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 necessary 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 instil 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.

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.

I have never read the Bible before like I am now.

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 has not been seen for over 100 years.

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.

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 the question: Am I infected?” says Nkgapele who works at Pietersburg Hospital in Polokwane, Limpopo.

Risk of compassion fatigue

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 Garth 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 first and foremost human beings” and, directly due to COVID-19, “they are like other humans struggling with mental health issues in this moment”.

“In some ways, we all have higher levels of anxiety and depression at this point in part due to factors like social isolation, lockdown, extended working days, lack of social cohesion, and this has been confirmed in a number of 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 on a daily basis, 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 themeselves and get better.

And, of course, this doesn’t factor in the at least 391 healthcare workers who lost their lives to COVID-19.

In December last year, President Cyril Ramaphosa said over 38 000 public sector healthcare workers tested positive for SARS-CoV-2 and nearly 5 000 of them were admitted to hospitals. The National Department of Health has not responded to a request for more up to date numbers.

Extra pressure

Sister Lorraine Malamule who works in one of the sub-districts of the Emalahleni Municipality in Mpumalanga, says that she has been significantly affected by the longer 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 in 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.

This additional strain is, of course, heavily linked to compassion fatigue and its consequences.

Compassion fatigue “can impact 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.

Impact on quality of care

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 make decisions and care for patients”.

Kegomoditswe Phetla* is a women 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 as well as 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 turns, [and are] affected due to 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.

I work through a traumatic situation every day that, even when it is payday, I do not relish my salary.

Unlike the first and second waves which both started in the Western Cape, the third wave began in Gauteng. Since then, the rest of the country has, at various stages, reached infection numbers indicative of a third wave, says Venter.

“We are working under stress, we fear for our lives on a daily basis. At times we just feel like quitting our jobs to stay at home and save ourselves and our families, but then we remember that we made a vow that we will always try our level best to ensure the health of our people,” says Anthony Motau*, a nurse on a testing team in Thembisile Hani Local Municipality.

While, under the third-wave associated lockdown, many individuals were asked to work from home, healthcare workers do not have the same luxury.

“We have lost families, colleagues, are dying right in front of us, people are getting infected like nobody’s business. We are even afraid of going to work,” says John Mahlangu*, another nurse on the Thembisile Hani Local Municipality testing team.

Increased demand, limited resources

Stevens says another factor placing pressure on the health system and individuals working in that system is that, in pandemics, the demand for health services increase resulting in healthy people unnecessarily utilising limited resources.

“In the general population in moments of pandemics, globally, you see an increase in health-seeking behaviour. People are much more aware of their health and there is a tendency of people going to health practitioners more frequently because they are afraid of their health status. This places an even greater burden on the system and on health workers themselves,” 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.

Hope in vaccination

As the third wave wanes and the fourth wave looms (it is expected between October and December according to Venter), the only relief comes in the form of vaccines and the successful rollout of the vaccination programme.

Nomonde Vilakazi, a 55-year-old nurse from Kariega in the Eastern Cape who has been a nurse since the age of 20, finds solace in the fact that she has been vaccinated.

“As a frontline worker at Dora Nginza Hospital [a public facility in Gqeberha], I have seen people dying of COVID-19 but at least I have been vaccinated, which makes me more confident,” she says.

Uptake of the vaccination programme has slowed in recent weeks – although it is expected to accelerate once the vaccination programme opens up to persons aged 18 to 35.

“Greater adherence to the vaccine rollout programme is one way of reducing the pressure on the health system at the moment but it’s really not a cure,” says Stevens.

While it is indisputable that the country’s public health system was not prepared for the onslaught of any of the COVID-19 waves, some like Siyabonga Xaba*, point out that people should not forget that the system, as well as healthcare workers, were equally unprepared for the emotional and mental burden of the pandemic.

Just imagine having to send eight people to a mortuary a day and go back to your family… Worse, what does that fo to your very soul?

“There is one occupational nurse and one clinical psychologist in place catering for 18 clinics and eight wards. How is it possible [to help everyone]?” asks Xaba, who is an orthopaedic nurse working at a rural hospital in Northern KwaZulu-Natal. “As for us nurses, just imagine having to send at least eight people to a mortuary a day and go back to your family. What does that do to your family? What does that do to the next patient you have to nurse? Worse, what does that do to your very soul?”

* Not their real names

With additional reporting by Charlotte Mnguni, Max Matavire, Montsho Matlala, Pamela Madonsela and Nthusang Lefafa

*This article was commissioned and edited by Spotlight and written by Amy Green. Green is the news editor at Health-e News.

This story was also published by the Daily Maverick and News24.