Gauri Seth, 25, a fresh medical graduate and a doctor at a government COVID-19 facility in Uttar Pradesh’s Sultanpur district, says she is hurtling towards a breakdown. “When I go home, I cry. I graduated with such different expectations.” The conditions at the centre she works at are dire and she finds it hard to cope: there isn’t even regular water supply, let alone oxygen for the patients.
“The doctors ask patients to lie prone. But when the patient is gasping and needs oxygen, what can we possibly offer as substitute?” she asks. Sometimes she is so shattered she leans on anti-anxiety pills; she has nightmares and says she needs to talk to a therapist. When home, Dr. Seth is gripped by the fear of transmitting the virus to her family.
Until May 18, Uttar Pradesh, India’s most populous State, recorded 18,072 deaths. As the casualties rose, the government was criticised for alleged under-reporting. Rather than address the deficits, the State government, at the peak of the second wave, threatened individuals and institutions who reported oxygen or medicine shortages.
As they cope with the enormity of the pandemic and the mishandling of it, India’s doctors, nurses, radiographers, lab technicians, anaesthetists, and young interns are under extreme psychological pressure. Many of them are reporting anxiety, insomnia and burnout. The unrelenting influx of patients, the mounting deaths, the endless hours of work, the helplessness at the lack of resources, the fears of contracting COVID-19 or infecting their families — everything is contributing to a budding mental health crisis in the healthcare sector.
Anger and guilt
At a private hospital in Bengaluru, Anjana Kumar*, 33, is a labour room nurse. Last week, when a patient’s test returned positive, Kumar panicked. She had attended to the patient for a whole day without PPE and returned home to her infant daughter and 60-year-old mother. “I immediately called my sister and asked her to take my baby and mother away,” she says. But as she waited for her own test results, Kumar felt wracked by guilt. And anger. “The hospital tells us to use PPE only if the patient is confirmed positive, in order to save costs. We often wash and reuse masks because there aren’t enough to go around.”
In Kolkata, even though the private hospital Dipanita Bhaskar*, 32, works for is relatively well equipped, she is seized by a sense of helplessness and despair. As an ICU doctor, she sees the sickest patients. All too often, no matter what she does, she cannot save a life. “I may be talking to them one day, talking to their families over the phone, and the next day they are no more.” There are days when Dr. Bhaskar is able to disassociate herself from work, but there are many days when she feels constantly anxious. Over the last week, the number of people who have died in her ICU has climbed to 10-12 daily. “I find it difficult to sleep,” she says, but steels herself and carries on.
Psychiatrist Sowmya Krishna is increasingly seeing these symptoms in frontline healthcare workers. “What I notice is that they are very averse to seeking help. There is a tendency to minimise their problems, internalise them,” says Dr. Krishna, co-founder of the Bengaluru-based Green Oak Initiative, a community mental health organisation that runs a helpline for healthcare workers. “If you look at the way doctors are trained, they are taught to manage emotions; you can’t feel upset, you just carry on.”
But with a catastrophe of this magnitude, people are going to ‘destabilise’, she says. “We are seeing stress, anxiety, lack of sleep because people are unable to switch off after a long day of work.” A sense of helplessness is almost all-pervasive. “Healthcare professionals strive to help people, but in this situation, no matter what you do, people die. There is a feeling of a lack of control.” And a patient’s death, says Dr. Krishna, brings a deep sense of loss that frontline workers don’t have the time to process.
A few weeks ago, when Usha B., 53, a nurse, was on COVID-19 duty at a government hospital in Chennai, a young patient in his 20s died. “He was just fine. I’d spoken to him, given him coffee and breakfast. Within 10 minutes, he had a heart attack and passed away,” says Usha. She was agonised, but all she could do was meditate to calm herself down.
There’s manpower shortage at her hospital, and the last 13 months have been mentally exhausting, says Usha. “Being responsible for so many people is extremely taxing.” When on morning shift, Usha’s day begins at 3.30 a.m. She makes breakfast and lunch for her family, washes the dishes, then leaves to get to work by 7 a.m. She puts on her PPE and N-95 mask, and the endless cycle of caring for dozens of COVID-19 patients begins. Sleeplessness dogs her and her blood pressure shot up last week. “There wasn’t even time to get a proper check-up because there was so much work,” she says. When Usha returns home, she soaks every single thing she has used in hot water — even her water bottle and handbag — before showering and greeting her family.
