Experiences of Kyrgyzstani frontline healthcare workers during the “Black July” in 2020: a qualitative study



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Abstract

Our study describes and analyzes personal narratives of COVID-19 outbreak survivors who were working as health care practitioners during the period of the so-called “Black July” of the summer of 2020 in Bishkek, capital of Kyrgyzstan. Our findings illuminate how identity can change during a traumatic event, such as a pandemic. Ten participants from healthcare services, including mental healthcare, were interviewed. Our participants’ narratives demonstrated post-traumatic growth resulting in changes of attitudes, lifestyle, and identity, both as individuals and as a professional class. Our participants’ narratives also indicated possible post-traumatic depreciation included an emerging desire for increased self-care which was characterized by resistance against a heroic Hippocratic ideal to “to save everybody”. Further research is recommended into, on the one hand, developing rehabilitation programs for healthcare workers with an eye toward future pandemics, and on the other, ascertaining possible ramifications that identity changes such as those found in this research may bear on broader society.

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The novel coronavirus pandemic has caused significant physical and mental health damage to healthcare workers (HCWs). Despite being forced to wear personal protective equipment (PPE), HCWs had direct contact with sufferers of COVID-19 and/or related pneumonia, thereby increasing their own risk of infection (Giusti et al., 2020). Resource shortages, overwork and perhaps particularly, if unspokenly, the Hippocratic ideal to save life provoked anxiety and uncertainty, and cumulatively took a severe toll on the psychological wellbeing and identities of HCWs (Greenberg et al., 2020; Ornell et al., 2020).

In Kyrgyzstan, the pandemic erupted against the backdrop of chronic degradation of governance structures, including in the arena of healthcare. In an unpublished study by Molchanova (2021) that was conducted in August 2020, following the crest of the pandemic in July 2020, 16% of Kyrgyz HCWs showed symptoms of post-traumatic stress disorder (PTSD), while 48% also reported symptoms on the anxiety-depressive spectrum. HCWs have found it difficult to allocate time to seek psychological help, while a culture of shame has made it difficult to commiserate with colleagues (Galbraith et al., 2020). These findings are consistent with what is being seen in other countries, such as China, wherein 19.9% of HCWs also showed symptoms of PTSD (Xiong et al., 2021). There is, however, a more complex story to tell about how Kyrgyz HCWs responded to the trauma of the pandemic than PTSD.

While PTSD is a significant concern, the aftermath of the COVID-19 pandemic represents an opportunity to explore not only post-traumatic depreciation (PTD), but also the phenomenon of post-traumatic growth (PTG), and particularly among HCWs. The notion of PTG was first identified in a study by Tedeshi and Calhoun in 1996 and has generated a lot of scientific interest ever since (Jayawickreme & Blackie, 2014). PTG can be defined as positive changes enacted by trauma survivors to cope with their trauma experiences (Moreno-Jiménez et al., 2021). Over time, trauma survivors reevaluate and restructure their experiences, deriving new meanings for themselves, resulting in potentially positive changes in themselves, their attitudes, and their relationships with others.

Studies are showing that PTG has occurred during the COVID-19 pandemic alongside PTD traditionally associated with PTSD. The patterns, however, remain to be understood. For example, one Greek study found that HCWs were more likely to undergo post-traumatic growth than the general population, even when compared to highly educated non-HCWs (Kalaitzaki, 2021). A Turkish study had similar results (Ikizer et al., 2021). The study which we will present here, which was conducted in Kyrgyzstan but did not include non-HCWs, nevertheless had similar results for HCWs.

Our study focused on the period of the so-called “Black July” in Bishkek, capital of Kyrgyzstan. Two theoretical models were applied to analyze the results: 1) Erich Fromm’s concept of “insane society” (Fromm, 1955), and 2) the dualism of self-identification and post-traumatic experiences as expressed in the archetype of the “wounded healer” (Schonau, 2012). Our study also had a speculative dimension. Partially due to our use of Fromm’s concept, we were curious as to whether major traumatic events can impact collective psychological states in addition to individual ones. To conceptualize this, we coined the term “(C)PTSD”, viz., “(collective) post-traumatic stress disorder”, thereby expressing the individual and collective aspects of trauma. We took care not to take a side on the debate over whether a collective is an entity sui generis or an aggregate of individuals, and while we hold that a collective, however understood, can be a bearer of mental states, and hence of trauma, we acknowledge this as speculative. Analytically, we were also careful to parse between what could be characterized as “meso-” versus “macro-” collectives, with the former signifying sub-societal collectives, such as an entire professional class (e.g., HCWs), and the latter signifying societal collectives, such as nations (e.g., Kyrgyzstan). 

With respect to our findings and preliminary conclusions, in brief, Kyrgyz HCWs perceive Black July as a turning point in their lives, expressing changes in their attitudes, lifestyle and identities, both as individuals and as HCWs. However, the pandemic was not only a complex individual phenomenon, but a complex social one, as well. Our participants repeatedly emphasized the interconnection between individual health, whether physical or mental, and the collective, whether governmental systems, general society or family. Intriguingly, they tended to highlight positive changes with respect to themselves as individuals and as a professional class, but negative changes with respect to Kyrgyz society. 

