New spikes in cases of COVID-19 due to the Delta variant have put additional stress on health workers, with some leaving in the middle of their shifts because they are mentally at a breaking point. Similarly, Simone Biles withdrew from various events at the 2020 Tokyo Olympic Games due to mental health concerns, prompting athletes to speak out about the need for greater mental health awareness. These events have emphasized the mental health strain of high-pressure professions.
In June, the U.S. Centers for Disease Control and Prevention (CDC) conducted a survey with State, Tribal, Local, and Territorial health workers to assess mental health and well-being. Among the 26,174 respondents, 53% reported symptoms of at least one mental health condition in the previous two weeks, including some with symptoms of depression, anxiety, and suicidal ideation. The situation globally is similar. A recent WHO report about attacks on health providers stated that more than 700 health care workers were killed and 2,000 wounded from 2018 through 2020, resulting in an increase of anxiety and fear throughout the workforce.
The safety and well-being of health and crisis recovery workers is an emerging area for The Task Force’s Focus Area for Compassion and Ethics (FACE), a program helping practitioners cultivate, harness, and channel compassionate and ethical action in day-to-day decision-making. It is also a focus area for Hummingly, a New Zealand-based organization and FACE partner which seeks to provide tools and resources to help people do well in tough times. On the heels of the recent crises in Haiti and Afghanistan, we spoke with FACE Director Dr. David Addiss and Hummingly Co-Founder and Director Jolie Wills about the need to protect the mental health of frontline workers in high-stress roles.
What are some of the mental health challenges among people who respond to crises like pandemics and natural disasters?
Addiss: The results from the CDC survey provide just a glimpse of how serious this issue is. For public health workers, these survey results were not surprising. We see overwork, anxiety, depression and moral distress daily in our colleagues and peers. As health workers, we view ourselves as the helpers. We’re the ones that go in and fix things. We’re tough; we don’t often acknowledge that we might be suffering ourselves.
At FACE, we are working to understand the factors that contribute to mental health problems in health and crisis recovery workers. There are obvious ones, such as overwork or the moral distress of people dying because of a lack of medical supplies. There are also more nuanced factors, such as how public health has become polarized. These types of factors have led more than 250 public health officials to leave the field during the COVID-19 pandemic. This is a wake-up call: in order for us to do our jobs well and to properly address health emergencies, we must address our health.
Wills: As David mentions, the disaster/crisis recovery space also sees a lot of burnout and mental health challenges among our colleagues. It’s very sobering and clearly not acceptable, sustainable, or necessary. In 2014, I became a Winston Churchill Fellow in which I traveled all over the globe to disaster recovery areas for tsunamis, hurricanes, terrorist attacks, and wildfires and found that in fact there were similar patterns of fatigue and burnout throughout the whole crisis recovery space. And now we’re seeing those same patterns of energy depletion and collective exhaustion in this COVID-19 public health crisis.
In the immediate aftermath of a crisis like COVID-19, there is always a lot of energy and unity, but as the crisis is prolonged, that’s when the challenges arise. As humans, we can put on hold for a short time our health basics and the activities that restore our energy. However, if our jobs demand that we do that for a long period of time, then there can be very harmful impacts on our health, relationships and performance. That’s why our goal at Hummingly and our collaboration with FACE works towards this idea that every person in these crisis response/recovery type jobs need a preventative plan to address burnout before it happens because prolonged stress will have serious impacts without intentional action. Each of those health workers responding to COVID-19 need what you might call PPE for their mental health and well-being.
What have been your experiences with mental health challenges or distress in your work?
Wills: My first interaction with mental health challenges in my own work occurred when I led a disaster recovery team in New Zealand after the Christchurch earthquakes in 2011. Recovery is a long, slow process and Christchurch had aftershock quakes for about 6 years, so we were providing crisis recovery services for a long time. Like every crisis, there were so many needs and the story I was telling myself during those high-pressure years was that I could do everything and that I should do everything. This ‘superhero curse’ as I call it taught me the hard way that I needed to acknowledge that even though I am a very capable person, I had to learn when to say no and have boundaries so that I could make sustainable, quality contributions to these communities in need.
