The word “burnout” has been used a lot during the COVID-19 pandemic to describe healthcare and community workers who’ve been pulling long hours, risking their own well-being to do their jobs, and witnessing unprecedented suffering and death.
Global health professionals know burnout well. Even before the virus stormed across the planet, Duke global oncologist Kristin Schroeder says she was no stranger to it and has seen it in many colleagues, even those early in their global health careers.
“There are frustrations of doing work in a low-resource country. You’re up against so many barriers — bureaucratic barriers and red tape,” says Schroeder, assistant professor of pediatrics and global health at Duke, who spends half the year working at Bugando Medical Centre in Mwanza, Tanzania, treating children with cancer.
The term is often used colloquially, but it’s a real diagnosis, says David Eagle, assistant research professor of global health at Duke, who has studied burnout extensively.
“It describes those who are overwhelmed by chronic stress from their jobs,” he explains.
The World Health Organization defines burnout in the International Classification of Diseases (ICD-11) as a syndrome characterized by "chronic workplace stress that has not been successfully managed."
There are three clusters of symptoms in burnout, says Eagle.
“The first is this idea that you become emotionally exhausted by your work — overwhelmed by your work,” he says.
Cynicism or “depersonalization” can happen, as well. “It’s when people become disengaged from the people they’re serving and start treating them more as objects than as people,” Eagle says, explaining that this emotional distancing is a coping mechanism.
The third hallmark of burnout is a loss of a sense of personal achievement in your work.
“For a long time, it was thought that emotional exhaustion developed first. But there’s not a ton of evidence to back that up. From my own work studying clergy, developing a cynical attitude about the people you serve may also be an early warning sign of burnout,” says Eagle.
Eagle adds that burnout and symptoms of depression — things like changes in eating habits and sleep, and feelings of irritability, or loss of interest in life — can be closely related.
There is a host of research on burnout among physicians, nurses, humanitarian aid workers, and front-line care providers, noted a July 2020 Forbes column by Madhu Pai, professor and Canada Research Chair of Epidemiology and Global Health at McGill University, in Montreal. But Pai wrote that it’s rarely discussed or studied in global health, even though it is a well-recognized issue. He pointed out that beyond the daily work of caring for patients in communities with fewer resources, there are many other factors that set the stage for burnout in global health workers, and COVID-19 has only complicated things more.
“Even during normal times, global health work involves diplomacy, political negotiations, advocacy, engagement of diverse stakeholders, and the ability to deal with mind-numbing bureaucracy. Doing such work, day after day, comes at a cost,” Pai wrote.
Societal norms in a culture can lend added pressures, too, Schroeder says. For example, in Tanzania, meetings are rarely on time.
“It’s almost a cultural thing. Time is a much more fluid concept. People are so busy and doing many other things that a strict timetable isn’t adhered to. Because people don’t show up on time, you can’t get scheduling done for procedures and appointments, or there isn’t someone available, or there’s the cost of doing it — things don’t work out,” she says.
She adds, “The real frustration comes from trying to do something, knowing it’s possible to do, and then being hit by barriers that from our point of view shouldn’t be there but are because of the environment and the cultural structure we’re working in. They’re not possible.”
Burnout can strike early in a global health career
Burnout is not just a mid- or late-career professional’s woe. In fact, Schroeder often sees it in people new to global health who come to work with her in Tanzania.
“I’ve had some masters students and other volunteers who it’s taken a pretty big emotional toll on, even if they come out here for a short period of time. Just seeing the amount of suffering and to see the inefficiencies and failures of the system for these patients,” she says.
Global health workers from high-income countries aren’t the only ones affected. Schroeder often works with brand new physicians from sub-Saharan Africa who come to volunteer for a year or so, hoping in time to get a position in the department.
“They often come in just as they’re finishing medical school and they are idealistic. And they work hard. They want to do everything that is right by the patient. They want to do everything that they can to be the best doctor they can be. And then they are hit with the institutional barriers and delays,” says Schroeder.
Over time, those young physicians sometimes become frustrated and disillusioned and then they start accepting that things are not feasible — and fighting for it can be tiring.
“I myself have fallen into that trap sometimes as well,” she adds.
Add COVID to the mix and people who are already feeling professionally frayed may struggle more, says Logan Tice, Research Program Leader at Duke Global Health Institute’s Center for Health Policy and Inequalities Research.
“What’s changed is that there’s a lot of family and social stress now, too. We talk about bandwidths – emotional bandwidths — people have lost a lot of control,” Tice says.