Kyrgyzstan 

Kyrgyzstan, officially the Kyrgyz Republic, is a post-Soviet country with a history of political instability. Since its independence on August 31, 1991, the country has changed seven presidents, five by means of violent street protests; Partlett (2021) stated its constitution has also been amended numerous times via referendums. The country’s chronic political instability has eroded its governance structures, including in the arena of healthcare. This is most acutely seen in terms of salaries: salaries for public HCWs are approximately 200 USD per month (Maslova, 2020), while average cost of living in the capital, Bishkek, is approximately 300 USD per month (Shabalin, 2019). Unsurprisingly, the financial situation has pushed highly-trained professionals to emigrate. Additionally, since the turn of the century, there has been a rapid and unregulated increase of private entrepreneurial clinics, many of which disappear as quickly as they appear. 

The COVID-19 pandemic nearly shattered this delicate situation. HCWs were thrown onto the front line of the fight against the novel coronavirus without the necessary support, whether PPE, treatment guidelines, planning or financial support. Medical facilities were overwhelmed, and patients were forced to seek treatment via daytime in-patient care or otherwise stayed at home, self-medicated and self-isolated.

Government officials, including the then-president, Soornbai Jeenbekov – who was overthrown by street protests in October 2020 that were partially inspired by the social and economic upheavals of the pandemic (Eurasianet, 2020) – not only failed to themselves obey the rules of the lockdown, but failed to take the situation seriously. Already in April 2020, an independent group of experts cooperating with foreign scientists predicted a peak during the summer. These predictions were presented to government officials, but were ignored (Abdubachaeva & Zhenishova, 2021). Civil society stepped into the gap. Non-governmental organizations (NGOs) established a call center run by volunteers; this call center received up to 8,000-10,000 calls daily. Telegram chats were organized by doctors, and mobile teams of volunteers, business representatives, and NGOs were organized to supplement and assist professional HCWs (Imanaliyeva, 2020; Litvinova, 2020).  

The first cases of COVID-19 in Kyrgyzstan were reported by the Ministry of Health on March 18, 2020, when three citizens who returned from Saudi Arabia tested positive (Orlova, 2020). On March 25, 2020, a lockdown was announced in the country. Schools, universities, entertainment sites, and hospitals were closed. Only government workers could physically go to work, including law enforcement and medical workers. The lockdown lasted two months and was lifted on May 10, although many restrictions continued.

Black July”, as it is popularly referred to, is generally considered the peak of the pandemic in Kyrgyzstan (Kabar News Agency, 2020). This designation partially depends on how cases were calculated before then, as until mid-June, the official number of COVID-19 cases did not exceed 100 cases per day. On July 17, 2020, cases were listed at 173, but then the Ministry of Health merged the statistics of patients with confirmed novel coronavirus and pneumonia, and on the very next day, this figure leapt to 900 (Kumenov & Imanalieva, 2020); by July 19, it leapt further to 1926. Nonetheless, the impressions of HCWs themselves indicate that the number of patients suffering from COVID-19 or related pneumonia did genuinely increase significantly in July to crisis levels.

During this period, one in four people in the Kygyz Republic who were infected with COVID-19 was an HCW (Dzushupov et al., 2021). Many HCWs, as well as psychologists and public figures, made live broadcasts and talked about their illnesses in order to reduce stigmatization of sufferers. However, they were subjected to pressure from both commentators on social media and national security servers for spreading disinformation.

Theoretical background 

The theory of “insane society” as formulated by Fromm (Fromm, 1955) postulates that not only individuals can suffer from a mental disorder, but so, too, can a society. Moreover, an individual in such a society will be unable to stay mentally healthy, as they will be repeatedly exposed to the ubiquitous mental disorder and undergo repeated traumatization. We hold that, due to endemic social problems and chronic political corruption, post-Soviet societies in general, and Kyrgyzstan in particular, fit the diagnosis for “insanity” so understood (Business Ombudsman Institute of the Kyrgyz Republic [BOI], 2020; Transparency International [TI], 2021; OSCE, 2015), both before the pandemic and after.

More specifically, where Fromm wrote about “insanity”, we are concerned with post-traumatic stress disorder, such that we are concerned that Kyrgyz citizens suffer from post-traumatic stress disorder, both as individuals and as a collective – hence, (C)PTSD. They suffered from (C)PTSD before Black July, and have experienced entrenched trauma of it during and since. The entrenchment occurred as the result of the actions – as well as lack of actions – taken by government officials, as well as the attitudes and reactions of the general public itself which, among other things, included stigmatizing patients and engaging in purchase panics that led to critical shortages of medical supplies.

How might (C)PTSD be examined? HCWs represent a faultline of sorts, via which researchers can trace the red thread of trauma that runs between, and unites, individuals and the collective. This faultline manifests as a dualism within an HCW’s self-identity, known as the “wounded healer” (Schonau, 2012). There can exist a discrepancy between the HCW acknowledging the patient’s woundedness on the one hand, and containing the latter’s hopes and expectations of being healed on the other. To overcome this discrepancy, the HCW can project a certain confidence, yet this can backfire on them, causing them to incorporate the patient’s woundedness, if metaphorically, into themselves (Guggenbühl-Craig, 1997). Yet, no patient’s illness is solely theirs as an individual; societal factors play a decisive role in how they become sick or wounded (Williams, 2003). So, too, is the HCW’s own status as an HCW a function of social structure, both the social structure of their particular class, and like their patients, the social structure of society itself. Mutatis mutandis, when the HCW incorporates the patient’s woundedness into their own identity, there is a reverberation here, from the collective of their society (macro-collective) and professional class (meso-collective) down to the individual, and then back from the individual up to the collective. 

