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Psychological resilience, fragility and the health workforce: lessons on pandemic preparedness from Liberia and Sierra Leone

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Laura Dean, Janice Cooper, Haja Wurie, Karsor Kollie, Joanna Raven, Rachel Tolhurst, Hayley MacGregor, Kate Hawkins, Sally Theobald, Bintu Mansaray


COVID-19 presents a time to redefine vulnerability; however, in discussions of vulnerability, the health workforce, particularly in regard to their psychosocial well-being, is often forgotten. Healthcare workers (HCWs) in fragile settings are constantly exposed to health system shocks, including; conflict, disease outbreaks and natural disasters, which compound the everyday challenges of working in an under-resourced health system. Based on a commitment to serve their communities, they often cope with repeated shocks and protracted crises through innovation and creative thinking. However, they also experience repeated acute and chronic stressors that can lead to psychological distress. For some, prolonged exposure to risk of psychological distress can lead to personal growth, for others, continuous exposure to chronic stress and uncertainty can lead to psychological injury. Psychological impact cannot be reduced to personal resilience, rather it becomes linked to dynamic interactions between an individual and the structural and social circumstance within which they live and work; as well as the level and type of support they receive. HCWs are central to health systems responses to shock, becoming the medium through which policies and programmes become adopted or adapted. Yet the long-term psychological well-being of health-workers is seldom considered in planning for health systems resilience.
HCW well-being is ultimately determined by structural factors and change that requires political will. Nonetheless, psychological support and attention to ways of alleviating distress throughout all phases of systems shocks is central to mitigating longer-term impacts on HCW mental health. Sierra Leone and Liberia both experienced decades of conflict and fragility that have rendered fragile health systems and have undoubtably influenced the psychological well-being of their health workforce.
They have few HCWs. Their communities are resilient yet vulnerable, and trusting relationships between governments, health systems and communities are precarious. Ebola is the latest in a series of historical traumas and health systems shocks. Now, global and local responses to COVID-19 may trigger anxieties and in some cases post-traumatic stress disorder among HCWs across Sierra Leone and Liberia. Such experiences may result from limited action to understand HCWs psychological trauma and a lack of aftercare to manage underlying psychological injury as a result of ongoing chronic stressors or stressors experienced during previous shocks.