Emotional labour of community health work

Every Tuesday I meet with the community health workers who are the face of our community health program in the rural area where we serve. They are an enthusiastic bunch of 10 people from the local villages, 8 women and 2 men. Hailing from modest backgrounds, they are workers with excellent people skills, cool conversationalists and go-getters who can accomplish tasks assigned to them with perfection. Every Tuesday when we meet, we start with greetings and the broad opening question, “How are you all today? How has the last week been?” Some days they are silent and take time to warm up and start talking, on most other days they just start talking about the activities of the week, the challenges they faced, the unique problems they solved and the doubts they have regarding their work. Our meeting room is the noisiest space in the office and sometimes we end up disturbing the work of others in the office. But, I think this dynamic and vibrant discussion space has been one crucial factor that has kept us going through some difficult times in the past 2 years. Some of the routine things we discuss every week are:

1.        Any patients who developed medical emergencies and required a hospital visit

2.        Any patients who had some new developments which require attention

3.        Any doubts they have regarding lab reports of patients, questions asked by patients

4.        Any social issues that they identified – domestic violence, child marriage proposals, political issues in the villages etc. 

5.        Any questions or doubts that they have related to their work

This usually runs for an hour and a half. Following this, we discuss some topic related to community health work. As the community health work is largely focused on non-communicable diseases, we discuss topics related to diabetes, hypertension, heart diseases, lung diseases etc. Sometimes we have heated debates and discussions on social and political issues. We have discussed about the scarcity of LPG cylinders and that led to discussions on the geopolitics of oil in the gulf. With the assembly elections in Tamil Nadu in full swing, we also discussed different political ideologies. 

 

One of the projects that we are working on, organizing community members into diabetes peer support groups and encouraging diabetes self-management behaviours, is coming to an end next month. So we were discussing the various issues that need to be addressed as part of study closure. The discussion was revolving around recollection of various activities that have been conducted as part of the study, and it organically evolved into an emotionally intense reminiscence of the past. The discussion was an eye opener for me and helped me see a completely different perspective of the work of a community health worker. 

 

“When I started this work 2 years ago, I faced constant rejection and insults and humiliation based on my caste. I belong to scheduled caste but having lived and brought up in a semi-urban area, I was never exposed to caste-based discrimination. But when I came and started working in the field here, people would keep me out of the house. They would not even give me a glass of water in the hot sun. It was painful, and I have even thought of quitting the job during my initial days. But I persisted and now I have gained full acceptance in the community. The other day, a family belonging to dominant caste, invited me inside, made me sit in the swing in the middle of the house and gave me coffee to drink. This is the sign of acceptance and result of my consistent and dedicated work.” When Mr. A, the youngest in the team said this, I was moved beyond words. Immediately after he finished this intense narrative, many others in the team also added how they have navigated the issue of caste in the community. Mr. S said, “When I work in the dominant caste cluster, I tell them I belong to their caste, and when I work in the oppressed caste area, I tell them I am one of them. This is the only way I can operate effectively in the area.” But one old man in the dominant caste saw Mr. S in his village when he was traveling somewhere. The next day when Mr. S made a home visit, the old man said, “I saw you in the colony (scheduled caste residential settlement). Are you a colony boy?” From then he stopped talking to Mr. S and asked him not to make home visits anymore. Mr. S said this hurt him deeply. In rural areas where casteism is prevalent, I am certain every community health worker is facing these issues. This is a huge psychological, emotional and social burden to bear. There is some literature in public health where caste compatibility between community health workers and communities has been explored and how it can affect the ‘efficiency’ of the community health work. But no research has explored the psychological, emotional and social burden of this caste discrimination on the community health worker. 

 

“The greatest challenge I faced was making home visits to men with diabetes, organizing peer support meetings for men and getting them to talk about their problems in the open” said Mrs. S. Community health workers often had to make home visits in the evenings, as men would be out at work during the day. Most evenings, some men would be drunk and inebriated when they made their visits and so they had to leave and come back another day. In an inebriated state, the men would speak rudely and sometimes pass lewd comments to the women. “I went to show the man the video on infections that commonly affect patients with diabetes. He was already drunk and sat there watching the video. The video came to a point where we were talking about genital tract infections. At that point, the man asked me to stop the video and asked me to come inside his home so that he can show me a rash in his genitalia. I was deeply disturbed and found it very inappropriate. I asked him to see the doctor in the clinic and quickly rushed out. I could not get over the emotional trauma of that episode for a long time” When Mrs. B said this, she was re-living the trauma and visibly shaken. Immediately following her narrative, several other women in the team shared their own traumatic experience of harassment and feeling unsafe during community health work. While issues of physical and sexual assault gets into the news and gets noticed, such types of harassment and abuse that women face as in the case of Mrs. B, goes unnoticed and unaddressed. Mrs. B herself never brought this up till the discussion organically evolved into these matters. 

 

“There was an elderly woman whom I used to visit. She was abandoned by her family. Her neighbors would give her food, and she would lay on her coir cot without any attention. I was the only person visiting her every week, whenever I went to that village. She used to look forward to my visit. We would sit and talk for about an hour. One day, when I went, her home was locked and the cot was empty. The lady had died the previous week. I was unconsolable. I did not even know about her death and could not attend her funeral. I took almost a week to get over the loss.” Mrs. R said this and had tears in her eyes. When we hear about the passing of a patient it does affect us. But the intimacy that a community health worker develops with their community is something very different from that a health care provider develops with their patients in the hospital. It is more personal. Following Mrs. R’s narrative all others started narrating heart wrenching stories of loss and grief that affected them deeply. Mrs. B said, “…That man was always so kind to me. Sometimes other members of the support group would be very far away working inside the fields, and I had to go all the way to call them for the meeting. The man would start his two-wheeler and take me there to invite them. He would do my work for me. One day he was hit by a lorry and passed away on the spot of the accident. It was too painful for me. I could not eat or sleep for an entire week.” Not only death, but amputation of feet, serious kidney damage, heart attack, and every complication that their clients developed took an emotional toll and a sense of deep failure among the community health workers. I realized that as doctors, nurses and health care providers, we are not just shifting our clinical tasks to community health workers, we are also shifting the emotional burden of care. 

 

I was wondering why I have never thought about this dimension of their work. What are they doing to cope with this emotional burden? How are they getting back on track and continuing their work? Mrs. P said, “I cry a lot. I come home and cry loudly. It helps me vent my emotions.” Mrs. T added, “What can we do? We must continue to work irrespective of how we feel that day. It is not just a matter of our salary and commitment, it is also that someone is dependent on us, how can we break down and sit like that?” It was one of the most mature definitions of professionalism I have heard from health care providers. “When we get home, our lives take over. We must take care of our families and children. We must carry on with our lives. That is our only coping mechanism. It is only when we get back to work, or when we enter the field again that we are reminded of all the emotional burden. When we are at home, we barely have any time for these thoughts” said Mrs. D. It was practical and mature. I realized yesterday that I am working with a bunch of highly evolved and mature emotionally intelligent human beings, our community health workers. I have a lot to learn from them in emotional intelligence and management.