Put another way, insofar that transformation within an HCW’s individual identity may be considered indicative of possible larger transformations in the identity of the collective(s) of which they are a member, we may be able to decipher the collective dimensions of trauma by examining this demographic. That being said, that it is possible to decipher the collective dimensions of trauma of a specific demographic within a society, much less of a society as a whole – and moreover, that one or both may be ascertained by studying individuals within that demographic and society – is not a foregone conclusion. We admit at the outset that such an examination is as much philosophical as it is psychological.

What can we expect to find when we examine HCWs’ identity after they have been “wounded” by (C)PTSD? Crucially, the metaphorical incorporation of the patient’s woundedness into themselves does not always have a pathological result. Trauma has its own dualism; it not only can cause depreciation, but also growth. Indeed, growth may be as much a feature of PTSD as depreciation (Jayawickreme & Blackie, 2014; Moreno-Jiménez et al., 2021).

Post-traumatic growth (PTG) is usually associated with positive personality changes following the experience of highly challenging traumatic events. Such personality changes usually include personal appreciation, a transformation of individual goals and life projects, increasing social intelligence and social interests, greater enjoyment of simple activities, and even changes in spirituality. Put simply, post-traumatic growth typically entails greater appreciation for life, as well as an active use of “lessons learned” in the aftermath of the traumatic situation (Park, 2010; Roepke et al., 2013).

At first glance, post-traumatic growth stands in contrast to post-traumatic depreciation (PTD), which is characterized by negative personality changes, such as increased fear of other people, increased cynicism, increased isolation, obscurantist thinking, loss of interest in one’s most cherished activities and even career, and so on. Yet, PTG and PTD can be seen in different proportions in the demographic group that has undergone a challenging traumatic event – such as our case study, Kyrgyz HCWs during the COVID-19 pandemic – not to mention even within an individual member of the group. This strongly suggests that they are two sides of the same coin (Marshall et al., 2015).

Research

Our study can contribute to understanding psychological responses to pandemic-related trauma, particularly PTG among HCWs, as well as understanding how the COVID-19 pandemic impacted healthcare systems beyond the West, particularly in the former Soviet Union and Central Asia. Note that three of our study’s four researchers are themselves mental health specialists who were themselves infected by COVID-19, two during Black July. There was thus something of a personal rationale at stake, as well.

Research question

What are the main differences between the life of health care professionals before and after COVID-19 pandemics? 

Study Design

Participants

Our participants were HCWs who had been diagnosed with COVID-19 during “Black July”. The inclusion criteria were as follows: 1) having possessed work experience in healthcare (whether mental or physical) during Black July; and 2) having been diagnosed SARS-CoV-2 during the same time period, either through self-diagnosis using a clinical manual, or through chest/lung scans by computer tomography, including (CT)/X-ray, and/or PCR and/or IgG/IgM blood test results; and/or being self-diagnosed according to the clinical manual. Additionally, 3) considerations were given with respect to whether they had been hospitalized, and their willingness and ability to discuss their lived experiences of COVID-19.

Ten participants were recruited for participation via the Internet (v.i., Table 1). Specifically, they were either self-recruited by replying to posts on social media (n=7) or intentionally selected by our team (n=3). All of them have survived COVID-19 and possessed working experience during Black July. Three of our participants were mental health specialists, while seven were physical health specialists. They were aged between 25 and 70 years old and all lived in Bishkek. Their identities were anonymized.

Both participants who were self-recruited and intentionally selected were first given a short introduction about our study and asked about their willingness and ability to participate. They were made aware that they would not be compensated for their participation. Following their agreement, interviews were conducted, both online (n=1) and offline (n=9) depending on the circumstance. An initial batch of six interviews were taken in December 2020, then a second batch of four in June 2021.

Table 1

Participant demographic information

 

Name

Sex

Age

Occupation

Ms. A

Female

26

Counseling-psychologist

Ms. B

Female

26

Family Doctor

Ms. C

Female

67

Psychiatrist

Mr. D

Male

46

General practitioner

Ms. E

Female

35

General practitioner

Mr. F

Male

28

Resuscitator

Ms. G

Female

46

Psychologist

Ms. H

Female

39

Medical cosmetologist

Mr. I

Male

28

General Surgeon

Ms. J

Female

21

Nurse

 

An informed consent form was used. This form contained the following information: a) our study’s procedure; b) the benefits and risks of participation; c) an explanation of how to acquire the results of the research; d) the availability of counseling services following the research; e) the nature of the participation as voluntary; and f) the contact information of the researcher conducting the interview.

For the interview themselves, we followed a semi-structured interview protocol. All research protocols were approved by an Institutional Review Board.

Procedure

Data collection began following approval from the Institutional Review Board of the American University of Central Asia. Immediately thereafter, participant recruitment began by posting calls on Facebook and Instagram, and via Telegram channels. After the participants were recruited, face-to-face interviews were scheduled, each for approximately 90 minutes; these occurred both online (n=1) and offline (n=9) depending on each participant’s circumstances and the epidemiological rules prevailing at the time of the interview.

