Shades of the invisible wounds —

psychological traumas of health workers in the pandemic

What is your impression of MSF field workers? Always full of energy and ready to save lives in the field? This description might be the expectation of many people, including the workers about themselves. However, humanitarian aid workers are not unbreakable. Stress and negative emotions can accumulate when exposed to the death of patients and because of the limitation of means and equipment that the medical staff may have. It is impossible always to stay in the best condition for the patients. Humanitarian aid workers experience moral dilemmas and various constraints in their work; this is not new, nor is it specific to COVID-19. But the pandemic has put a new light on aid workers, who are keen on their work at the front lines around the world, complete every mission without fear and try their best to take care of patients. They also need to deal with anxieties and fears. The professional image has always hidden these troubles that lie underneath.

Heartbreaking: life-and-death decisions

Dr Koana Rojas is a pediatrician from Venezuela. When the pandemic hit in 2020, she decided to join MSF and support a COVID-19 ward in Caracas.

“Deep inside, I knew that there were things I could have done.”

Dr Koana Rojas still remembers a patient—a 40-year-old-pediatrician—who had been admitted for COVID-19. From the beginning, he had a lot of difficulties breathing. The only thing that she knew would help him was to put him under intensive care. But there were not enough beds are machines there and she could only send him to palliative care. And he passed away shortly afterwards.

“For seven years I had only seen pediatric patients, now I am admitting adults, which is completely outside of what I prepared for. The expression “palliative care” is a very strong one. It means that there is nothing else that we can do. We were not being able to give him the care he needed. I watched as his heartbeat slowed and he lost consciousness… I looked at him draw in his last breaths.” Dr Koana Rojas still choked up when she recalled, “It was really hard because… because it could have been me. I remember that his son, while crying and caught in desperation, kept repeating, “I know that you did all you could. Don’t worry, doctor. I know you did all you could.” But it was hard for me to look into his eyes because deep inside, I knew that I could have done more. There were other things we could have tried. We could have transferred him to intensive care, for example.”

If she could turn the clock back, Dr Koana Rojas would like to spend more time with him. “I knew that he was not going to make it. He was aware of it himself. This is why I would have liked to share more with him, maybe show him videos of his family. Try to accompany him in his last moment so that he won’t feel alone.” Following the advice of MSF psychologists, she started her self-healing journey by speaking to her unconscious mind. She then named her emotions one by one to tease out the problem. "Connecting with nature helps me overcome these conditions, a flower, a pine tree... close my eyes, savor all the smells, be in it, I can let go of everything, like breathing, tell me things will be all right, tomorrow is new again one day."

Feeling painful: being misunderstood

Manqoba Sikhondze is a home care nurse with MSF in Eswatini.

“People were unable to understand that some of these things were systematic.”

During the outbreak of COVID-19, Manqoba Sikhondze from the home care team in Eswatini kept receiving calls from different places in the region. Most of them are elderly, critical patients with other serious conditions. As a healthcare professional, he needed to prioritise the treatment needs for each individual. However, not everyone understood the limitations he was working under. Some patients and their family members misunderstood that you walked away of not helping them.

Manqoba recalled one of the caregivers told him, "Actually, he told me that he thinks I'm coming at this time of the hour because I want to earn a lot of money. He claims that when we are actually working at night, we get a lot of money. There was no monetary benefit whatsoever that we were getting, and it was just our normal remuneration. So, for me, it was actually quite painful."

"People were unable to understand that some of these things were systematic. It was not our own fault, and these were things that were beyond our control, but because we were the ones that people were seeing on the ground, we were the ones that people were actually venting out to with their anger, with their emotions and everything."

Sometimes, Manqoba would think of those people they were unable to help, “Even though it is painful, I do a personal review. I do personal introspection, I say, "maybe that person, is there something that perhaps I would've done differently to save that person? "

Tormenting: separated from loved ones

Dr Marisela Douaihy is an intensive care specialist in Venezuela.

“I haven’t hugged my daughter for one year.”

COVID-19's rapid spread created an unprecedented challenge to the humanitarian work. At the same time, it also put our field workers in a dilemma. As borders started closing and travel restrictions were imposed, some of them had to decide whether to stay with MSF or go home to support their home countries and stay with their loved ones. “The difference with this pandemic is that anyone will potentially need advanced life support. And you can’t provide it because you have only a few beds for Venezuelan people. How do you choose between 15 people with the same condition?” Dr Marisela Douaihy admitted that she felt suffocating at the sight of all those people who could not breathe. “Obviously, your human side is touched when you see this disaster. You see people asking you for help but you can’t do anything about it. “She added, “It’s true that we [intensive care doctors] are used to death, but we are not used to seeing ten patients or more die in a single day. I had to start seeing a psychologist to be able to mitigate a bit the pain of telling ten families a day, “I am sorry. We did everything we could, scientifically and according to our knowledge, but there is nothing else I can do for your relative.”

For Dr Marisela Douaihy, the most important support is from her family. "I come from a family that always comforted each other in difficult moments." However, she had to isolate herself from them due to her high risk job. This made her feeling lonely during the most challenging times. "The hardest part is the lack of physical contact, and I had not hugged my daughter for one year." She can't hold back her tears when she remembered that.

