The covid-19 pandemic is taking a harsh toll on healthcare workers. In the Mirror newspaper on 20 January 2021: “52,000 NHS staff are off sick with covid.” [1] Over 850 UK healthcare workers are thought to have died of covid between March and December 2020; at least 3000 have died in the US. [2-3] Worldwide, the death toll and the impact on the physical and mental health of healthcare workers are staggering. The long term costs are yet to be counted. But, a number of countries, mainly in Asia, have been able to manage covid outbreaks without sustaining any healthcare worker infections at all. [4-6] The means to do so are now widely recognised. They are costly and inconvenient to implement and require an acceptance of the predominance of aerosol transmission of this virus and its application in a rigorous, safety-conscious infection control system. [7] But it can be done. 

Much has been written about why and how healthcare workers are not being protected. Words like groupthink, hubris, timidity, inertia, lack of strategic vision, and psychopathy (my preferred descriptor) all feature in the debate on the failings in healthcare management in 2020 and more generally. [8-12] However, I am going to turn to a parallel question that has baffled me and so many others: how is it possible that healthcare workers around the world continue to allow themselves to be “shuffled,” with so little active resistance, “up the line to death”, as the title of Brian Gardner’s anthology of first world war poetry so aptly put it? [13]

Popular enthusiasm for healthcare workers boomed in Britain in the early months of the pandemic. From the Thursday evening “Clap for Carers” (shame on you if you didn’t join in), to the Telethon-adjacent mania of “Captain Tom’s 100th walk for the NHS”, which raised over £30 million for NHS charities and culminated in a promotion and a knighthood for him in July 2020, there was an outpouring of mass emotion not seen in Britain since the late summer of 1914. 

Over time that effusive outpouring has waned somewhat, as it did a hundred years ago, but there continues a near religious expression of “love for the NHS” and for the “healthcare heroes”, so hyperbolic that it is arguably blatant manipulation. The implication is that if we keep telling you you’re wonderful, then you’ll have to keep putting yourself in harm’s way to look after us.

In July 2020, I called for an immediate end in Australia to the rhetoric of “healthcare workers as heroes,” identifying it as a damaging distraction from the legal and moral imperative to accord healthcare workers the same standards of occupational safety enjoyed by workers in other industries, such as construction or mining. [14] That rhetoric has now largely abated in Australia, helped here by the extreme paucity of covid cases since October, though we are no nearer achieving a safe workplace for healthcare workers. 

In the UK, the sanguine acceptance of healthcare worker harm by the public, the NHS, the government, and also, it must be said, healthcare workers themselves, has been an awesome sight to behold. But effusive public rhetoric, the corollary to which is a fear of being found wanting, is surely only part of the story.

Let us speak plainly now, not just about the NHS, but about healthcare systems all over the world. They are top down, “command and control” bureaucracies, not dissimilar to military organisations. Though they brim over these days with fine words and caring mission statements, we all know they are rigid, unkind bureaucracies, the main purpose of whose management subunits is less to deliver healthcare, than to take and hold organisational territory. In such authoritarian, often bullying regimes, the pressure to conform need only be explicit occasionally. Fear of censure, and fear of letting others down, will do the rest. 

The “new abnormal” is to believe that it is entirely reasonable for healthcare workers to go to work with the expectation that they will eventually contract a life-threatening illness. Almost everyone, from the public to the healthcare workers themselves, believes this. And why not? The self-serving organism of the NHS, with the connivance of the government, has engineered this torrent of individual sacrifice, ostensibly for the collective good. 

As long as the implication is generally accepted that healthcare workers have an unequivocal moral obligation to treat patients, irrespective of any risk to themselves, then governments are conveniently released from the obligation to provide a safe workplace. In law, however, employees are not compelled to work in an unsafe workplace. Neither are they ethically obliged to do so. [15-17] That they widely believe they are, is another success for the year-long gaslighting campaign against healthcare workers.