At the outset of each interview, our study’s research goals, confidentiality, the potential risks of the research, and the participants’ right to withdraw at any time were explained. On their signature of consent, the interviews were conducted following the interview protocol. All interviews were audiotaped and kept strictly confidential. The participants’ names were replaced with pseudonyms, meaning that they were anonymized in subsequent write-ups and materials submitted for publication of the report.

Following the close of each interview, verbatim transcriptions were made to facilitate phenomenological analysis. Everything was transcribed, including verbal tics such as “hm”, “ok,” “ah,” “yeah,” “um,” and throat clearing. After transcription, all relevant records were deleted from the researchers’ desktops and other electronic devices.

To analyze the data, interpretative phenomenological analysis (IPA) was used. IPA is based on a thorough interpretation of in-depth interviews and centered on the lived experiences of the interviewee (Alase, 2017; Biggerstaff, 2012). Transcripts were read by researchers fully to understand lived experiences of participants. Afterward, researchers identified and labeled meaningful units in each transcript (Giorgi, 1997).

Our analysis of interview transcripts has yielded 450 meaning units, viz., statements deemed significant in connection to the participants’ experiences during “Black July”. Each statement has been interpreted into phenomenological codes, with similar codes grouped together into themes.

Findings and discussion

The following themes have been identified and verified through member checking: a) the HCW’s life before and after COVID-19; b) a Fromm-style “insane society”; c) the HCW expressing a new identity; and d) the HCW coping with trauma through connection. The theme of “insane society” also contained the sub-theme of stigmatization within medical and social circles. Narrative descriptions of themes culminated in the synthesized essence of the COVID-19 survivors’ experiences. We will now discuss each of these themes.

Before and after COVID-19

Our participants tended to divide their life “before” and “after” the pandemic. For example, Mr. D. remarked:

Well, let's imagine, we were all participants in a very serious [car] accident, and we were forced to… lie for several hours in a wrecked car among many patients and even corpses. Currently, we have come back to life, and it [the car accident] has become a part of our lives...

Intriguingly, the distinction of a before and after carried over into infections and carried an even more pointed temporal meaning, as those of our participants who were infected during Black July actively referred to themselves as “infected in July” in contradistinction to those “infected in other months”.

All the participants evinced the feeling that COVID-19 in general was a terrifying, physically overwhelming, and emotionally devastating experience. Indeed, intense negative emotions were prevalent in all interviews, such that all participants exhibited resistance at the prospect of retelling their past. They consistently used terms such as “catastrophe”, “all-consuming fear of death”, “ambulance sirens”, ''deaths”. For example, Ms. A. explained:

It was such an existential fear that the world wouldn’t remain the same, it would change. Activities like walking along the streets, driving in the car, were banned. The restrictions exacerbated my [physical] state, and also stimulated such thoughts: What if I did not see my relatives [ever again]? What if I did not walk as before? These moments affected me heavily, you know.

The critical moment for many of our participants came from their own physical health disturbances, many of which persisted from six to 18 months. Bodily symptoms varied (e.g., mild vs. severe), as did etiology (e.g., the novel coronavirus itself vs. community-acquired pneumonia) and rate of infection (e.g., one-time infection vs. recurrent infections). For example, Mr. I. described his condition as light: 

Well I had a mild COVID. I saw how people suffered from severe cases. I was also afraid at that moment, to be honest. Because even young guys, girls were sick, and their recovery was very- troublesome. That is why I was afraid of having such severe symptoms as others...

Ms. E., by contrast, described her condition as more severe:

My legs and muscles hurt every day, I have tremors. I would like to work without any problems... I can't get well because I still need to do a lot of [blood] tests. Recently, … a neurologist said I had neurological changes; all reflexes have been inhibited… I haven’t recovered yet, so I can't come to this [perfect]day,” i.e., a return to normalcy. 

Consistently, though, it was not even the intensity of infection as being infected itself that struck our participants as truly significant. This can be seen with respect to how infection in-itself rather than its severity seemed to impact their relationships, both in society (v.i., §4.2.1) and with intimates (v.i., §4.3). 

Due to the physical disturbances, it became difficult to invest the same amount of time and energy into their work. Intellectual capacities were also weakened. A normal working day thus became perceived as long and exhausting. In Mr. D. 's words:

Mm, I wish we could have a part-time job, only until 12 pm for covidniks [COVID patients]. Don’t expect from people who have suffered [from covid] to work full-time. Especially, don’t expect [job performance] from people who have survived severe COVID-19 cases. After 12 pm, they’d better have lunch, walk, and attend a support group, how they are called, hm… ‘Hello, I survived covid’ - and all people respond: ‘Oh, hello, how are you doing?’

In addition to physical disturbances, our participants struggled with negative moods and thoughts for approximately one year after infection. Ms. B. described her psychological state in the following manner:

As if something is wrong with me and I perceive the world differently. I don’t know, but I have such feelings. (Pause). Of course, the coronavirus has changed a lot in our lives, my life has completely changed. I guess I have some mental malfunction; probably it’s better to say I developed a mental disorder.

