The sharp focus that has been put on our healthcare workers and healthcare system during the Covid-19 pandemic has illuminated some dark and uncomfortable truths that are not easy to digest. Many of these are not even easy to name. 

But name them we must, for what remains unnamed also remains unchanged. 

These big, complex issues that often hide under societies’ metaphorical rug must be brought out into the open – the power of doing this is best illustrated through the paraphrasing of a children’s story by Jack Kent:

One day a small boy, Billy, awoke to find a tiny dragon on his bed, the size of a kitten. He looked at it curiously and patted it. He ran downstairs to tell his mom and she simply said: 

“There is no such thing as a dragon!” 

Billy went off to school, but throughout the day the dragon continued to grow and grow and grow until it exploded through the roof and filled the house. 

The father came home to see their house being carried off with the dragon inside and when the mother looked at this, she was forced to concede that: 

“I admit now, there is obviously such a thing as a dragon.” 

Suddenly, the dragon started to shrink until it was kitten-size again and eventually Billy’s family got their house back from the dragon. 

All the dragon needed was recognition it existed. 

This story powerfully illustrates how the things in our lives that we don’t acknowledge can grow so big that they completely destabilise us, and it is only when we confront and name them that we can address them. 

The issues regarding burnout of healthcare workers are large, complex dragons that are suffocating our healthcare workers and healthcare system and they need to be named, to be addressed. 

These issues aren’t new to South African society – we frequently hear of tragedies including the many healthcare worker suicides, post-call car crashes due to fatigue and the multiple safety incidents that have plagued hospitals of late, and yet year after year, the system remains unchanged and somewhat immovable.  

Other high-risk industries like aviation have responded to the realisation of the need to manage risk and the health of their employees proactively to ensure safety by introducing limits on the number of hours worked, regular health checks and basic checklists to reduce error. Yet, the medical profession has done little to protect its workers and, in turn, to protect society from the harms of exhaustion. 

This isn’t just an issue focusing on the wellbeing of healthcare workers – it is an issue rooted in health equity, questioning if the status quo allows for those who serve in the healthcare system to care for patients from a point of dignity. 

For all the darkness and loss that has characterised this pandemic, could somewhere in this messy despair be filled with the illumination necessary to change this system? 

Covid has shown us how interconnected we are – a disease starting in one country with one patient has swept the planet and impacted us all significantly, but also inequitably. 

These facts of interconnectedness and inequity reveal that the issue of healthcare workers’ burnout will impact us all differently but impact us all it will, healthcare worker or not, as these issues are pervasive across geographies and everyone at some point needs to interact with a healthcare worker. 

One of the big dragons in the system is the normalisation of healthcare workers functioning from a point of exhaustion, burnout and disconnection from ourselves and others. However, to understand why this normalisation has happened, allow me to give you some context around this issue. 

The status of junior doctors

The status quo in South Africa for junior doctors is that there are two years of compulsory internship after graduating, followed by one year of community service. During this time, junior doctors will be subject to 200 hours of involuntary overtime a month – four times more than that outlined as legal by the Basic Conditions of Employment Act of 1997 and only 80 hours of which are paid. In an article in the SA Medical Journal, Nicolette Erasmus described junior doctors as “slaves of the state”.

This overtime shift work requires continuously being on your feet in the ER and the wards, often without any time to sleep and eat, and averages around 30 hours a shift. 

A study by Williamson and Feyer (2000) showed that when doctors work more than 20-25 continuous hours, their psychomotor performance decreases to the level equivalent to someone with a blood-alcohol level of 0.1% –  to put that into perspective, the previous legal driving limit in South Africa was 0.08%. 

Imagine being the patient who is about to be operated on by this doctor, and then imagine being the doctor who is too exhausted to think straight and has no choice but to operate despite it not being safe. 

Surely, we can do better for all involved. 

We are told year in and year out that fatigue is simply part of the profession and this is simply the way it’s always been done. Evidence is clear this is dangerous for everyone involved, and yet the system continues. 

This exhaustion, coupled with the steep hierarchies, microaggressions, lack of mental health support and culture of stoicism that healthcare often models, means that junior healthcare workers frequently have no space to raise their hand and ask for time off or support when needed, but are forced to operate from a point of disconnect and exhaustion that harms patients, harms themselves and harms our society. 

Perhaps we need to question why we are operating within an old model of healthcare rooted in charity and unhelpful norms that don’t allow carers to have boundaries, rather than reimagining and creating a healthcare system that allows for both employees of the system and those being cared for to be seen, humanised and valued, whoever they are. 

Our responses to these issues must be bigger than just individual-level responses for the most impacted individuals, or only for one profession. 

As clinical psychologist Dzifa Afonu poignantly puts it, this individual approach “is like putting out a single match whilst standing in a forest fire”. Rather, we have to start asking ourselves and those around us honest questions about what type of healthcare systems we are building, and whether this is sustainable. 

In our lifetimes we will face the next big threat of climate change and antibiotic resistance, both of which require healthcare workers to assume leadership in the protection of our society. However, we cannot expect those healthcare workers to make wise decisions about health and building a more sustainable future if they are permanently exhausted and running on empty because our legislation and systems fail to look after them.

The care of carers should be embedded in systems, and for this transformation we need to look to all of us. 

• To the healthcare workers to courageously share more openly and honestly the stories of our lived realities; 
• To those who design the health curriculums; 
• To policymakers; 
• To the media, 
• To seniors within the healthcare system who themselves have been traumatised by a dehumanising system and often subconsciously repeat cycles of harm; 
• To the patients; 
• To those in all other sectors and to anyone who cares about creating kinder, more dignified ways of being and working. 

Enough is enough – the pandemic has made it clear that this is our urgent, collective mandate.

The documentary, “A Quiet Implosion”, was produced to tell these stories and change the narrative on what should be normalised in healthcare, as part of my fellowship in health equity as an Atlantic fellow at Tekano. 

The launch took place on 27 May 2021 and saw over 200 people from around the world joining the conversation. It’s my sincere hope that “A Quiet Implosion” can inspire a community to take action and change. 

Our actions can no longer merely be polite requests for this or that to be addressed – powerful advocacy and campaigning is essential. These brutal truths need to land on the desks of those who make the decisions. 

The dragons that have for so long remained unnamed need to be acknowledged, or we face the risk of burning in the fire they breathe into our healthcare system and society. 

If you missed it, you can find the recording here.

Here is the summary video of the documentary, with highlights.
Here are the interviews with Dr Anesu Mbizvo, Dr Brendan Savary and Dr Nic Thompson that form part of the docuseries capturing the untold narratives of junior doctors. 

Please feel free to share as widely as you wish, or use them as teaching tools or conversation starters in work or communities. DM/MC

If you are a healthcare worker struggling to cope, please see the resources listed below:

• 24-hour Healthcare Workers Care Network Helpline – 0800 21 21 21 (available 7 days a week). SMS 43001. Website www.healthcareworkerscarenetwork.org.za. Fill in the online form on the homepage to request individual therapy and support.
• The dedicated Medical Student Helpline will assist all medical students, interns and young doctors with any mental health issue. This 24-hour service provides free telephonic counselling via a toll-free helpline 365 days a year. Contact 0800 323 323 or visit www.sadag.org.