Shall we persist in cajoling and manipulating healthcare workers “up the line to death”, or shall we pay them the respect they deserve and do whatever it takes to accord them a safe, dignified, caring workplace? To begin, governments must immediately proclaim a target of zero occupationally acquired covid infections in health and social care workers. To meet this entirely achievable goal requires us to shed the nihilism that has bedevilled the matter so far. It is not “inevitable” that a healthcare worker should routinely catch covid at work, as it is not “inevitable” that a construction worker should fall from a scaffold, or that a miner should be crushed by a rockfall. It is not “prohibitively expensive” or “completely impossible” to carry out the required structural improvements to ventilation systems and buildings and to provide personal protective equipment against airborne transmission within a rigorously policed infection control system. It is the will alone which presently fails to deliver these prerequisites of a safe workplace. 

The moral injury of avoidable harm to health and social care workers cuts deep and the scars will persist, as the scars of the first world war lingered into the twenty-first century. Reflect on that when you are next tempted to prod “our healthcare heroes” into harm’s way with your self-serving cheers.

David Berger, GP emergency doctor, remote Australia. Twitter: @YouAreLobbyLud 

Competing interests: I have been campaigning for healthcare worker safety since March 2020 and a recognition of the importance of airborne transmission of covid. In January 2021 I started a small business to retail portable CO2 monitors online in Australia with 10% of any profits destined to healthcare worker-related causes. 

References:

[1] Glaze, B. 20 Jan 2021. Ministers under fresh pressure over PPE for NHS heroes on coronavirus frontline Daily Mirror.

[2] Shone, E. More than 850 health and social care workers have died of Covid in England and Wales since the pandemic began January 27 2021 The Scotsman

[3] Our key findings about US healthcare worker deaths to date January 20 2021 The Guardian

[4] Liu et al. Use of personal protective equipment against coronavirus disease 2019 by healthcare professionals in Wuhan, China: cross sectional study BMJ 2020;369:m2195 doi: https://doi.org/10.1136/bmj.m2195  (Published 10 June 2020)

[5] Koh et al. The fight against COVID-19: disinfection protocol and turning over of CleanSpace® HALO™ in a Singapore Hospital Updates in Surgery volume 72, pages 311–313(2020) http://dx.doi.org/10.1007/s13304-020-00809-3

[6] Wong, E L-Y et al. What is appropriate PPE? Lessons learned from healthcare worker COVID-19 infection in Hong Kong. BMJ 2020;370:m2641 https://doi.org/10.1136/bmj.m2641  (Published 07 July 2020)

[7] Tang et al. Dismantling myths on the airborne transmission of severe acute respiratory syndrome coronavirus (SARS-CoV-2). Journal of Hospital Infection. In press, available online: 13 January 2021. https://doi.org/10.1016/j.jhin.2020.12.022 

[8] Berger, D. Our infection-control response is broken. We need a new model – and fast August 29 2020 Sydney Morning Herald. 

[9] de Silva, P. Tackling psychopathy: a necessary competency in leadership development? Progress in Neurology and Psychiatry September/October 2014 pp4-6.

[10] Coull, R. Blowing the whistle. BMJ 2004;328:040264 https://doi.org/10.1136/sbmj.040264 

[11] Rao, V. The Gervais Principle, Or The Office According to “The Office” October 7 2009. Ribbonfarm.com 

[12] Boddy, CR. Corporate Psychopaths, Conflict, Employee Affective Well-Being and Counterproductive Work Behaviour Vol. 121, No. 1 (April 2014), pp. 107-121 Journal of Business Ethics.

[13] Gardner, B. 1964. Up The Line To Death: The War Poets 1914–1918. Methuen Publishing, New edition 1986. ISBN 9780413595706

[14] Berger, D. 26 July 2020. Please stop calling healthcare workers ‘heroes’. It’s killing us Sydney Morning Herald.

[15] Schuklenk, U. What healthcare professionals owe us: why their duty to treat during a pandemic is contingent on personal protective equipment (PPE). Journal of Medical Ethics. 2020;46 7 http://dx.doi.org/10.1136/medethics-2020-106278 

[16] Schuklenk, U. Health Care Professionals Are Under No Ethical Obligation to Treat COVID-19 Patients. 2020 April 1st Journal of Medical Ethics Blog 

[17] Mason, G. The moral obligations of our health care workers in a pandemic. April 3 2020 The Globe and Mail.