There are times where our world can feel so different and certain diseases seem relegated to other times and other places. As Covid-19 spreads widely in the United States, predictions are that it will tax our health system to its limit, and, cause health workers to face unprecedented challenges in their duty to patients. There are many lessons that we can learn from our international colleagues around the world.
The USA has more than three million nurses, over 950,000 physicians, and millions of other frontline health professionals. It appears to be well resourced but almost all of them have never been part of an outbreak or pandemic response.
As a collective of health professionals from several countries, who responded to several outbreak and humanitarian crises we share lessons in order to support our health workforce during the next several months. We suggest concrete steps that can be taken by institutions to ensure that their health workers are equipped not only physically but also mentally to “keep safe and keep serving”.
Moral duty, risk to self and family:
Savior Flomo Mendin, nurse who worked in an MSF Ebola Treatment Unit In Liberia , shares:
“During the Ebola outbreak in Liberia, I went to work everyday without any hope of ever returning uninfected. I was not afraid for myself but always at the back of my mind, I knew that I was never going to forgive myself if I became infected in the frontline and then pass it on to my family. It was utterly distressing for me one day when I saw a young girl just the age of my daughter in the ETU; her eyes were bloodshot red and she was groaning in pain. I kept replaying that scene in my mind and thinking: this is how my daughter would be if I got her infected.”
Health providers have family members, elders, young children. With each potential exposure, health workers must consider potential risk to themselves and loved ones. The percentage of healthcare workers has ranged from 3.5% to 26% of the total infected population.
COVID-19 is a very different disease than Ebola, but we must emphasize more on the moral distress that health workers face. This is exacerbated when colleagues and patients and their families become sick or die. Institutions need to put systems in place to prevent, detect and treat the trauma that is inevitable as a result of this distress. Mental health providers trained in psychological trauma should be made widely available in person or through telemedicine and peer support groups should be nurtured.
Burnout and Quarantine:
Graciela Cadet, a nurse leader in a large tertiary care facility in Haiti comments on the last two years of working through civil unrest mentions that she had to “administer direct clinical care on the wards because line nurses cannot come in due to a loved one who has been injured or killed, or because the roads are blocked by barricades.”
Providers will need to provide care at the top of their license, and other health professionals with more administrative roles may be required to provide direct clinical care. In COVID-19, the health workforce may not have the infection but be isolated for safety should they have symptoms, colleagues will be asked to work outside of their normal skill set and care for a higher quantity of patients. Being forced to work outside one’s usual scope of practice contributes to moral distress that persists over time.
Stigma against health providers:
As health workers are on the front line and closest to those that are sick, communities often fear that they will transmit the illness further. In many cases, this fear translates into stigma of health workers. Doris Kollie, a Liberian nurse shares : “One thing I remembered well was the stigma because I was working in an ETU. Neighbors became afraid of me. ”This stigma removes a support system that many health workers usually experience in the larger community. Institutions need to be standard bearers of truth and not misinformation to quell misplaced fears while also providing appropriate caution to their communities.
Structural Solutions for Stretched Workforce:
Doris also recounts “I was caught between the scissors during the crisis. I had the choice to stop working and save my family from exposure, but during that time, I was the only breadwinner for my family, as my husband was not working.”
Doris continues, remembering a conversation with her daughter: “Mama, I know when you catch Ebola I will catch it too because I will not go away from you, I love you too much. She jumped into my lap. I then started to shed tears.” In this epidemic as well, there will be a differential ability to choose to be part of crisis response based on earning capacity, with some frontline providers having little choice due based on socio-economic status. Paid time off during quarantine could alleviate some of the financial risk and worry differentially experienced across the health workforce.
Provider facing testing must be provided for those who have low risk cold symptoms in order to not unnecessarily quarantine our workforce or separate parents from their children. In the event of transmission to health workers, housing options for those who want to quarantine away from their families to minimize risk would be helpful. As schools close, health workers will require centrally organized childcare.
Communication Around Evolving Circumstances, Especially Personal Protective Equipment:
Anup Agarwal, a physician from India states during a dengue outbreak: “More than 50% of the pediatric and medicine residents suffered from Dengue, mostly from in-hospital transmission of Dengue and poor hygienic conditions in the hospital. A med student died during the outbreak.’ There were shortages of bed nets for patients, which put health care providers at risk for Dengue.”
Transparency regarding shortages of equipment including PPE (personal protective equipment) and tradeoffs that may put health workers at risk need to be discussed early and often. Staff must be kept informed with proactive, regular communication that reflects these dynamic times. Virtual town halls twice a week with leadership is imperative.
Conclusion:
Many providers around the world have much to teach us regarding what promises to be a difficult time for the US population and our health providers. From Liberia, to Haiti, to India, some of the lessons that rise to the service include a) proactive psychological support for the moral distress health providers will face, b) prepare for stigma that may unfold against health providers, c) structural support of paid leave and housing support for those health providers quarantined, d) health provider facing testing to both keep people working and decrease worry of active infection, and finally consistent communication at the institutional level(virtual town hall twice weekly) to name challenges, and transparently keep front line providers supported.
About the authors
Sriram Shamasunder is an Associate Professor of Medicine at UCSF, and co-founder and faculty director of the HEAL Initiative, a health workforce strengthening fellowship working in Navajo Nation and 9 countries around the world.
Ami Waters is an Internal Medicine-Pediatrics Physician. Dr. Waters completed Health Equity, Action and Leadership (HEAL) fellowship and now works as the Co-Medical Director of Last Mile Health and practices at UT Southwestern in Medicine and Pediatrics.
Graciela Cadet is the deputy chief nursing officer and ICU nurse manager at University Hospital in Mirebalais, Haiti.
Savior Mendin is Last Mile Health’s Training and Quality Management Advisor. In this role, Savior oversees training and quality assurance activities as a member of the Medical Team.
Doris Kollie is the Community Clinical Supervisor for Last Mile Health and works with the Rivercess County Health Team.
Anup Agarwal completed a global health fellowship with the HEAL Initiative at the University of California, San Francisco, following his residency in Internal Medicine. As part of his fellowship, he spent time with Jan Swasthya Sahyog in Bilaspur, India and Last Mile Health in Liberia.
Jessica Bender is a Clinical Instructor of Medicine at University of Washington. She completed her Global Health HEAL fellowship in 2017 and is on the front lines of COVID response at University of Washington
About the authors:
We have read and understood the BMJ Group policy on declaration of interests and declare no competing interests.