Addiss: When I left the U.S. CDC in 2006, it was a very low time for me. I had been in the Commissioned Corps of the US Public Health Service for 20 years. I really believed in the Corps’ mission and had dedicated my life to responding to public health crises and challenges. However, soon after the 9/11 terrorist attacks on the Twin Towers, the culture and mission at the agency changed radically. Instead of an ethic of global interconnectedness – we are all in this together – we became focused on national civil defense. It became difficult to justify our work on global health issues like neglected tropical diseases, which were not a big threat in the U.S. The agency to which I had dedicated my career became in some ways unrecognizable and I experienced moral distress. During that time, I could have really used some support, but it was not available within the agency. Ultimately, that experience has led me to focus on this issue now because I know there are others who need that kind of support no matter where they work within the public health sector.
Solving the Problem
What are some ways that these and other sectors can fix this issue?
Addiss: A culture shift will be required in the global public health sector to accept the depth of suffering reflected in the CDC report and to develop systemic responses to address it. For example, the U.S. military, the Federal Bureau of Investigations, U.S. fire departments, the American Red Cross, and many corporations recognize the spiritual dimension of working in these high-pressure sectors like defense or disaster recovery and they provide support accordingly in the form of chaplains or spiritual care specialists who can help employees deal with exhaustion, grief, or traumatic experiences that come with the job. There are few, if any, chaplains in U.S. public health that provide support to employees. At FACE, we’re exploring the role that chaplains could have in the public health sector. One common objection is the misunderstanding that chaplains would force religion on the public health workforce. The reality is that chaplains play a very different role than traditional religious leaders such as priests, rabbis, pastors, and imams. They support individuals in times of crisis by helping them discover meaning within emotionally and mentally taxing situations, regardless of religious beliefs. Chaplains work closely with psychologists and other mental health professionals. The spiritual framing that they provide has proven crucial for addressing moral injury, which was first noted in U.S. soldiers deployed to Iraq and Afghanistan. Similarly, several recent articles and studies have highlighted moral injury in healthcare workers since the COVID-19 pandemic began. I believe that all health workers could greatly benefit from this type of support.
In another example, a few years ago FACE surveyed human resource directors of organizations that received the prestigious Hilton Humanitarian Prize about employee burnout. Surprisingly, factors that were identified as contributing to burnout were primarily organizational or structural – such as poor relationships with supervisors, unpredictable working hours, and ambiguous job expectations. It wasn’t due to the stresses inherent in the work itself or its mission to alleviate suffering, but to factors that could be improved through better management and more humane and compassionate systems. To address the mental health crisis in public health, the sector needs to evaluate how it does business and to initiate internal systemic changes.
Wills: At Hummingly we talk about a triple responsibility for worker wellbeing, with responsibilities at the organizational, team and individual levels. For example, everyone is carrying a set of bricks with each brick representing the various concerns or challenges they have in life and at work. During a big public crisis, that set of bricks grows exponentially for people who are working in these high-pressure, community-facing jobs that help to stop a crisis or communities to recover from it. At the beginning, people in those jobs may think quite optimistically that they’ll be able to carry these extra bricks for a bit and then in three or six months the load will get lighter. However, in crises like COVID-19, three and then six months pass and the bricks are still accumulating. From an organizational perspective we must recognize that an individual’s responsibility for self-care is important but not enough if we keep adding bricks. We can break even the strongest, most resilient of people if we load them up too much for too long.
Organizationally, we can think creatively about how we are adding bricks to our employees’ loads and how we can reduce them. Whether it is by updating systems as David mentions so that they match the current environment better, prioritizing employees’ well-being, or removing a self-sacrificing type of work culture, finding ways to understand organizational bricks and creatively lighten the load is important.
We forget how powerful a team can be in both undermining and supporting each other’s well-being, so there is a team responsibility to check in with each other and do your bit to create a positive environment for your teammates – the smallest gestures can make all the difference.
