Health workers in the hot zone
Karachi’s medical, ambulance staff cope with extreme stress to maintain their humanity
Toughened by threats and routine violence, the nurses, ambulance drivers and doctors of Karachi’s main metropolitan hospitals must cope with extreme stress to maintain their humanity. But who heal will heal Pakistan’s healthcare heroes?
“We have all sorts of people coming [to the ER]. They can do anything. They can pull out a gun. They can open fire,” says Imtiaz Ali, a supervisor nurse, who has worked at its largest government hospital, Jinnah Postgraduate Medical Centre, for a decade.
“When there were [ethnic riots], they’d put a gun to your temple and demand you see their patient first.” One of his co-workers, another supervisor nurse with 14 years of experience, Shehzad Masih, candidly explains how they react. “When you see the gun, you hop to it,” he says. “Your whole body shakes.”
These healthcare providers work in one of South Asia’s biggest, and, until recently, most violent cities, with an estimated population of 22m.
Violence against healthcare workers is widespread yet underreported. In 2015, an ICRC study found that 65% of 822 staffers at 18 facilities had experienced or witnessed violence. Abusive language topped the list (82% had experienced it), but other forms include pushing, punching, kicking, slapping and even being killed. From 1997 to 2002, 270 healthcare workers were murdered in Karachi.
The worst outbreaks take place in the Emergencies, followed by the Gynaecology Emergency ward. The violence comes overwhelmingly at the hands of agitated relatives and friends accompanying a patient. A culture of support means that it is normal for 12 people to bring one patient in but as the ICRC study found, the higher the number of attendants the higher the chances of violence breaking out. The numbers swell if a political party worker is injured.
Crowd control is also a major challenge outside the hospital setting as ambulance drivers will tell you. Khalid Mehmud from the free Edhi service once dived into a mob to save a robber who had been caught red-handed in Karachi’s electronics market. “They wanted to set him on fire,” he says. “We’ll burn you too, [they said]. I said, you can set me on fire but let him go. They beat me.”
‘My blood pressure shoots up’
Working in this environment is taking a toll on these healthcare workers. “My BP shoots up,” says Alishba Albert, 45, a nurse at the Jinnah ER. “Then I sit down, have a bit of water. I’ve been doing it for 17 years, so this is routine.”
Dr Seemin Jamali, who has been running Jinnah hospital’s casualty since 1988 and is now the institution’s executive director, says staff often become agitated after an incident. “They can get very angry. Emotionally they are very disturbed,” she says in response to a question on what symptoms can emerge. “You can see them cry at the drop of a hat. They can lose their temper. And specially when they feel insulted,” she adds.
According to Dr Mirwais Khan, who is leading the ‘Health Care in Danger’ project for the ICRC out of Peshawar, there is a long-term psychological impact that these healthcare providers are only just beginning to become cognisant of but stigma is attached to being open about psychological distress.
“They avoid discussing these things. Disturbing memories, repeated memories of that event. Fear of repetition,” he says. “People remove themselves as if nothing has happened. It is a form of disassociation.”
Staff tends to react by taking time off, if the system gives them the space. Nurse Sehrish Rana says that after an incident, especially if a patient or their attendants have abused her, she doesn’t feel like coming in to work.
“Your heart doesn’t want to,” she says. “You are feeling like, am I doing my real job? Am I satisfied by this? Should this be happening to me? These questions bother you even after you have gone home and you are off duty. Just keep going over it. How could they do that? You feel anger. You want to cry. I get really mad. After incidents, I didn’t want to come back to work. But you have to.”
Edhi ambulance driver Rehan, 28, is one of the lucky ones as he recognised he was burnt out. Aside from facing the stress of being on-call for 36-hour shifts, ambulance drivers in Karachi are beaten, shot at, and roughed up regularly if a family perceives that they have arrived late even though traffic jams are the reasons for delay.
“I couldn’t sleep,” he says. “I was irritable with people I love.” His family had nicknamed him “Duty” because he was always on stand-by. After five years as a driver, he requested a rotation and now has an easier shift. He feels his depression has improved as he gets to spend more time with his three-year-old.
But not all healthcare workers realise that they need to decompress. In fact, it is their high tolerance for being on the receiving end of violence that is part of the problem. They valorise developing a tough skin for it.
Medical messiahs with a mission
“When I was katcha [raw], I got beaten,” says Khadim Hussain, a security guard of 17 years at Jinnah hospital. “Now I’m pukka [hardened]. When I became pukka, I didn’t get beaten.”
He clearly states that retaliation is not an option when violence breaks out in the ER. “It’s a tension job,” he says. “You just eat it, the stress. No one goes mad in Jinnah. Such a big circus, tamashas [dramas] happen here daily.”
Nonchalance accompanies the interpretation of the impact of violence. Nurses and paramedics use the words “routine” and “normal” to almost scoff at it. Malik Asghar, 36, who has been an Edhi ambulance driver for 15 years, puts it plainly.
“If we started to feel guilty, we’d also be hanging from the ceiling fan.” They press ahead no matter what. Edhi driver Khalid Mehmud disregarded his own safety to respond to a shoot-out. “I was shot,” he says. “I thought a stone had come from somewhere. A gunshot [victim] was lying in front of me and I felt when I touched myself I felt something dripping. But I forgot myself and went to get that guy.”
At the heart of the problem is their coping mechanism of shielding themselves from the psychological trauma by inadvertently adopting a ‘messiah’ complex. Nurses such as Shahzad see themselves as “chosen by God” to do this work without complaining.
The Edhi ambulance drivers call it an Islamic “sawab” or God-pleasing deed to serve people and turn the other cheek no matter what. There is extreme pressure to conform to the image of being armour-plated mini-heroes. They explain away the violence as understandable given how distressed a patient’s family can be, which is why they rarely press charges or document verbal and physical abuse.
In severe cases, police complaints are registered but no one is penalised. “They win the sympathy of others,” says Dr Jamali, referring to attendants turning violent if their patient has died. And then it feels bad to get them penalised… The humane factor keeps us away from doing that.”
Even superheroes get the blues
The good news is that there is a concerted effort to train staff on how to “de-escalate” a flammable situation. Dr Iqbal Afridi, who heads the Jinnah hospital department of psychiatry, holds workshops on how to break bad news and in what setting. They train staff in progressive muscle relaxation, which helps brings their blood pressure down.
“We show them how to do it in 10 minutes. If not this we use mental visualisation methods,” he says. They are told that they need to take breaks. According to Dr Mirwais Khan, the project has helped the staff gain an understanding of violence.
“This means the threshold of acceptance of violence is being challenged,” he says. “[We are] telling the healthcare worker that this is not [just a normal] part of your job.” For her part, Dr Jamali has radically changed the architecture of the ER to aid triage and increase spatial barriers and cordons that enhance the security for staff. The violence may be routinely taking place but that doesn’t mean it is “normal” by any stretch and should be tolerated in any way.
This has made a difference, but as nurse Shahzad says: “Yes, we get fed up. But to tell you the truth, we say that we are nurses and we are chosen by God, not by human beings. We want to serve humanity.”
This story was commissioned for the Red Cross Red Crescent magazine.