Face of government
The fear of contracting the disease and infecting families is very real. Since the start of the pandemic, Pavithra Niranjan, 38, an assistant professor of pathology at Rajiv Gandhi Government General Hospital, one of the major State-run hospitals in Chennai, has tested positive twice. The second time she contracted COVID-19, in October, its impact was more intense. “I developed fever, severe myalgia, and had to be hospitalised. Being a doctor who understands the progression of COVID-19, it was frightening.” As she pushed aside her anxiety, recovered, and went on to become assistant resident medical officer for COVID-19 wards, her worst fears came true. Her father, in his late 60s, became infected and had to be hospitalised earlier this month. “It stressed me out. For almost a year, I had lectured him to wear a mask, wash his hands. But he ended up in hospital,” says Dr. Niranjan.
The sense of fear is not only about getting infected. Medical professionals also fear violence and abuse from the families of patients. Harjit Singh Bhatti, National President, Progressive Medicos & Scientists Forum, works at a private hospital in New Delhi and has been dealing with COVID-19 patients for a year now. “Families are angry and frustrated with the government, but doctors are the face of the government,” he says. “We try to ignore the verbal abuse, but I have seen physical abuse. One of my friends was beaten up by a family member. Young doctors and interns who face abuse can lose confidence.”
Francis J. Kattady, 30, a senior resident, Department of Critical Care, St. John’s Medical College, Bengaluru, had just finished his PG residency when the pandemic hit last year. Appointed to a COVID-19 ICU, he has already seen it all in this short span of time. Yet nothing prepares him for the despair he feels each day when talking to families of patients. They are difficult conversations, he says. “In the second wave, the patients are younger and more critically affected. I have had to lie, assure them that they will get better. Most of them don’t survive. I feel helpless. How do I tell a new mother with 70% lung infection that she won’t live to see her three-month-old? Another patient asked if he would get to celebrate his 40th birthday with his mother next week. I lied to them all,” he says.
There is a generalised anxiety among most of his peers, says Dr. Kattady. They suffer from mood disorders. Some young residents have asked for psychiatric leave. “Earlier, we would go out to play football or catch a movie together. But we can’t do all that now. The only way to get through this is to depersonalise,” he says.
At PVS Hospital in Ernakulam, a 32-year-old nurse says that most nurses are on duty for over two weeks without a break. “Many of us are testing positive even after both doses of the vaccine. We recently lost a 42-year-old with no co-morbidities to COVID-19. Such deaths are haunting,” he says. Remya Mol V.R., 32, is a nursing officer in AIIMS, New Delhi. Everything is drastically different this time, she says. “The patients are younger, their condition worsens in just two-three days. We could have saved so many if there had been oxygen or blood. We felt completely helpless. All we can do is talk to each other, cry to each other. But the next minute, we pick ourselves up and get back to work.”
More and more healthcare workers are reporting burnout issues, says Soumya Raj, a psychiatrist with the District Mental Health Programme in Ernakulam. Stress-induced sleep disturbances and anxiety are the most common complaints. Calls are also on the rise from ASHA workers, whose workload has grown exponentially, says Dr. Raj.
Dr. Krishna reiterates that we are likely to see more burnouts and post-traumatic stress disorder (PTSD) very soon if things continue at this pace. “We often see PTSD after a catastrophic event is over, when people finally sit down and say ‘Oh, my God, this has happened to me’. The flashbacks start,” she says. As Remya says, “I think many of us are in the denial phase now. We just want to get a grip on this pandemic and return to normalcy.”
Though there is a specific helpline for health workers in every district, the response to these has been poor, says Muhammed Issudeen, nodal officer at the District Mental Health Programme, Kozhikode. “This could be because they don’t have the time to seek help or because of the stigma associated with mental health,” he says. Dr. Bhatti echoes this when he says, “Doctors don’t talk about it. They are afraid it will affect their careers. And senior doctors and colleagues don’t take it seriously either when their younger colleagues talk about feeling the stress.”
What can hospital administrations do? “They can try and reduce work hours, get in more manpower, and make sure staff members get their days off,” says R. Thara, vice-chairperson, Schizophrenia Research Foundation, Chennai. “Second is to make sure they get emotional support, both at home and outside. This could be access to helplines, so that they have someone to talk to if they want to,” she says. Even something as simple as being given a few minutes break from the stifling PPE they wear, time off to eat, hydrate and use the restroom can help, says Dr. Krishna.
“But most importantly,” she says, “they need a space that is conducive to talk. They need to be told that it is okay to not cope. That you are human. That it’s okay to feel stressed. That it’s okay to cry.”
*Names changed to protect identity.
(With inputs from Omar Rashid, Julie Merin Varughese, Zubeda Hamid, Serena Josephine M., and Abhinaya Harigovind.)