We should note that the negative psychological changes also had a ripple effect beyond our participants. For example, Ms. E. describes how her infection impacted her family dynamics:

[Relatives] are tired that I have been ill for a long time... Even if I tell my husband that I am sick, he doesn’t react. My mother-in-law looks at me with disapproval... (pause), she forces me to leave the house. For example, she constantly says to him: She is very bad and sick. She is 40 years old, she will not give birth anymore. Well, I'm only 35.

At the time of their interviews, some of our participants were considering undertaking psychotherapy. In fact, three had already visited mental health counselors. Ms. H. explained: 

I approached a psychologist because of mood changes. I had been going through this stress for six months. I had believed that it would pass, but it didn’t. I have been in therapy for two-three months and observed how my mental health improved. I am no longer scared, (pause), well, apathy ceased ... Gradually, I have been recovering, I am back to normal life which is no longer the same as before. Anyway, I am still cautious about PPE and pay attention to someone’s sneezes and coughs.

Of those who had sought counseling, one of them, Ms. E., had a severe COVID-19 infection that negatively impacted her physical functioning, which in turn caused depression and suicidal thoughts. Also note that Ms. C. and Mr. I. worked in red zones and felt overloaded by patients. Although they had not seen any fatalities, the fact there were fatalities at all caused them severe distress.

In sum, the before-after dynamic evinced by our participants revolved around how the pandemic had significantly impaired their work, social, and family life. All of them made a point to describe COVID-19 in medical terms as a disease that activated stress-response. Mr. D. expressed concern about the long-term impacts not only to himself as an HCW, but to Kyrgyzstan as a society, particularly with respect to its skilled labor pool, and called for psychotherapeutic intervention:

It is a real problem because we can simply lose a third of the society in the next three-five years. This third is the working part of the society, most people aged 40-50, who have been severely infected... They are experts, they can share knowledge, they have to. I guess they will endure fears that make them outcasts... A whole generation of human capital will simply vanish... Middle-aged people… yes, they are in urgent need of therapeutic interventions.

Societal “insanity” in the face of the pandemic

Our participants consistently perceived the novel coronavirus as a social issue that revealed deficiencies, not only materially in the Kyrgyz economy and healthcare sector, but also psychologically in terms of how Kyrgyz society as a whole responded to those who were infected. We will begin our discussion here with the material deficiencies, which ranged from insufficient preventive measures and healthcare management, to service inaccessibility and, most crucially, financial insufficiency. For example, the expense of services compelled Mr. F. to forgo certain diagnostic services: “When the condition worsened, I decided to skip MRI, CT due to unnecessary radiation and a high price for the services... I didn’t want to spend money just to diagnose troubled breathing. The situation became so dire that Ms. J. found herself thinking in terms of triage, but due to economic rather than medical factors: 

It was impossible to get a state ambulance visit. Only private medical care was available, but their services were unaffordable. Thus, I concluded that patients who could pay for their services survived, and those who [couldn’t pay], well. I had such patients, and tried to help an old lady, aged 90. She lived alone, without care, she also died. [I lost] in total two patients.

Participants also highlighted obstacles to care thrown up by the governmental response, and how this intensified uncertainty. Ms. A. elaborated: 

Well, initially, I hadn’t yet encountered restrictions to stay at home after 9 pm. When we were permitted to leave for personal needs… I was able to tolerate them. By that time, it had been considered a norm, and a wise decision, again, for the safety of citizens. [But] then curfew was announced, and it caused discomfort, chaos, as it was unclear what happened next. Regarding the restrictions, I didn’t get the point of the transport ban between cities. It was very difficult to accept this norm.

When one of our participants, Mr. D., was themselves infected, they needed to fend for themselves in the face of an overwhelmed healthcare system, essentially serving as their own doctor: 

Since all the hospitals had been booked, it was impossible to be hospitalized… It was tough to stay in day-night stations, so I negotiated with good friends to secure a bed in a private clinic... All doctors were working in intensive care units, so none of them were able to help me. I was a moderate patient, not an emergency case. I started to take antibiotics, well, in general, to employ treatment: [examining my own] medical history, [conducting my own] health examination and [blood] tests... I started to solve this issue as a health specialist.

Similarly, Mr. I. needed to depend on his apartment roommates for help when he fell ill, “I went to the hospital to have a drip put, and all the rest I managed at home. Parents were not in Bishkek. Well, I bought everything myself… I share an apartment with roommates; I asked them to buy groceries, and they did.”

Self-medication was prevalent among the general population, as well. Ms. A. highlighted how public panic led to compulsive purchases of medication: “I remember that we didn’t have enough drugs [because] panic attacks triggered everyone to take drugs off the shelf, when in fact, people did not need them. So, I decided to avoid medication...” Ms. C. explained that the panic began when, “[They] prescribed drugs, whatever they wanted. People started to take those drugs and even engaged in self-medication: drips, antibiotics, then hormones, and all other stuff.” Ms. C. further suggested there was a lack of understanding between HCWs and the general population, the former “hav[ing] a more cold-hearted approach,” the latter “discriminat[ing] against proper medication.”

