"Bilkul psycho ho gai ho (You've gone mad)," is what Dr Quratulain Khan's husband tells her when she gets up in the middle of the night in panic.

"I keep checking my eight-year-old son's forehead to see if he has developed fever; if my husband so much as coughs, I check his pulse and thrust a thermometer in his mouth. He says I have lost it completely, but he doesn't know what I know and what I am witnessing every day," says the 36-year old assistant professor, working in the critical care unit in one of Karachi's private hospitals treating patients infected with Covid-19.

While insomnia keeps her awake most of the night, mornings are no better for Dr Khan. Since the last two months, she's been waking up with a feeling that's "something more than heaviness".

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At the back of her mind is the niggling feeling of what if she catches the infection. But even greater is the dread of what if she infects her husband and her son.

My husband and son have not left our home in two months and we have asked our domestic help not to come in either. So I am the only person who goes out and could well be a carrier, says Dr Khan.

Though they live in the same city, Dr Khan has not met her parents in nearly two months. "I cannot visit them so I call them up and sometimes I can't help but start crying."

According to clinical psychologist Dr Asha Bedar, many healthcare providers (HCP), including doctors, nurses, and paramedical staff, have dealt with mass emergencies before, but, she said, nothing could have prepared them for this. "Dealing with the constant flow of patients in critical condition and then death is eerily similar to a war-like situation, except this time there are no soldiers fighting the enemy, only doctors themselves, and that is an immense physical and psychological burden to carry."

Dr Khan says she feels like being in the trenches with some idea of what soldiers go through when sent to fight. "And yet this is different. The family of the martyred soldier is consoled with praises for his bravery; as for us, along with our death, we would have infected our family as well," she adds, forlornly.

Dr Khan is not alone going through the turmoil and research is bearing this out, says Dr Ali Madeeh Hashmi, Associate Professor of Psychiatry at the Lahore-based King Edward Medical University (Kemu).

HCPs experience a tremendous amount of stress and exhaustion and its consequences: depression, anxiety, insomnia, even early post-traumatic stress disorder, explains Dr Hashmi.

A new research carried out at Lahore's Mayo Hospital shows a high incidence of anxiety and psychological symptoms among those at the frontline.

Similar psychological issues were experienced by HCPs in Wuhan, China, and before that during the Sars and Mers outbreaks. "The reasons are multiple and include fears of getting infected, infecting their families and loved ones, lack of sleep from overworking and anxiety which then affects their performance in addition to suppressing their immune system. All these factors combined makes them more likely to get sick from Covid-19," Dr Hashmi points out.

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Dr Sadaf Siddique, consultant anesthesiologist at the Dow University of Health Sciences, finds Personal Protective Equipment (PPE) extremely uncomfortable as donning it means one is perspiring profusely inside. She also constantly sprays her PPE with a disinfectant. "I shower at the hospital after doffing off my gear and then again as soon as I reach home," she says, adding: "I have two elderly parents and I am really concerned about their health." Additionally, being asthmatic, the N95 mask makes breathing even more laborious for Dr Siddiqui, admitting it may be impacting her performance.

But while many continue to work with all the stresses and anxiety, there are others who either cannot or will not. A young doctor told her seniors that her husband had told her point blank that if she were to treat Covid-19 patients she need not return home. There are many senior doctors at public sector teaching hospitals who have taken their leaves now so they do not have to treat infected patients.

With the easing of the lockdown, Dr Hashmi can only see the situation taking a turn for the worse, with more and more patients piling up in hospitals. "It’s the ultimate nightmare scenario which they went through in Lombardy, Italy, then Spain, and which New York City is going through right now," he says.

"Here in Punjab, our epidemiologists and public health experts are telling us that we are going to hit our peak (of Covid-19 cases) by May 15 and with our already stretched HCPs on the frontline and a dire lack of essential equipment, it can potentially become very problematic; for patients and their families, for HCPs, and for society at large."

In addition, many HCPs also suffer what is called 'moral injury' where they have to take the decision about rationing precious healthcare resources e.g. who gets to be on a ventilator and who does not because enough ventilators are not available.

Seeing death in the face is different this time around

Watching patients die is not easy. But having to compromise one's own safety over someone dying of an infection and passing it on to you because the healthcare system does not have enough PPEs is not what most HCPs had bargained for.

"Every day as they work, not only are they seeing more than the usual suffering and death (and who knows for how long), but they also know that their own health or lives and those of their families are at risk. This is an immense amount of stress to experience on a regular basis," says Dr Bedar.

"It is the uncertainty, the lack of control, the lack of complete knowledge, not having algorithms, being under-resourced etc," points out Dr Ayesha Mian, associate professor at the Aga Khan University Hospital.

Healthcare providers are distressed by questions like: Is this level of protection enough? How exposed am I? Am I putting myself and my family at risk? Are these symptoms Covid related or otherwise? Do we know the protocols? Is there enough evidence for this management or that?

