With the SARS-CoV-2 managing to reach practically every nation on the globe, governments are facing the biggest challenge since World War II. Most nations have resorted to a range of promotive methods such as social distancing and handwashing drives to highly restrictive methods like complete lockdowns and curfews. Irrespective of the intervention, a group of citizens of every affected nation is at the forefront waging a war, while others have chosen to or been forced to remain away from battle lines. The composition of this group is relatively same everywhere – doctors, nurses, hospital attendants, sanitary workers, health counsellors and epidemiology or field staff (collectively termed Health care workers – HCW), and the police, firefighters and personnel deployed for maintaining essential services like power, water supply and banking. Among these HCW face the greatest risk from direct contact and care of COVID-19 patients and their contacts.

This war is far from over. Many nations were caught unawares, while others chose to ignore warning signs. Some failed to learn from other’s mistakes while few are helpless due to severe manpower and financial crisis. Amidst all this, one paradox appears to be universal. Across countries, HCW who need to be given the best armamentarium to fight the disease are going to battlefield ill-armed.

The focus of most countries has been on defence and industry; allocation of funds for health care is meagre with little emphasis on public health. Not surprisingly then, we have this paradox to deal with during a pandemic that cannot be fought with the best of machine guns or the mightiest of nuclear war heads. Notwithstanding, HCW have been in general empathetic to the helplessness of governments and patients and have plunged into this battle with whatever is available. Governments and public have chosen to reciprocate in different ways.

In Italy, people isolated at homes came out to their balconies and sang for HCW. In Spain, the citizens came out to their windows and applauded the service of HCW shortly after the government announced confinement of public to their homes. In India, government requested citizens to clap or make sounds with utensils to thank HCW. Later this was reinforced by a request for lighting candles or flashing lights for nine minutes on the ninth day of April at nine ‘o’ clock in the night. On a subsequent occasion, Indian armed forces flew over major hospitals showering flowers as a tribute to HCW and all frontline workers. Such gestures symbolically offer tributes to the frontline warriors. However, they might mean more than that.

To Governments it might be a way of demonstrating empathy; of course, well aware of the lack of or inability to empathize in areas of concern such as personal protection of HCW. Large-scale demonstrations of gratitude instill feelings of pride, belonging, confidence and responsibility in HCW. Dismay and helplessness are easily replaceable with a combination of the above in HCW, who already have an innate tendency to forgive and forget personal distress when confronted with duty towards care of patients. The public at large are sympathetic towards HCW and comply with requests of governments. They derive a sense of fulfilment following such symbolic gestures and some are genuinely concerned. Families of patients, recovered individuals and friends and families of HCW probably relate deeper to such gestures than others, for obvious reasons.

Symbolism, however, must not replace pragmatic approaches to ensure safety, comfort and confidence of HCW. “Symbolism paradox”, could be used to describe the co-existence of empathy, solidarity and care for HCW in symbolic terms along with feelings of suspicion, hatred, hostility and sometimes physical assaults on HCW in real settings. In the West and Europe the latter element of this paradox takes the form of extensive lawsuits against HCW for the most trivial incidents; in low and middle income nations it often manifests as vandalism and public shaming particularly through highly popular social media platforms.

There is no doubt that gestures of support and empathy are much needed during extraordinary times akin to morale boosters for soldiers going into a war. Yet if the frontline warriors are not armed to fight the invisible yet ubiquitous enemy, symbolism carries little meaning. Pragmatic approaches to ensure that HCW go to battle with adequate personal protection, confident enough to face the challenges of the COVID 19 pandemic are as important as symbolic exercises at personal, organizational and governmental levels. Hiking pay of HCW, or at least exempting them from general pay cuts and providing decent rent-free accommodation for work related quarantine could all be simple pragmatic steps that carry huge symbolic bonuses that could strengthen the cooperation between organizations, governments and HCW. It is therefore paramount that governments use symbolism to complement pragmatism and not supplement it.

About the author

Aneesh Basheer is Professor of Medicine and Vice Dean of Medical Education at Pondicherry Institute of Medical Sciences, India. He is a FAIMER fellow with interest in training medical students in Evidence-based Medicine.

Competing Interest

I have read and understood the BMJ Group policy on declaration of interests and declare that I have no conflict of interest to disclose.