Finding a livable balance between despair and hope can be a daily, even hourly struggle for health-care workers in West African's Ebola crisis. In a world where death is ever present, health workers may see more lives end in a week than most humans would see in a lifetime.
Caring for patients requires health-care workers to make a connection with the people who fill the rudimentary compounds that are Ebola treatment centres. But making connections in the Ebola zone is an emotionally perilous business, some who have worked on the outbreak admit. Seven out of 10 people infected in this outbreak die from the disease, the World Health Organization estimates.
Watching patient after patient after patient succumbs taxes one's coping skills, acknowledges Ane Bjoru Fjeldsaeter, 31, a psychologist from Trondheim, Norway who recently returned from a month in West Africa.
"A good friend of mine, one of the nurses ... he said that the hardest thing about this mission isn't seeing all the suffering. It's how hard you have to work with yourself to stay human," says Fjeldsaeter, who was in Liberia -- the worst hit country -- with the medical response group Medecins Sans Frontieres.
"Because the easiest thing, actually, is detaching. It's caring a little less every day, because you're just so overwhelmed."
Fjeldsaeter is one of a number of psychologists and psychiatrists that MSF -- also known as Doctors Without Borders -- has sent out with its Ebola response teams.
They head teams of local staff who work with infected patients and their anxious or grieving families. They also tend to the mental health needs of the staff of the treatment units and the burial teams responsible for the grinding but critical job of safely disposing of the corpses of those who lose the battle with Ebola.
Nyassa Navidzadeh, a Montreal-based psychiatrist, says the work involves helping people to understand that the stress they are feeling and the way it may manifest itself -- through nightmares or flashbacks, for instance -- is a normal reaction to an utterly surreal reality.
"You're feeling these things because these are not normal situations. These are not normal things that you're seeing every day at work," she tells them.
Navidzadeh spent a month in late summer working at an MSF treatment centre at in Liberia, at Foya, near the border with Sierra Leone. She is planning to go back to the Ebola zone in December.
She says she understands the tension Fjeldsaeter describes: How do you continue to care when caring hurts so much? But if you stop caring, what then?
"It is traumatizing. Because you go there and you see patients and you know from the beginning, this patient has a high probability of dying." Navidzadeh says.
"You have to get somewhat attached to the patients so you can be empathic and be there for them. But also be aware of the reality and realize that at least you are there for the person, for that patient. If that person passes away or dies, well at least you were there for them. And they did not die alone. So I think that can comfort us."
Fjeldsaeter described the Ebola health responder's struggle in a heart-rending first-person article published in late September in Britain's Guardian newspaper.
In it she described developing what she knew to be an unwise attachment to a boy named Patrick, whose mother had died of Ebola and who was himself coming down with the disease. Through it all, Patrick was just a little boy who wanted a bicycle.
Fjeldsaeter feared Patrick wouldn't live long enough to learn to ride, and cursed herself for caring so much for a child who seemed fated to die. She worried her ability to do her job would be eroded by his seemingly inevitable death.
"You become scared of connecting. You become scared of getting attached," she said in a recent interview with The Canadian Press.
Against the odds, Patrick pulled through. Fjeldsaeter, who maintains contact with her touchstone case, posted a photo on her Twitter account this week of Patrick on a bicycle bought for him by a couple in Geneva, Switzerland who had read her Guardian article. "He's gained weight and looks healthier," she tweeted.
But many stories don't end up this happily. And in addition to coping with fear and fatigue, health-care workers have to deal with the accumulation of losses. Navidzadeh says some people bring family member after family member to the treatment centre, often when they are too sick to be saved.
"And you're there supporting this one person who has lost about six or seven people. So it's difficult," she admits.
Reine Lebel says the teams working at the treatment units become very close and offer each other a lot of support through the tough times.
"We're very close to sadness and joy, life and death," says Lebel, psychologist from Pontiac, Que., who is on her second MSF Ebola mission in this outbreak. Both times she has been stationed at Gueckadou, in eastern Guinea. Lebel also worked on a 2012 Ebola outbreak in the Democratic Republic of Congo.
Lebel says for her, paradoxically, going home can be tougher than the relentless work of an Ebola treatment centre. It is hard to explain to family and friends what life in the field is like.
"People don't always understand. And it's a bit overwhelming for them," Lebel says.
Fjeldsaeter says there is talk in MSF circles about whether there should be a cap on how many missions a volunteer can do. Some people are working their third or fourth tour and are deeply fatigued, she says. An Ebola treatment unit is a dangerous place to be for someone who is exhausted.
There is also concern about the national workers, who make up the bulk of the staff at Ebola treatment centres and on burial teams. Navidzadeh says MSF has been insisting that national staff actually take the day off when they get a day off. Some work another job on those days, she notes.
Where international volunteers go to the Ebola zone for four weeks or a month at a time and are then flown home, the national staff have been living this gruelling reality for months on end. And a day off can actually be dangerous for them -- it's more time in a community where Ebola is spreading.
Some face pressure from family members to abandon treatment unit jobs, because of the stigma attached to the disease and the danger of the work.
"They are really in a high stress situation. I think the strategy is probably going to change, and is changing in terms of support that they need. And rethinking time off," Navidzadeh says.
Fjeldsaeter says one of the hardest things for the medical responders is the feeling of inadequacy. The outbreak continues to spread. Even with heroic efforts from those on the ground the virus is still winning.
"One of the nurses said when I came that what we're doing here feels like trying to stop a tidal wave with an umbrella. I think it's a really good picture," she says.
"We have felt inadequate. We have felt like what we have is inadequate. And I think that's probably right now the most stressful thing for our staff."
