June 9, 2016 — The psychological and mental health needs of the primary health care workers who served during the Ebola epidemic in Sierra Leone merit immediate attention, the International Rescue Committee said today.
The health workers working in primary health care facilities, rather than specialised Ebola units, were at the highest risk of infection during the 2014 – 2016 Ebola epidemic. They were often the first point of contact for Ebola cases and 21 to 32 times more likely to get infected with Ebola than the general adult population. More than 400 primary health workers died across Guinea, Liberia, and Sierra Leone.
The study, led by the International Rescue Committee and Charité - Universitätsmedizin Berlin, Durham University, Durham, Liverpool School of Tropical Medicine, Liverpool, Njala University, Freetown, and Mercy Hospital Research Laboratory, found that these primary health care workers felt stigmatised and isolated by friends, family members, fellow health professionals, and the broader community. Along with experiencing changes in their professional lives, communities, and at home, they described a profound sense of loss, loneliness, anxiety, isolation, and sadness. Despite these challenges, they remained committed to their work as health professionals.
“Emotional and social support, as well as psychological care, are often neglected during outbreaks,” said Lara Ho, Senior Advisor for Health Research at the International Rescue Committee. “Ongoing efforts to address Ebola and other diseases that trigger panic and stigma should explicitly consider the social and mental health landscape of a disease.”
In 54 interviews, health care workers described the passion and decision to continue working in health facilities, despite the fact that they were at high risk of infection. As one health care worker said, “I was really stressed, but I withstand it because I knew that as a soldier for that condition I needed to be brave.” Another said, “Well the risk is too much but I have no choice because if we the health worker are also afraid and we relax saying that this sickness is dangerous, it will still continue. That is why we are still fighting to it to end.”
These de-facto first responders describe suffering, loneliness, isolation, and feeling “full of sadness.” Many yearn for the way things were before Ebola. They feel that they were “not trusted,” “not loved,” and “not respected by the community.” Some add that they had fewer friends, and that people kept a distance from them. Suspicion and whispers from neighbours followed them throughout the community.
One health worker said that the community perception of her was killing her spirit. She tried to improve the situation by reminding them of why she was continuing to provide health services in the midst of Ebola:
"If you are scared of me, it makes me feel bad. And what if I feel bad and get angry and decide not to go to the centre again? What if all the health workers sit down and refrain from treating Ebola patients? Who will do that job? People have come from other countries to help us fight Ebola. If we sit in our own country and say we will not take part in that fight how will the disease go?"
Some of the most painful adjustments described by interviewees related to their relationships with patients.
One provider said that she felt as though she was “turning [her] shoulder” when she interacted with patients:
"I feel bad because I am a medical person, and this disease is preventing us from touching patients. I am an MCH [maternal child health] Aide and I always carry out deliveries and immunisation. I must touch my patients."
This stood in contrast to previous facility practices where health workers “were open, welcoming,” “would check patients with our bare hands,” and would “suffer alongside” patients. One woman felt she was no longer connected to her patients:
"It used to be that patients would just come to the centre without being screened, and we would allow that patient to enter. Whether the patient came with a contagious disease or not, all of us will just suffer through it."
In extreme instances, respondents described how patients cursed, slapped and attacked providers because they heard rumours of providers “injecting Ebola” and ‘selling bodies” as a means for personal financial gain.
“The study shines a light on the fact that recovery efforts cannot bypass the primary care providers who continued providing basic health services despite experiencing the horrors of this outbreak,” Ho said. “Despite their sacrifice and service, the mental health and psychosocial needs of frontline health workers receive relatively little attention. Efforts to improve health systems in the countries affected by Ebola are critical, but they are insufficient if they do not address the mental health and psychosocial needs of those critical to stopping both the last, and the next, epidemic.”