Stigmatization

This divide in approaches between HCWs and the general population points to the sub-theme of stigmatization, which was also quite salient among our participants’ responses. They repeatedly remarked that non-HCWs focused on their personal safety and easily became frightened whenever they heard about COVID-19 infections. They also reported use of sarcasm and disdain directed toward survivors from those who had not yet been infected yet (or more accurately, given the prevalence of non-symptomatic infections, those who believed themselves to have not been infected). Ms. C. explained: 

People who had already been ill were stigmatized as dangerous. They were considered to be contactable only at a distance. Some were determined to engage in such [stigmatization], while other people, well, made fun, treating infected people with irony... Some people weren’t able to tolerate their fears; consequently, they started to request social distance in private communications.

According to our participants, their relatives, colleagues and friends believed that COVID-19 differed substantially from seasonal cold or any other disease with respect to its potential danger. One participant, Ms. C., described themselves as being treated by their intimates as though they had been disabled; another, Ms. J., remarked that they were actively referred to as “covidnik” or “crowned” (a reference to the crown-like structure of the novel coronavirus). Ms. E. illustrated this: 

My husband hadn’t even come within 10 meters of me for two-three months… They delivered food from an open window leaf as I lived in a separate room. It was good that we were all isolated; consequently, they either got infected in a mild form or were not infected at all. Nonetheless, they started to treat me as if I had plague or leprosy. Had they been doctors, they would understand that [COVID-19] was a regular viral infection, and even after infection, you would still have some consequences.

The general population exhibited two negative tendencies. On the one hand, HCWs could be the focus of blame for supposedly transmitting infections; they were also frequently accused of giving ineffective treatments or being professionally incompetent. Ms. J. described her experience in this respect: “And (pause), I realized that some people, not all, didn’t develop the capacity to accept help. I came during lunchtime, in non-working hours, and delivered free medical care. I was very upset; they belittled me… I just wanted to help and was paid off by arrogance. I wanted to cry.” On the other hand, HCWs could also be the focus of conspiracy theories, as in the case of Ms. G.: 

I shared a very open and detailed post [about COVID-19 infection] on social media. Many haters bombarded me via direct messages. Mainly, people supported, even consoled. Yet, many people sent me messages like, ‘How much did the Ministry of Health pay you for?’ and ‘Nobody is sick.’ They wrote it to the person, me... who was severely infected. They wrote, ‘Come on, it might have been a lie; we couldn’t see that you were sick.’

Although HCWs noticed the attitudinal changes in their social environment, it was difficult for them to accept those changes. The research team noticed that their difficulties in this respect had persisted to the present, when they were recounting their experiences during the interviews. They also expressed being more guarded in Kyrgyz society than they had been prior to infection as a consequence of their mistreatment. 

Finally, our participants also complained about the behavior of state hospital administration. In the words of Ms.H., hospital administrators consistently took “the patient's side, not their employees”, which amplified their sense of being on their own. Our participants also alleged that hospital administrators attempted to manipulate statistics by strictly considering positive PCR results as evidence of infection, thereby excluding community-acquired pneumonia and other health complications potentially linked to the novel coronavirus. Nevertheless, HWCs continued to work, albeit with increased distrust toward their supervisors, to whom they also allot a portion of blame for high mortality rates.

New identity

Even before Black July, Kyrgyz HCWs risked burnout from a workload consisting of long hours, night shifts and employment at multiple workplaces. During the height of the pandemic, HCWs came to feel devalued by the general population, believing this to be due to how patients consistently failed to comply with quarantine measures. As Mr. I. explained: 

[Patients] are arrogant, demanding, and eventually, the doctors are to blame. Well, it happens all the time. I work in intensive care surgery. They say, ‘You have to treat us; you are the doctors.’ For sure, we are doctors, but doctors have specializations. We refer them to other doctors, and they complain. [This] often happens, almost every day.

Similarly, Ms. B remarked: 

After exiting the red zone, I had already started to work fully in the duty stations, and suddenly a wave of disappointment swept me. My colleagues and plenty of health professionals worked hard, some of them died. Despite these facts, [regular maintenance of] social distance hasn’t been accomplished yet. People are reluctant to wear PPE, sanitize their hands; none of them do it. I feel that we [HCWs] have come a long way for nothing. People are unlikely to comprehend, well, (pause) the essence of the coronavirus, the lockdown, and all this stuff.

Our participants confessed to being unprepared for the pandemic in every way, ranging from their own training and specializations to the lack of proper management, such as having appropriately detailed clinical protocols. In the words of Mr. I: 

My friends are proctologists and urologists who have never been familiar with respiratory diseases. And they [told me]: ‘Believe it or not, we had to learn how to treat [COVID-19]. The clinical protocol was not detailed, [but] we treated accordingly, and people died. Then we started to treat it incidentally, and we failed.’… We have been wondering and searching for the right treatment modality.

The research team discerned the “wounded healer” at work in our participants’ accounts. As part of their personal narratives, they consistently included the stories of patients. They also invoked many of the beliefs traditionally encoded into HCW identity, using terms such as “almighty”, “know-it-all”, and “powerful”. These thought patterns initially led many of them to resist seeking psychological assistance and to instead focus solely on treating the physiological dimension of their own infections. Some even showed signs of possible denial, even at the time of the interview, as in the case of Ms. C.: “I didn't have pneumonia; only my stomach and muscles were infected. Therefore, I didn’t consult with anyone, I made a treatment plan. I didn’t take drips or any medications, only a ton of vitamins, multivitamins. None of my relatives got infected during that time.”

