What breaks us is not the work, but the conditions

Author: Faith C Nasoni

“The ethical frameworks I had been trained in assumed time for reflection, sufficient resources, and the freedom to choose between morally defensible options. The system I entered offered none of these.“

I realised early in my first job that if I wasn’t careful, the work would end me.
Three months after graduating, I was working as a mental health practitioner in a psychiatric hospital in Malawi. One evening, I came home after witnessing something my training would have described as unethical. I won’t describe it here – not because it was extreme, but because it was ordinary. Routine. And therefore invisible. 

That moment clarified something my education had not prepared me for: ethical harm is not only produced through dramatic violations, but through small, repeated compromises made under conditions of constraint. The ethical frameworks I had been trained in assumed time for reflection, sufficient resources, and the freedom to choose between morally defensible options. The system I entered offered none of these. Instead, it demanded rapid decisions in contexts of scarcity, where harm was not avoided but redistributed, and where the question was no longer what is right, but what can be sustained.

What lingered was what ethicists describe as moral residue: the psychological weight left behind after being forced to choose between competing harms. It is not resolved by good intentions or best effort. It accumulates. So each day, my colleagues and I tried to soften the damage. Therapy was reduced to brief interventions between crises. Admissions lasted no more than seven days not because patients were well, but because beds were needed for those waiting. Discharge was determined by capacity, not recovery.

Over time, these decisions ceased to feel exceptional. They became routine, folded into ward rounds, handovers, and discharge summaries. What should have been moments of ethical pause were absorbed into the tempo of the institution. We learned how to document “improvement” not as recovery, but as temporary stability—enough to justify discharge in a system that could not afford to wait for more. The residue was not located in a single decision, but in the repetition of being asked to act as though this was enough—and to do so again the following day.

By the end of my first year, I was on anxiety medication. Not because the work was hard, but because my mind refused to accept what had become normal. It could not reconcile sending patients away with incomplete medication because supplies were rationed. It could not accept repeatedly retrieving people who had attempted suicide from police custody and having to argue, again and again, that mental illness should not be criminalised.

Eventually, I left—but only after staying longer than I should have. In a system this thinly resourced, departure is never neutral; it redistributes scarcity and leaves new absences behind.

For a population of roughly 20 million people, Malawi has fewer than 10 psychiatrists in the public system and only a handful of trained clinical psychologists. Specialist mental health care is concentrated in three facilities nationwide. Outside these centres, care is absorbed into general outpatient departments, delivered by overextended clinicians with minimal supervision and few referral pathways. Yet the system continues to function—not by resolving these constraints, but by redistributing their weight. Strain is transferred downward into the bodies and minds of its workers. Exhaustion becomes professionalism. Emotional numbing is reframed as resilience and distress, if expressed, it is treated as individual failure rather than a predictable response to structural constraint.

Care in Context exists because these experiences are rarely named, let alone recorded. It is a space for mental health practitioners, students, and others working in care to examine how care is shaped by history, resources, policy, and power—and how those forces settle into us over time.

What this space offers is not resolution, but recognition: language for experiences that are often misnamed, permission to stop carrying structural harm as personal failure, and a record of how care is practised under constraint and what that practice costs those who remain inside it.We resist stories that locate ethical harm in individual weakness or celebrate endurance as virtue. We refuse the idea that clinicians must simply become more resilient in order to survive fragile systems.

We believe that how care is organised matters as much as care itself—and that when these experiences go unnamed, they do not disappear; they are erased.If you are a practitioner, student, or care worker who has felt the tension between what you were trained to do and what you were able to offer, this space is for you. You are invited to read slowly, to recognise yourself where you can, and to contribute when you are ready—not as confession, but as record; not as heroism, but as honesty.

I did not leave because I stopped caring.
I am writing because I still do.