More than PPE, healthcare workers need SEPPE

The case for SEPPE – spiritual and emotional support with PPE – during COVID-19 and beyond.

‘Trust in the Lord with all your heart and lean not on your own understanding; in all your ways submit to him, and he will make your paths straight.’ (Proverbs 3:5-6)

As I sit down to write this, my mind goes back to the welcome ceremony during my first year of medical school back in Bukavu in the eastern part of the Democratic Republic of the Congo (DRC).  About 600 first year students were packed in the hot auditorium.  ‘Ladies and gentlemen, welcome to medical school,’ the dean said.  ‘Congratulations for making it here out of the 1,200 applicants.  We felt it was you to whom we could give the chance to graduate from this prestigious institution.  We hope that one out of every ten of you will graduate after six years.  So, your job is to prove to us that you have what it takes to graduate as doctors from this institution.’  Seated at the back, I felt my head begin to spin.  Is it that difficult to become a doctor?  The question was tortuous.  Fast forward one year and of those seated in the auditorium, only 230 entered the second year.  A hundred and twenty-three reached the third year, and 53 entered the fourth year.  I leave the rest to your imagination.  The pressure had just begun.  

Recently Dr Mona Masood, a psychiatrist from Philadelphia, started the free National Psychiatrist-Run Hotline to offer doctors on the frontline Emotional PPE (EPPE).  She first presented the idea in a Facebook forum.  The response was immediate.  Psychiatrists started to contact her saying, ‘Please let me be a part of this. I want to volunteer.’  Dr Masood said, ‘In most cases, we have a lot of emotion on both sides.  There are a lot of tears, a lot of relief.  “If not me, then who?” they say.’

This enthusiasm to help fellow physicians is understandable.  Physicians have been facing mental health challenges since before the pandemic and doctors have long struggled with stigma while seeking psychological help.  They tend to chase perfection and have high expectations of themselves, their patients, colleagues and family.  These expectations don’t stop at medical school; they only get worse afterwards.

It is said that in medicine – whether academic, clinical or research – you need to keep up just to stay in the game.  Physicians are known to talk about medical stuff during social outings, even on dates.  It is not uncommon to see a group of surgeons bragging about how long it takes them to perform a particular procedure, that it was an open surgery, or that it was a minimal access one, or that they now perform remote surgeries thanks to the da Vinci system.  The pressure to keep up never ends.  By the time one is familiar with one procedure, another must be mastered.  This pressure can set people up for mental distress. 

Studies show that nearly 30 per cent of medical students and residents in the US have experienced depression.  A serious study that compared data from 2003 to 2008 for suicides among the general population and physicians showed that physicians who died by suicide were less likely to have consulted mental health experts, less likely to have been diagnosed with mental health problems, and less likely to have antidepressants in their system at the time of death.  Another recent study done in China suggests that the COVID-19 pandemic could exacerbate these trends.  Out of 1,257 healthcare workers interviewed in Wuhan in January and February this year, a significant number reported symptoms of depression, anxiety, insomnia and distress.  This was especially true for women, nurses and all frontline healthcare workers directly engaged in diagnosing, treating or caring for patients with suspected or confirmed cases of COVID-19.

What makes it worse is that this inner distress is never expressed.  Doctors often feel they can’t share their fears even with family members, largely because of societal pressure to act the part of a hero on the frontlines of what is being framed as a war.  Heroes are not supposed to complain or show vulnerability.  You don’t want to look like a coward.  Even for those not directly on the frontline there is no escaping the pressure.  As a friend of mine said, ‘I feel guilty that I am not on the frontline like my colleagues. I feel like my medical training is wasted. I should be out there helping people.’

Could it be even worse for Christian doctors?

Faith is the first casualty in our busy profession.  ‘We expect more from God.  He promised not to leave us nor forsake us after we gave our lives to Jesus,’ doctors say.  But it is Christian doctors who give very little time to God.  We hear people say, ‘I don’t have time to go to church or even read my Bible.  I’ll try and do that when I finish my residency.’  Then comes marriage and starting a family, and before you know it, faith is out the window.  It is not uncommon to see alcohol taking over or the pursuit of money leaving little time for faith related matters.  Soon, they are more in the world than in Jesus.