Of our participants who self-medicated at home, they reported experiencing isolation and lack of support, even from intimates, in ways that eventually impacted their identities. According to our participants, there persisted a perception of “doctors as doctors,” i.e., of those who gave care but needed to receive none in return. Ms. B. demonstrated how this lack of belief that HCWS could actually become infected manifested itself both in bureaucracy and at home: “I didn't tell I was infected, because [the management] would require proof of the infection (negative PCR) despite symptoms. [Even] my acquaintances, my friends, colleagues, well ... they would also request evidence besides PCR, for example, X-ray, CT scan, or IgG blood tests.” This reveals the social nature of personal identity: our participants were not only “healers” because of personal conviction, but also because of societal expectations.

We should note that some of our participants came to understand that they needed more than purely physiological self-medication. However, they expected that the Ministry of Health would organize free-of-charge rehabilitation and counseling groups for HCWs. However, these hopes went unmet. Worse yet, HCWs were and, at the time of this writing, largely remain uncompensated for their risk (Dzhamankulova, 2021), an issue that intersected with their chronically low salaries and the problems of service access. Ms. B. explained: 

I wish (laughs) the Ministry of Health would implement some projects aimed at mental health and improvement of health workers’ status… Death is often an unexpected and frustrating event for anyone, even health professionals… I noticed that the cost per [psychotherapy] session was 2000 soms (=25 USD). Taking into account the salary of a medical worker, I think it is oh-oh-very expensive.

Slowly, new identities began to form, our participants reported. These new identities were characterized by re-sorted life priorities and altered self-perceptions and relations to the notion of disease. All our participants evinced a more person-centered approach to their patients, such that the person, rather than the illness, was the main subject in the communication. Ms. E. remarked: “(Pause). I learned to understand diseased people. Before, it was principal-agent relations; they needed medical care, and we provided it. I relate to them as my patients, but there is more compassion now. I am inclined to get them out of trouble.” Ms. E. also noted the persistence of her sense of duty as an HCW: “At the moment, I have been struggling with ill-health, yet still, I’m trying to help others…”

Another significant shift occurred in taking more time for self-care, as when Ms. H. explained: “I meditate regularly. I do meditation, sports, go to work, and meet with friends. It helps me to restore my social life, it is the way to reconnect with people.” As a group, they expressed pride, worth and significance in the way their profession tried to rise to meet the challenge of the pandemic. As individuals, they consistently expressed greater appreciation for intimates, a renewed capacity to search for help, and a desire to advocate for positive changes in Kyrgyz society. In the words of Ms. C.: 

Well, I concluded that one should care for health... For example, I developed pneumonia after… I caught a cold and didn't care much about the temperature regime. I advise everyone (pause) to eliminate stress as it negatively impacts the immune system, well, if possible...

Coping through connection

According to our participants, availability and variety of support significantly improved their psychological and physical functioning during the pandemic. As our sample size included both mental health and physical health specialists, we identified two distinct approaches. Mental health specialists appear to have been more competent in searching for emotional support, whereas physical health specialists, already more competent in treating their infections, appear to have focused on success stories and practical progress.

Mental health specialists found it relatively easy to establish networks of support with their supervisors, other therapists, family members and colleagues. For example, Ms. A, who was experiencing generalized panic, informed her supervisors of her condition and then actively sought individual psychotherapy. Mental health specialists also had greater capacity in psychological self-care, limiting their self-criticism and consciously practising self-compassion. They also avoided engaging in avoidant behaviors, such as excessive working or social isolation, and even set aside one to two months for rehabilitation. For example, Ms. G. initially resisted psychological treatment, explaining that sessions were “hard, frankly speaking… Taking into account memory and attention problems which were important to the working process, you began to feel sorry for yourself.” But as her feelings of self-pity increased, her psychological training kicked in: “I realized that I needed help. Well, damn, well, I had to care about myself, and only then about others.”

Meanwhile, physical health specialists deprioritized their mental well-being. Mr. F. explained: 

In regards to [my] mood, I was [more] concerned about the situation of my society. At that time, [I felt] we shouldn’t grieve or feel sad; we ought to work as there was a shortage of doctors... I worked as usual, although [I] got exhausted sooner. Sometimes I had to work despite feelings of not wanting to and while enduring fatigue.

Instead, they tended to throw themselves into learning more about the novel coronavirus, sharpening their diagnostic skills, devising treatment plans and sharing information with colleagues, who were focal points of contact. For example, they shared the most recent clinical manuals, success stories and new COVID-19 medications.

Physical health specialists were also quick to use social media to disseminate information, as well as to work with patients. Mr. F. explained: 

Social networks were beneficial to overcome this period. I couldn’t imagine any other effective medium of communication… Volunteers, many doctors used social media… I consulted patients on WhatsApp, shared posts about pseudo-medications that became popular. I made live broadcasts on the mayor's web page. When I was sick, people contacted me. Social media was useful, that's for sure.

Ms. H. used social media to collaborate with her own colleagues: “And, my girls, they are health professionals and work in Moscow [and] together we developed a treatment plan.”