Individually, it is more about being honest and patient with yourself. You can expect to lose perspective and you become fatigued at some point throughout a crisis, so don’t let that ‘superhero curse’ consume you. Make a proactive plan for yourself so you can sustain yourself and your support to communities.
Rather than waiting until someone falls over from the amount of bricks they are carrying, let’s get intentional about providing support and tools so health and crisis recovery workers can continue to be well and do great work to support others.
How are FACE and Hummingly contributing to support people who work in the global public health and crisis recovery sectors?
Addiss: FACE’s role lies in connecting the world of global health with groups who are experienced and committed to promoting well-being, emotional health, and compassion. We’re not psychologists or chaplains or meditation instructors, but we work with people who are, and we understand the needs of public health and global health workers. The Task Force’s reputation as a trusted convener helps us link experts in well-being with those of us in public health. For example, we collaborate with the Center for Compassionate Leadership to offer a course in compassionate leadership and resilience for global health professionals. We also collaborate with The Compassion Institute to offer a six-week course called Caring From the Inside Out. Hundreds of public health workers have taken these courses, which offer tools to improve mental and emotional well-being through self-care, resiliency-building, and collective care with colleagues.
We also support other Task Force programs. For example, The Task Force’s Training Programs in Epidemiology and Public Health Interventions (TEPHINET) will be sponsoring a keynote address on mental health challenges for field epidemiologists in their upcoming regional meeting for the Americas. The stress on field epidemiologists and other public health workers has only increased during the COVID-19 pandemic as they have been put on the frontlines of response. FACE is working with TEPHINET to find ways to help field epidemiologists address these mental health challenges. Often it is as basic as making them aware of the well-being tools that exist such as ones that Hummingly provides.
Wills: As David mentions, one of Hummingly’s first projects was producing these Doing Well cards. We knew that when you are a person who cares for others, prioritizing caring for yourself is really hard, so we wanted to create a tool that makes it easy and quick for people to put a protective plan in place when the pressure is on. The Doing Well cards are playing-card sized with mental health tips and reminders that people can use to create their plan and help themselves be intentional about managing their well-being.
One of the other projects that Hummingly is really passionate about in the disaster recovery space is about supporting the systems with which communities impacted by disasters interact. The systems can often be a greater source of stress for affected communities than the disaster itself and those systems are also under stress which additionally puts stress on the people working in the systems. So we’re working to ensure that compassion is retained as you move between first responders who are seeing the very real impact a disaster is having on a community and those upstream who are designing and implementing the systems. Often compassion gets lost throughout our systems, so we’re working with organizations to retain compassion with the end-user in mind.
As a global public health organization, what are some of the ways The Task Force can help address this issue in public health?
Addiss: The Task Force can help by leading in the following ways:
- Reflecting on our own employees’ safety and well-being, as well as the structural issues that promote or inhibit well-being. Similarly to what Jolie spoke about, there are creative ways an organization can lessen the burden on employees. For example, ensuring that employees have a voice, demonstrating that leadership cares, and clearly communicating policies and strategies;
- Encouraging other public health and global health organizations to focus more intentionally on these internal issues and take appropriate action;
- Convening public health leaders from different perspectives to develop a frank assessment of what is happening and why. The Task Force traditionally has served as a convener of difficult conversations to address big problems and we can do it here too.
Advocating for the mental health and workforce challenges of public health to be supported by governments at state, local, and national levels. Task Force recently joined other like-minded organizations to support the Dr. Lorna Breene Health Care Provider Protection Act, which is being introduced in the U.S. Congress to address the mental health of healthcare workers. Coming together to support this kind of legislation is a tangible step in the right direction.
Header photo: During the COVID-19 pandemic, Yemen was one of the developing countries that recorded COVID-19 cases. This photo when FETP Yemen team investigation of SARI and COVID-19 cases at ICU in hospital. Photo courtesy of Yemen FETP.