The world is a depleting place.  But I don’t for a moment think God agonises over what is happening in the world saying, ‘Oh no!  What is going on?’  Jesus said, ‘I have told you these things, so that in me you may have peace.  In this world you will have trouble.  But take heart!  I have overcome the world.’ (John 16:33).  In Four Screenplays, William Goldman sums up the fruit of the world: ‘Life is pain, highness.  Anyone who says differently is selling something.’  This is the difference between what God gives and what the world offers.  The Bible is not trying to sell us anything. 

There are numerous biblical accounts of troubles or crises that occur right when Jesus is present.  Reread those passages to see what set the crisis in motion.  In Matthew 14:28-33 we see Peter sinking in the waves.  Just moments before, he had walked on water but then he stopped focusing on Jesus and looked instead at the extreme weather.  He feared and started to go under.  Then Jesus got hold of him and rebuked him for having ‘little faith’.  I know Peter is not the only one.  In times of crisis, stress or fear, we take our eyes away from Jesus and so our ability to think straight is impaired.  You’re driving in traffic and someone cuts you off.  The words that come out of your mouth are not reflective of who you are in Christ (to put it mildly).  As Prof Steve Reid would say, ‘How many of you will still be calm or Christian at 3 am when a drunk in ER swears at you while you stitch his wounds?’  In a crisis, the line between ‘sane’ and ‘insane’ gets blurred.  Some of us don’t even need a crisis to act crazy.  Focusing on Jesus, who has overcome the world, is what transforms the situation.

What is the lesson from crises like COVID-19?

My Mandarin is very limited.  I had to confirm the following with Dr Samundra Rana, our RR for South Asia.  In Mandarin, the word ‘crisis’ is written using two symbols:  危机.  These two symbols stand for two words: danger (危) and opportunity (机).  Maybe we can draw inspiration from this Mandarin word to ask ourselves each time we face a crisis: Is this crisis dangerous?  And what is the opportunity it brings into my life and into the lives of the affected?

So, what is the danger?

As we practise medicine, we need to keep in mind what John Wyatt said about our ethical dilemma: ‘The medical profession has always been associated with risk to healthcare workers.  COVID-19 just reminded us of the risk of our job as well as our vulnerability as professionals.’  But there is no room for worry.  As the Bible verse I quoted right at the beginning says, we need to learn to trust God and not rely on our own understanding.  And yet most of us remember Jesus’ words only when we face danger and crisis: ‘Can any one of you by worrying add a single hour to your life?’ (Matthew 6:27)

What about the opportunities?

A crisis like COVID-19 is an unprecedented opportunity to make leaders.  Prof Nancy Koehn from Harvard Business School says, ‘I have studied courageous crisis leaders for two decades, and through this work, I know that real leaders are not born; the ability to help others triumph over adversity is not written into their genetic code.  They are, instead, made.  They are forged in crisis’.’  Crises are opportunities for leaders to either rise to the occasion or fall into obscurity.  As David Foster Wallace said, we need ‘real leaders to help us overcome the limitations of our own individual laziness and selfishness and weakness and fear and get us to do better, harder things than we can get ourselves to do on our own’.  Read the Bible for examples of crises where ordinary people emerged as leaders and others who disappeared.  

So where do we start? 

Many people are now calling on God saying, ‘Where are you when we need you the most?’.  And Jesus responds, ‘Right here with you’.  His promise is to never leave nor forsake us.  And we constitute his Church – not the building but the hope for the nations.  We are the only Jesus some in the world will ever see, the only Bible some will ever read.  The Bible says, ‘You show that you are a letter from Christ, the result of our ministry, written not with ink but with the Spirit of the living God, not on tablets of stone but on tablets of human hearts’. (2 Corinthians 3:3)  Can we be like Jesus, open to a desperate and burning world?  As you open yourselves to the burn, remember you are not alone.  Jesus is right there with you. 

Firstly, pray.  The Bible exhorts us, ‘Rejoice always, pray continually, give thanks in all circumstances; for this is God’s will for you in Christ Jesus.’ (Thessalonians 5:16-18)  Once a man was asked, ‘What did you gain by praying regularly to God?’  He replied, ‘Nothing. . . but let me tell you what I lost: anger, ego, greed, depression, insecurity, and fear of death.’  Sometimes, the answer to our prayers is not gaining but losing – which is ultimately the gain.  I paraphrase Archbishop William Temple: When I pray, things happen and people say, it is just coincidence.  Well, I don’t know.  But what I do know is when I stop praying, those coincidences stop happening.

