only received their results once they had already recovered from the virus. 

At my clinic, close to half of our staff developed COVID-19 over the past six months. So we often lost a pair of hands that we needed at quite a crucial stage. 

Increased patient loads with about half the staff complement was a serious challenge. I became irritable and started to develop a sense of apathy towards patients — and felt intensely guilty about it. 

But what saved me — ironically — is that I contracted SARS-CoV-2 myself. The two weeks I had to isolate myself, gave me the desperate break that I needed. 

Ambulance workers’ fear of COVID influenced which patients they were prepared to transport

There was also the massive ambulance shortage in the Eastern Cape. This situation was compounded by the fact that some ambulance staff had not only contracted the virus, but the work choices they made were directly influenced by their fear of the virus.

When we would call for ambulances for patients, paramedic staff would often choose to allocate ambulance spots to non-COVID patients.  

There were times patients were stuck at the clinic when they needed to be referred to a higher institution. Because we saw COVID patients outside (in front of the clinic) to curb the infection risk, sick people on oxygen had to wait for ambulances for hours during ice cold winter evenings.  

It stripped them of their dignity and it made me, as their doctor, feel helpless. 

The lessons I learned  

I’ve learnt three important lessons in this time.

The first is that it’s important to acknowledge that you’re not going through this pandemic alone. All your work colleagues face the same struggle. Everybody’s pulling their last straw in order to give their best. Recognising that and consciously talking about your daily challenges with your peers is helpful and a crucial form of support. 

The second lesson is that I’ve learned to make use of mental health organisations that can support me. In South Africa, the Healthcare Workers Care Network offers both clinical and administrative staff free counselling services. Counselling doesn’t just improve your mental health as a doctor, so you can serve your patients better. Your mental health also impacts on your family — being healthy for them is as important.   

The third and last lesson I learned is that I now know it’s okay to ask for help — and to say that you’re not coping. Although the medical field is hierarchical and authoritarian and this environment often encourages excessive mental resilience, health workers should realise that it’s alright to acknowledge that they are suffering from mental stress. 

At the Junior Doctors Association in South Africa I’ve come across many junior doctors who are unwilling to take advice on how to deal with issues of mental health because they think it will affect their careers negatively. They believe they will be perceived as ‘weak’;  but that unfortunately leads to poor health seeking practices. 

The only way to deal with issues of mental health and moral injury among health workers is to get to the bottom of what causes medical staff to be reluctant to seek help. Only once we understand how doctors and other health workers are wired, will we be able to create an environment where they feel they’re allowed to experience mental stress and that it’s okay for them to ask for help.   

Tshepile Tlali is a community service medical officer currently working at a community health centre in Mdantsane in the Eastern Cape. He is also the acting chairperson of the Junior Doctors Association of South Africa