Determined: continue to contribute

With COVID-19 infections in Hong Kong hitting new highs, MSF has rapidly organised a project team to step up its response to fight against the outbreak. Dr Henry Pang, a medical doctor, is one of the key members of the project team.

“I used to think that we were A-grade students.”

This year, amid the fifth wave of the COVID-19 epidemic, its scale and extent took us by surprise. For the first three weeks of March, Hong Kong ranked first in the world in terms of the number of deaths from the disease in proportion to the population. According to official data, residents in residential care homes for the elderly and residential care homes for persons with disabilities have accounted for 55 per cent of such fatal cases, while over 95 per cent of the deaths were among people aged 60 or above.

"I used to think that we were A-grade students." Dr Pang said with a smile. Before the COVID outbreak in Hong Kong, he was working abroad on a cruise ship supervising COVID protocols and testing. While chatting with his colleagues, he was proud that Hong Kong was a haven from COVID-19. "Before the 5th wave, our situation was relatively stable and had a lower death toll compared with the other countries and regions." However, the 5th wave of the outbreak shook the confidence of Dr Pang.

"During that time, I worked in the Accident & Emergency Department of a public hospital. As a frontline medical doctor, I tried my best to help Hong Kong’s COVID situation and treat patients, like many other healthcare workers. Unfortunately, no matter how hard we worked, we saw people dying in the cold and wet weather on the street, without basic human dignity. I believe not only medical care staff, but anyone who witnesses these would feel upset.”

Dr Pang continued. "The local medical system has long been flawed, and this may probably be the last straw on the camel's back. This experience has shaken many people, including some of us on the front lines.” The sense of helplessness became so intense that a doctor from the Department of Accident and Emergency of a public hospital broke down in tears during a staff meeting in March.

An “alternative therapy” for the silent wounds

Driving systematic change is never an easy topic, but as an individual, can we take any small step first? Dr Pang thought about that all the time in the fifth wave outbreak. "Whenever I see a gap, I will try filling it."

At that time, he worked closely with different local organisations and NGOs. In April, he joined the MSF project team to participate in various initiatives like infection prevention and control assessments for private elderly care homes and the free medical consultation sessions in a series of vaccination campaigns. And he found many frontline workers sharing the same belief. "Many community organisations and charities tried their best to collect and allocate supplies during the 5th wave. Social workers also went door to door to deliver RAT test kits and food to those in need to ensure that they could receive proper care. They were trying hard to fill the gap."

Dr Pang recalled, "When we went to conduct assessment in one of the elderly homes, the care workers couldn't hold back tears while recalling the scene where many residents got infected at the same time. They couldn't help thinking about what should be done better or even if the elderly got infected from them.”It looks like these care workers are also suffering a similar kind of pain to the medics. “They are not doctors, but with great teamwork and mutual support, they tried their best to use the resources at their disposal to support the recovery of every resident. I admire their perseverance; it also reminds me why I would like to be a doctor." He paused and said, "I am still keen on this and want to further contribute to the community in need."

He is determined to apply what he has learned from various countries to local programmes, and help further develop community health care services, so that vulnerable groups can receive proper care. "Perhaps we have never been an 'A-grade student'. This pandemic is an opportunity for us to reflect on how to improve and address needs in the less visible corners of the community."

To relieve stress for Frontline Workers

Staying mentally well is essential for everyone, including MSF staff. After months in the field, staff are often tired and have many new encounters to reflect on. They may need help to better cope with their emotions and natural reactions to traumatic events. The COVID-19 pandemic has added extra stress for field workers. MSF has undertaken the “Silent Wounds” video project and a research study of experiences that bring about moral distress to understand our staff’s ethical challenges. Such understanding is essential to developing the resources we need to support them. Watch more videos of our aid workers sharing their pandemic experiences.

Supporting our teams

For all staff recruited to work overseas with MSF, we provide comprehensive preparation training, which includes psychosocial components, to guide them on addressing topics like stress management, self-care, ways of coping, short- and long-term responses to trauma, and managing unexpected events and burnout.

Every operational section has a psychosocial unit—and all field workers are encouraged to use the support—whether they have general questions or need help because they’re feeling unwell. If a team has experienced a traumatic incident or exceptionally high stress, an MSF psychologist might travel to the project location to provide support. Counselling is also available for all staff by phone or video call.

Supporting our patients

In 1998, MSF formally recognised the importance of providing mental healthcare as part of our emergency work. In 2020, our staff provided 349,500 individual mental health consultations. The psychosocial support we provide through these consultations and groups focuses on helping people to develop coping strategies after they have lived through traumatic experiences. The immediate goal is to reduce their symptoms and help them be able to lead a normal life. Many people, in many countries around the world, are experiencing stress and/or anxiety during the current coronavirus COVID-19 pandemic. MSF teams are providing mental healthcare to people affected by the pandemic and have offered tips on how to manage stress. In Hong Kong, we invited psychologists to design the “How Are You?” website to share self-care tips and tools; for example, a series of free children’s storybooks to assist parents to deal with children’s anxiety. Please click here to read more: https://howareyou.msf.hk/en/