Both types of HCWs were reluctant to seek support as they did not want to risk their intimates’ health. As Ms. B. explained: 

[My] parents, of course, were worried… [They] asked many questions, such as whether I was passing blood tests, CTs, and other screening tools. But I replied that everything was fine, and I worked as a doctor, even in the red zone; therefore, I could make a self-assessment. And (pause), well, I guess that stopped them.

In general, our participants tended to prioritize the well-being of their intimates over their need for emotional support. Nevertheless, some of our participants expressed appreciation for the love that was shown to them, as in the case of Ms. J.: 

I noticed that my relatives and friends worried, supported, and cared a lot. My girlfriends looked after me, cooked at this time. Mom wanted to move into my apartment. (Laughs)... I realized how much they cared about me, and I started to appreciate them more. I honor my family and friends; yes, our friendship is getting stronger.

Conclusion
As the foregoing findings suggest, Kyrgyz HCWs perceive Black July as a turning point in their lives. However, the pandemic was not only a complex individual phenomenon, but a complex social one, as well. Our participants repeatedly emphasized the interconnection between individual health, whether physical or mental, and the collective, whether governmental systems, general society or family. Our participants described a collective that was largely unable to meet the needs of its individual members, whether in the form of government policies and administrative apparatuses becoming an obstacle to HCWs’ ability to perform their duties, or how everyday people and even intimates stigmatized, panicked and/or failed to grasp the situation for HCWs, as well as for patients. All told, Kyrgyz society, already “insane” in Frommian terms before COVID-19, became all the more “insane” during the pandemic, both exhibiting and re-entrenching (C)PTSD.

This intertwining of the individual and collective aspects of the pandemic expressed itself in a “wounded healer” dynamic within the very identities of our participants. On the one hand, an image of the healer who was omniscient and vigorous persisted in their narratives, indicating a resilience of this ideal-type even in the face of a disempowering situation. On the other hand, there was greater self-awareness in at least two arenas. One was with respect to our participants’ limitations as HCWS, as evidenced by the turn of some to psychotherapy and the turn of others toward collaboration, in both cases signaling a shift away from the individual self-reliance fostered by the traditional image of the almighty healer. Another was with respect to their own values and perspectives, as evidenced by greater appreciation for their intimates, taking more time for self-care, accepting the unrealistic expectations of patients as unrealistic and hence as no measure of their own worth as a professional, confronting paranoid and false claims made by patients and on social media, revising their treatment frameworks to include more direct compassion, and so on. The breadth and depth of these changes varied according to the individual participant, but all exhibited some degree of change, indicating a collective change across our participants as HCWs, and by extensions, indicating that similar changes may have occurred throughout their professional class. Moreover, all of our participants identified conditions arising in the collective as the cause of their changes, whether directly or indirectly.

To put the foregoing together, the central theme of our participants’ narratives was the formation of a new personal (individual) and professional (collective) identity that consisted of at least three components: a) an acceptance of a new reality; b) the need for care and appreciation of the self, intimates and patients, as well as the need for support, especially from fellow colleagues but also, when possible, from intimates; and ascribing symbolic meaning to a traumatic experience. Indeed, with respect to the latter, there were pronounced tendencies to describe COVID-19 as a triage-style situation, with one participant even using the same analogy of a motor vehicular accident resulting in mortalities, and to identify symptoms of PTSD not as limiting conditions but actually as part of an accelerated process of adjusting to a new reality (Ahmed et al., 2020). In other words, there was a tendency to identify PTG over PTD with respect to themselves as people and professionals.

Simultaneously, while our participants highlighted growth with respect to themselves as HCWs as a professional class, they highlighted depreciation with respect to Kyrgyz society – so to speak, PTG with themselves as a meso-collective, PTD with respect to Kyrgyzstan as a macro-collective. They consistently anticipated that negative side effects would beset the formerly infected for six months to two years, and consistently estimated significant losses to the Kyrgyz labor force for the next approximate decade (until circa 2030) if, in their estimation, Kyrgyz society continued on its present course.

Limitations and suggestions for further research
Our study had at least two limitations. First, we were unsuccessful in controlling for possible biases from our research team, being as we are citizens of Kyrgyzstan, as well as the fact that three of our four team-members were themselves infected. Second, our study lacks a quantitative aspect, which would be crucial for confirming whether the identity changes we have identified here truly do extend to Kyrgyz HCWs as a professional class, as well as indicate possible changes in broader Kyrgyz identity. All that being said, we assess that further research is needed into how trauma operates at the collective level, both in terms of PTG and PTD, whether with respect to HCWs and/or with respect to the societies in which they conduct their work.

×

About the authors

Elena Sergeevna Molchanova

American University of Central Asia, Bishkek, Kyrgyz Republic

Email: emolchanova2009@gmail.com
ORCID iD: 0000-0002-4268-9008

Full Professor, American University in Central Asia

Kyrgyzstan

Veronika Sergeevna Kharsun

American University of Central Asia, Bishkek, Kyrgyz Republic

Author for correspondence.
Email: veronika.kharsun@yandex.com

Zhibek Sovetbekovna Kenzhebaeva

American University of Central Asia, Bishkek, Kyrgyz Republic

Email: kenzhebaeva_z@auca.kg

Aigul Sagynbaevna Alikanova

American University of Central Asia, Bishkek, Kyrgyz Republic

Email: aigulia0105@gmail.com

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