During lockdown in late March, I got an e-mail from a friend and surgeon colleague in New York: a mutual friend of ours and a remarkable paediatric neurosurgeon, James Goodrich, had just died of COVID-19. He had contracted the disease while working in the frontline. As a surgeon, he had gained global recognition for his seminal work on conjoined twins (craniopagus twins, joined at the brain). He was the pride of Montefiore Medical Centre, Albert Einstein College of Medicine, New York, where I was surgeon-in-chief.
The painful sensation a patient feels in a limb that has been amputated (sometimes long after the limb is gone) goes by the clinical term “phantom pain”. I couldn’t help but feel an emotional “phantom pain” with the passing of my friend. As healthcare professionals, we all experience this phantom pain when we hear about the loss of a colleague.
A high-profile report relating to the head of the emergency department of a noted New York hospital had an even sadder ending — death by suicide after suffering from COVID-19 and recovering, yet dying of anguish from her predicament over the numerous patients she could not cure. Perhaps the face of the disease shall remain Li Wenliang, who raised the alarm of an atypical viral pneumonia in Wuhan as early as December 2019, and later died of coronavirus at the hospital he worked.
Challenge at the frontline
Reports from around the world provide a rather grim picture of the challenges faced by frontline health workers who dedicate their lives to save others. By any count, we have lost thousands of these heroes — doctors, nurses, emergency technicians and other health workers, to this pandemic. While the loss of some may be seen as unavoidable, the loss of many can be ascribed to “avoidable harm” in medical parlance, where the WHO has set a goal of “zero harm”.
News from the early stages of the pandemic sounded alarm that hospitals lost many of their doctors and nurses in Wuhan and Italy — as many as 20%, from sickness, burnout and post-traumatic stress disorder.
Reports from subsequent months also suggest that around 20% of health workers may be infected. In India, an April ICMR report says that of one million tested, 40,186 tested positive, of which 2,082 (5%) were healthcare workers. Extrapolating the report to 6,50,000 cases in India, currently about 30,000 healthcare workers may have contracted the virus. Based on recent death rate, there is likely to be about 800 deaths among health workers.
Loss of such life has many dimensions: each life means a loved one, and each loss a huge deduction from valuable healthcare human resource. In countries with a high number of coronavirus cases, India has one of the lowest density of nurses and physicians. So, a toll on health workers poses a clear and present danger in times of COVID. The collective departure of our colleagues leaves a void, attenuates our morale, and will stay with us as “phantom pain”. Relief from such phantom pain signifies larger well-being in society, and can come from addressing the safety of frontline health personnel.
A prescription
I am hoping that this year’s apt theme of “health worker safety” for World Patient Safety Day, September 17, by WHO will generate sustainable solutions, including establishment of a global repository of health worker mortality and adverse outcomes, paired with mitigation strategies.
Many healthcare workers continue to perform their duties despite extreme hardships. First, due to their dedication and commitment (this is why they chose the profession in the first place), they endure extreme stress, trials and tribulations of losing patients, getting infected and passing deadly infection to loved ones at home. Second, they do not wish their colleagues to be overburdened by not doing their own bit and take on more than what is optimal. And third, and most unfortunately, they suffer in silence, enduring long duties, even without proper personal protective equipment, unable to raise their voice for fear of retribution.
There are many more factors, but these salient three require disparate, but overlapping strategies and tactics. The first factor requires more effective psychosocial support systems for healthcare professionals, not only doctors and nurses, but also all frontline workers. Often, as healthcare professionals, we maintain “stoicism” and do not convey our anguish and internal conflicts, until it precipitates into depression, burnout and other stress disorders such as PTSD and perhaps most painfully, suicide.
The second factor requires system planning and duty roster design, with the moral compass of empathy for healthcare workers, and not imposing harsh work hours by coercion or financial incentives alone. Effective patient-centred care requires facilitation of collective decision-making with care continuum teams.
The third factor requires robust mechanisms to capture the voices of health workers and address concerns systematically and in real time, in a “blame-free” culture. Provision of effective personal protective equipment (PPE) and training are a major shortcoming across the world, India no exception. Despite ramping up of efforts in India, demand may outstrip supply due to rapid rise in COVID-19 and the looming threat of a second wave. Since this is in our collective control, there shall not be any excuses for not providing adequate PPEs to frontline heroes.
While we prepare an offence against SARS-CoV-2 with vaccines and new treatments, strengthening our frontline is a great defence to save lives and mitigate human suffering.
The author is president of All India Institute of Medical Sciences, Mangalagiri
Published - July 05, 2020 12:43 am IST
