Protecting our doctors and nurses from pandemic-related mental health problems

Healthcare professionals in Sabah have been under tremendous mental and emotional stress dealing with the exponential increase in Covid-19 cases over the last month. — Bernama

There has been a surge of Covid-19 cases since the middle of last month (September 2020).

The number of reported positive cases have doubled from 10,031 cases on Sept 16 to 20,498 on Oct 18, with active cases increasing by about 11-fold from 668 cases on Sept 16 to 7,049 on Oct 18.

After a three-month lull from mid-June to mid-September, there is a dreaded sense of déjà vu with the exponential increase in numbers of reported positive cases.

It took us 213 days to get from 21 reported cases on Feb 15 to 10,031 reported on Sept 16, but only 33 days to get to 20,498 reported cases on Oct 18.

Despite the restrictions and conditions of the movement control order (MCO) – physical distancing, wearing of face masks, handwashing and isolation from family and friends – the country appears to be back where it started.

Apart from the physical and psychological impact on those diagnosed with Covid-19, the pandemic has caused much collateral damage due to the accompanying socioeconomic consequences of the MCO.

This increases the risk of developing psychological and psychiatric disorders, especially anxiety, depression and post-traumatic stress disorder (PTSD) – all of which are associated with an increased risk of suicide.

Sabah in particular, has experienced an exponential surge of reported positive cases since Sept 8 (see graph).

Reported deaths also increased from four during the period of Feb 15 to Sept 16, to 53 for the period of Sept 16 to Oct 18.

The situation in Sabah is becoming grave, as acknowledged by the Health Ministry itself.

Some experts are even saying that the Sabah healthcare system may collapse.

It was recently reported that 71% of the beds allocated for Covid-19 patients in the state have been filled.

In fact, all the wards in Hospital Tawau have reportedly been converted into Covid-19 wards, with all other patients being diverted to a field hospital.

Moral injury

It was well documented that healthcare professionals during the SARS (severe acute respiratory syndrome) and Ebola outbreaks in 2002-2004 and 2014 respectively, were at particular risk of mental health problems like stress, insomnia, anxiety and depression.

There are similar reports and symptoms indistinguishable from PTSD being reported during this current pandemic.

The causes include overwhelming workload; inadequate personal protective equipment (PPE) which, even if easily available, is uncomfortable to wear; fear of spreading Covid-19 to family; and feelings of being unsupported.

The trauma, grief, helplessness and hopelessness when faced with patients’ sufferings, and even deaths, lead to moral injury.

Moral injury occurs when healthcare professionals perpetrate, bear witness to, or fail to prevent, an act that transgresses their moral belief of “Putting the needs of patients first”, which is the cornerstone and guiding principle of their professional lives.

Healthcare professionals generally have a personal sense of responsibility for their patients.

When their patients are threatened, particularly by a rapidly spreading illness like Covid-19, they want to do everything they can to help.

This means going the extra mile by working harder and longer, which inevitability leads to fatigue, exhaustion and its consequences.

In addition, whenever any healthcare professional shows any sign of, or is diagnosed with, mental health problems, it is perceived as letting their colleagues down personally and professionally.

The Health Minister stated on World Patient Safety Day (Sept 17) that among the concerns raised by the ministry’s staff were stress from being away from family, having to comply with strict standard operating procedures (SOPs), exhaustion and issues concerning the Covid-19 special allowance.

The critical situation in Sabah has been vividly described by doctors on the ground in the media, with an open letter by a Health Ministry specialist to the Prime Minister describing the difficulties faced being one of them.

This goes to show that the healthcare professionals in Sabah are at risk of moral injury.

Despite the aforementioned letter being addressed to the Prime Minister, it was the Health director-general who responded, expressing his disappointment with the specialist for revealing the identity of a Covid-19 patient in his letter, although noting the doctor’s “good views” on PPE.

Health is without doubt a federal matter.

However, what is surprising, to say the least, is the absence (as of Oct 19) of any (reported) visit to Sabah by the Health Minister or DG to assess the situation on the ground and address the concerns of the healthcare professionals there.

Can a public health emergency like Covid-19 in Sabah be contained remotely from Putrajaya?

Lend us your ears

While physical PPE is essential, the provision of psychological PPE, i.e. individual and system-level actions to safeguard and support the mental health and well-being of healthcare staff, is critical for all healthcare systems globally.

This is applicable in all countries, including Malaysia, and particularly now in Sabah.

The excitement of the challenges of the unknown and the adrenaline that drove many healthcare professionals has disappeared for some and is disappearing for others.

Many are running on empty; they are demoralised, depressed and devoid of energy and/or ideas.

Healthcare professionals are society’s last line of defence against Covid-19 and other diseases.

When their physical and psychological safety is affected, the consequences will be an inevitable shortage of trained personnel to provide adequate and safe healthcare for the population, with dire consequences for the sick.

The Health Ministry can make a start, albeit late, by listening attentively to healthcare professionals, particularly in Sabah, with an open mind.

Just as a patient can tell when a doctor or nurse is not listening, Malaysian healthcare professionals can also tell if the ministry is listening or not.

Last, but not least, I believe that former British Prime Minister Winston Churchill’s advice is still relevant today: “Criticism may not be agreeable, but it is necessary.

“It fulfils the same function as pain in the human body.

“It calls attention to an unhealthy state of things.”

Dr Milton Lum is a past president of the Federation of Private Medical Practitioners Associations and the Malaysian Medical Association. For more information, email The views expressed do not represent that of organisations that the writer is associated with. The information provided is for educational and communication purposes only and it should not be construed as personal medical advice. Information published in this article is not intended to replace, supplant or augment a consultation with a health professional regarding the reader’s own medical care. The Star disclaims all responsibility for any losses, damage to property or personal injury suffered directly or indirectly from reliance on such information.

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