Second, take time to recharge.  The lack of sleep will be paid for whether you want to or not.  We will realise thatwe are only human; it is only a matter of time before our body announces its weakness to us.  Even our Lord took rest during the work of creation, so who are we to believe that life revolves around us?  As the saying goes, ‘If you knew how quickly your boss will replace you if you die, you will pay more attention to your family’.  Let wealth not be your focus.  My mentor, the late Prof Sam Fehrsen, once told me, ‘In medicine one can be guaranteed a job, a stable life, maybe a good wife or roof over your head.  But being rich is not part of the package.  If you see a rich doctor, you must know that somewhere, somehow, somebody is paying the price.  Whether it is your family, your health, your patients or your values the price has to be paid.’  As Jan Kunene said, ‘Our theology of health will shape our theology of healing’.  Understanding the role of God in the healing process will take away some pressure from us healthcare workers.  Remember the famous words of the sixteenth-century French surgeon Ambroise Paré: ‘I dressed the wound, but God healed it.’  

Third, spend time reading the Word.‘It is written: “Man shall not live on bread alone, but by every word that come from the mouth of God.”’ (Matthew 4:4)  Very often we read the Bible as part of our routine, our daily devotion or just in church.  And if the pastor has not touched a particular subject in a year or his/her theology is focusing only on one aspect of the Bible, we slack off.  I encourage you to read 2 Corinthians 4:1-20.  In the chapters leading up to this passage, Paul reflects on his ministry, the fragrance of Christ, his sincerity and a reliance on the Holy Spirit.  In this passage, Paul continues to share his own personal philosophy of ministry in the face of troubles, difficulties, unbelief and struggle.  Know that it is possible for God’s servants to ‘lose heart’ or ‘to be utterly spiritless, to be worn out, exhausted’ as is often seen in our profession.  However, Paul recovered from the hurt and discouragement due to the sincerity of his motive.  He was doing what God called him to do and knew that he had this ministry through God’s mercy!

What about those not on the frontline?

A friend said to me, ‘I just can’t justify to myself how I feel about being a doctor but not being able to use my skills where they are needed.’  As Desmond T Doss said in the movie Hacksaw Ridge, ‘I don’t know how I’m going to live with myself if I don’t stay true to what I believe’.  The answer to this is to get involved.  Look around you.  We are all either infected or affected – such are the challenges that COVID-19 presents to us.  ‘I don’t want to be a burden to others,’ some people say.  But this is not a biblical thought.  What COVID-19 has showed us is that we are interdependent.  In the early church ‘. . .there were no needy persons. . .’ because people looked after each other. (Acts 4:34)

Being involved requires that we be ‘others focused’.  We can all do all or some of the following:

• Mobilise resources or raise funds for the homeless or people who can’t afford to buy food.
• Gather useful information and share with friends (medical and non-medical).
• Contact people whom you have not spoken to in a while.  Check on them even if they are in another town or country.  Now that you have a bit of time on your hands ask how they are doing.   
• Check on colleagues, especially those on the frontline.  Don’t assume they are okay.  Your call may be the only thing that separates them from suicide.  
• Start thinking about how things can change from the way you have always done them.  Maybe learn a new skill or take that online class you have been procrastinating about.
• How about reading a book that has been collecting dust by your bed, or even write one?
• Reflect on how ready you are for a future should something worse happen – this may be needed.
• Work on your house more than the car which is rusting in the parking lot. 
• As St Francis of Assisi said, ‘Preach the gospel at all times.  When necessary, use words.’
• Add value to people’s lives through your money or time.  After all, we are the hands and feet of our Lord.
• Spread words of encouragement and hope, not of fear.
• Avoid conspiracy theories; they don’t help anyone or any cause.
• Don’t forget to sing praises to the Lord throughout the crisis. 
• Choose to be joyful in the crisis.  As Habakkuk 3:18 says about rejoicing in the storm, focus on praising him, confess your feelings, ask the Holy Spirit to help and sing. 

Remember this wisdom, ‘No candle loses its flame by lighting other candles’.  We are the light and the salt of the world.  Let us show the way and preserve the world, as our Lord requires us to do.

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Dr Augustin Lutakwa is AEO for the Sub-Saharan African region of ICMDA.