Photo by Israel Palacio on Unsplash

Going to War with Health Care Workers

By C. Gist & O. Tempora†

We are a nation that inevitably invokes wartime metaphors when confronted with humanitarian disasters. Wars have been declared on poverty, drugs, cancer, and countless other crises — and without fail, the COVID-19 pandemic. With comparisons drawn to other “attacks on the homeland,” such as Pearl Harbor or 9/11, and references made to “frontline” staff, “mobilizing” health care workers, “deploying” vaccinations, it might be said we live and die by the war metaphor. So rather than resisting this overly simplistic framing in vain, we might instead consider all the less than glorious ways this so-called war on COVID-19 is impacting its “foot soldiers,” our health care workers.

The British politician Philip Snowden once observed, “Truth… is the first casualty of war.” The war on COVID-19 has proven to be no exception, with early pronouncements from prominent politicians that there was essentially nothing to worry about despite every indication to the contrary. Leading infectious disease experts were sidelined, overruled, and even ridiculed. When it became undeniable that COVID-19 was not simply going to “vanish,” treatments such as convalescent plasma or hydroxychloroquine were promoted without evidence beyond anecdote. Limited testing for COVID-19 made it difficult to draw enemy lines and establish verifiable safe zones. As the numbers of cases climbed at exponential rates and strained health care systems in the spring of 2020, supplies of personal protective equipment (PPE) proved inadequate. When health care workers voiced concerns about the personal risks they were being forced to assume, some faced retribution from the health systems that employed them. This is not to suggest that all or even most health systems betrayed their clinical staff. Nevertheless, for many health care workers, there was reason enough to think twice about speaking the same truth that so many others had already forsaken.

The early days of the pandemic call to mind the words of Donald Rumsfeld, former Secretary of Defense, who in 2004 said, “You go to war with the army you have,” when he was asked by servicemembers why troops deployed to Iraq did not have sufficient protection against explosive devices. Never mind that the US government spends more money on its military than the next 10 countries combined, and that the conflict in Iraq was planned well in advance, soldiers were being told that their physical safety was a wartime luxury we could not afford. Similarly, even though the US spends about twice as much on health care compared to other developed countries, and it was known for years that a pandemic was not a matter of “if” but “when,” health care workers were sent into battle without their physical safety ensured. Pre-COVID-19, the use of adhesive tape to hang a sign on the wall was a citable infectious disease risk by governmental agencies. In the time since, nurses have been reduced to repurposing trash bags as protective gear and reusing masks designed for a single use. If truth was the first causality of the war on COVID-19, then the trust health care workers placed in institutions responsible for their welfare was a close second.

As COVID-19 took root across the country, imposing its greatest devastation on marginalized communities, the more affluent quickly achieved a semblance of normalcy. Many could simply go about their days, living virtually, and escape many of the hardships of this war. Just as deployed servicemembers have borne the brunt of recent wars while a largely disengaged citizenry carried on with their everyday lives, a relatively small number of health care workers toiled long hours. They did all they could to mitigate disaster one patient at a time, often falling short through no fault of their own. Many had to quarantine from their families for long stretches, just when they needed their loved ones’ comfort and support the most. Bedside clinicians were forced to ration care and make triage decisions typically reserved for actual battlefield situations. The losses mounted and many health care workers felt they began to die a little inside, going numb to the world around them, observing the “thousand-yard stare” in their colleagues’ eyes. Adding insult to wartime injury, the then president insinuated that physicians were committing fraud by overcounting COVID-19 deaths out of self-interest. Just like the scorn some Vietnam Veterans encountered when returning home from a war many had been conscripted to fight, health care workers were being blamed for others’ misdeeds. But in truth, this country owes a tremendous debt to our health care workers. To repurpose Winston Churchill’s words of gratitude for the Royal Air Force in 1940, “Never was so much owed by so many to so few.” Like those pilots who fended off the Nazis during the Battle of Britain, health care workers held the line against unmitigated disaster.

What will come of these perversions of truth, trust, and a debt owed? As history teaches, many combat veterans struggle long after war ends. Even if we are able to wrangle COVID-19 in the months ahead, as many now believe may be possible, we might expect that a good number of health care workers will pay a heavy toll for years to come. Many will leave the profession. Many will become estranged from loved ones and themselves. Many will turn on one another and turn to food, alcohol, and other substances instead. We will see spikes in depression, anxiety disorders, insomnia, Posttraumatic Stress Disorder (PTSD), and suicide. In the months and years ahead, we will not be able to say we did not see it coming.

What should be done? Certainly, everything we can to learn from our mistakes so we can be better prepared next time, for our infectious disease colleagues assure us there will indeed be a next time. But how do we even begin to set things right with our health care workers today? Following World War II, the US Congress passed the Servicemen’s Readjustment Act of 1944, better known as the G.I. Bill. The specific components of this bill do not apply to the current circumstances, but the mindset does: we should respond in a way that is proportional in magnitude to the debt our nation owes its health care workers. To start, health care workers could benefit from some “R&R,” including paid time off to recuperate and reconnect with themselves and loved ones. Health care workers should also be included in the national conversation about student loan forgiveness. Commissions should be established to adjudicate claims of unfair workplace practices including improper punitive actions and terminations.

Going further, learning from the Veterans Health Administration, health care workers can be cared for in post-deployment clinics, where they can be screened for symptoms of behavioral health and medical conditions for which they are now at an elevated risk of developing. And as loved ones of returning combat veterans can attest, the psychological causalities of war are often transmitted to family members and loved ones, children included. Therefore, these programs should be made available to all impacted. To be clear, we are not advocating for lunchtime webinars on “resilience” or simply encouraging more self-care, the superficial bandages frequently offered to “burned out” health care workers in the pre-pandemic days. More is needed, much more. Furthermore, given the potential concerns about trust and conflicts of interest, it may be more appropriate to establish post-deployment clinics and other programming separate and apart from the health systems that employ health care workers. Though this is not to say that health care systems should not work hard to reestablish trust with their employees. Granted, it will take time and careful study to truly understand just how, and to what degree, the war on COVID-19 will have impacted our health care workforce. It is quite likely that it will take even more time to determine how we can most effectively set things right. We need to learn more. But this much is known: we need a course of action. Franklin D. Roosevelt said in 1937 that “war is contagion.” If we do not end this war with health care workers, our current war on the coronavirus contagion may spread and take out our best, last defense against future contagions.

†The authors used pen names because they were advised that as employees of a health care system, they may face personal retribution by their employer for expressing an opinion that included a reference to health care workers facing retribution by their employers for raising safety concerns. Closeted (C.) Gist is a psychologist based in a health care system who, among other roles and responsibilities, consults with health care workers on the sometimes stressful and even traumatic experience of providing health care. (O.) Tempora is a palliative care physician actively taking care of COVID-19 patients.