After six years as a global health physician, Schroeder has learned a few tactics to help stay resilient. At work, for example, she may push back on cultural norms in order to get certain things accomplished.
“Sometimes, I do try to push timetables with people. You can’t sit for four hours waiting for somebody to show up for a meeting if you have patients waiting or people involved in meetings internationally,” she says.
She also takes care of her own mental health — what Eagle refers to as maintaining good “mental health hygiene.”
“What I have learned about myself here is that I’m in a high stress environment with high emotional stress. A lot of patients are dying. They come in very sick. There are frustrations with things that I know are curable but I know that I can’t cure because of current circumstances or cost, or availability of different medications, or training, or capacity. The number one thing is to pay attention to your cues. I know when I’m getting frustrated. Or on the flip side, I know when I’m not getting irritated enough at things that I should be upset by,” she says.
When those cues start rearing their ugly heads, she takes time out and does something that “shuts my brain off” or makes her laugh. Enter: RuPaul’s Drag Race.
“It is a happy show that has absolutely nothing to do with medicine. Or seriousness in the world or politics. I can sit and enjoy it and it makes me laugh and it shuts my brain off for a while of all the other stuff going on. Or I will sit and paint. Anything to sort of give my brain a break and allow me to decompress. And I routinely do that,” she says.
Being aware of mental health challenges that you’re facing and addressing them before they get out of hand is really important and can be preventive against burnout, Eagle concurs.
Blandina Mmbaga, a pediatrician at Kilimanjaro Christian Medical Center and an adjunct associate professor at Duke Global Health Institute who is based in Moshi, Tanzania, has worked in global health for more than seven years.
Mmbaga says earlier in her career reaching a point of exhaustion from work was more common due to long hours, fewer resources and leaner staff. Even now, it’s not uncommon for her to work until 10 or 11 p.m. at night. But in recent years, she always makes sure she gets at least 6 hours of sleep a night and she gives herself the weekend to recharge.
“On Saturday and Sunday, I get rest, sleep. I go to the market and I try not to look at the computer screen. In the evening on Sunday, I read medical manuscripts, but it’s something that doesn’t take a lot of energy. On the weekends now, I want to rest my mind so I can start fresh the next week — that helps me Monday through Friday,” she says.
Traveling to meetings for work in pre-pandemic days used to provide time to rest, too, Mmbaga says. Since she hasn’t traveled this past year, though, her weekend time off has been all the more important for fending off burnout.
Marisa Viljoen, a PhD student at the University of Cape Town, who works as a project coordinator for Duke Global Health Institute’s Lauren Franz, says burnout is “definitely” an issue at times, but finds inspiration through the strength of others.
“I am often inspired by the positive attitude some people have who live in extremely challenging circumstances. It is as if they choose to focus on what they do have and what they can do, instead of what is lacking,” Viljoen says.
Be a mentor, or find a mentor
Taking the time to stop and ask how a colleague is doing is important, Tice says.
“When we’re stressed, we have this tendency to rush. Pause and see people as human and full people. And really check in with how they’re doing. And don’t just making assumptions that because they have letters after their name that they are doing perfectly well,” Tice adds.
Schroeder looks out for her students’ and colleagues’ mental well-being by making time for what she calls “mini discussions” with them when stressors arise.
“We talk about what happened when there is a particular event. Just discussing it and realizing that we are doing everything we can and there are some things that are really beyond our ability to control in this environment — or any environment. Just recognizing that and recognizing that if we were not trying our best for our patient it would have been a very different kind of outcome,” she says.
Mmbaga says she lets the interns on staff who are working long hours know how much their efforts are appreciated. Gestures, such as sending cake for a treat to their work units, helps keep spirits up.
Eagle also recommends global health workers reach out to friends outside of work to talk. Exercising is key for stress management, too. And seeing a counselor can be a huge support for global health workers. If a person is suffering from clinical depression, it needs to be addressed. You can’t overcome burnout when you are clinically depressed.
Tice says mindfulness-based stress reduction is another approach, including progressive relaxation. She also recommends “job crafting,” which involves working with your supervisor to find tasks that bring you fulfillment, not just stress. And figuring out ways to end a workday on a high note “instead of a tough meeting or tedious task.”
Schroeder says that the challenges of global health are what draws most people to it, yet that can be a conundrum because it can lead to burnout. So, it’s important to take it one day at a time and recognize progress made.
Like a mantra, she says, “I’m just constantly reminding my students and reminding myself, even if today was a bad day, in the last year, we have made so many advances.”