Not knowing much about the virus and changes in knowledge almost on a daily basis is another reason leading to stress for the HCPs, says Dr Hashmi. But along with the fear of the unknown, the structural problems in Pakistan's healthcare system, a "perpetual source of stress", seem to exacerbate the situation, he says. "Underfunding, lack of essential medicines and supplies, shortage of critical staff, bureaucracy etc were all problematic before the pandemic; Covid has just magnified the problems manifold," he adds.

Reluctance to seek help

Dr Hamid Mehmood, consultant anesthesiologist at the DUHS, says they were witnessing HCPs breaking down. "Not everyone among us is trained for this war-like situation," he says, citing the recent example of a colleague.

"A surgeon recently treated a patient for appendicitis. The patient showed no symptoms for Covid-19 but after tested positive after the operation. The surgeon got so paranoid, he insisted that he had developed symptoms of breathlessness and got himself tested. In the meantime, he also isolated himself from his family. The test came out negative. But he remained unconvinced. So another test was carried out and that was also negative. But he insisted that he had developed symptoms and so a third test was carried out and this too was negative," narrates Dr Mehmood.

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In those seven days, the surgeon remained miserable and his behaviour toward patients was irritable. "He clearly was not able to perform his duties well. And if the shift incharge is behaving irrationally, it affects the work of the entire team," says Dr Mehmood. Finally he was forced by his colleagues to seek professional help.

"The problem of not seeking professional help is common among doctors. They insist that they can deal with the situation and there is also certain reluctance towards seeking therapy," says Dr Mehmood. Denial, minimising, and setting aside are coping tools that most HCPs come up with.

Dr Mian found this to be very common and explained that due to lack of exposure to psychiatric teaching and learning, many HCPs remain unaware of the early signs and symptoms of mental stress and distress. "They may not be able to recognise mild symptoms, like changes in sleeping and/or eating patterns, inability to focus, becoming more prone to distractions and a decrease in concentration, lack of interest in previously pleasurable activities, pervasive feeling of helplessness or hopelessness, mood changes, increase in irritability etc," she says.

In addition, Dr Mian acknowledges that the stigma around seeking help for mental health and illness was significant amongst the medical fraternity globally.

Dr Khan acknowledges that her work has been draining her physically, emotionally, and mentally, but when asked if she sought help from a mental healthcare professional in order to unburden herself, she says: "We don't have the time; it's a luxury."

Self medication

Due to the reluctance to seek professional help, it is common for doctors to take matters into their own hands and self medicate. "There is a role that medicines play in all illnesses, whether psychiatric or not. There are specific parameters to when the role of medications begins. It is usually in addition to lifestyle changes. Medicines used for mental health related symptoms and disorders are no less harmful or safe than medications used for other conditions. They are generally safe to use, and are not addictive," says Dr Mian. However, she emphasises that there is a "way to prescribe medicines, to monitor their efficacy", and should be only be done by a trained professional.

Dr Hashmi too finds indiscriminate use of psychiatric medicines not only unnecessary but "problematic".

"Since they affect the brain, it can affect one's thinking, judgment, memory, and even motor skills (which HCPs on active duty cannot afford)," points out Dr Hashmi. A much easier solution would be "simple mental health intervention strategies" which do not require sophisticated psychological or psychiatric training, he suggests.

Psychological first aid

At the King Edward Medical University 's telemedicine center, training in Psychological First Aid (PFA) is being provided to all frontline HCPS. "This is an evidence-based WHO-approved intervention for disaster (and pandemic) situations which can be provided even by appropriately trained lay people. The training is simple, takes 1-2 sessions of 1-2 hours each," informs Dr Hashmi.

He says research had shown that providing PFA to patients, their families, and HCPs greatly reduces the incidence of mental health issues both immediately and later on.

Further, it will serve a dual purpose. The HCPs will have some basic training to provide PFAs to Covid-19 patients and their families and they will have some psychological 'immunity' to mental health problems themselves since they will have gone through the training, says Dr Hashmi. In addition, Kemu's department of psychiatry is available 24/7 for both patients and HCPs at Mayo Hospital, he adds.

Planning for the worst

With an ease in the lockdown, Dr Hashmi predicts a sharp increase in infections and a spike in deaths. "We keep hoping that that does not happen but as they say 'hope is not a plan,'" he says.

So at Kemu, they are planning for the worst case scenario on the mental health front. Other institutions are also coming up with similar plans. The Higher Education Commission (HEC) has just constituted a high powered national committee to come up with a plan on how to incorporate psychosocial support and care into the country's national healthcare plan, Dr Hashmi shares.

"We are going to be working with the National Disaster Management Authority (NDMA) and other relevant national and provincial bodies to develop policies and plans on how to deal with not just Covid-related mental health issues, but also, hopefully, any and all future crises," he adds.