The coronavirus outbreak, finally declared on March 11 as a pandemic, has upended our personal and professional lives, wreaked havoc on the global economy, and continues to claim lives. It has exposed the weakness of our health systems and its inherent limitation given current financing policies and misplaced priorities.
Health systems not anchored in the principles of Right to Health with investment in health workforce and protecting health worker rights as it’s central theme cannot improve patient quality of care. During the Ebola crises, it was evident that even when there is sufficient financial resources and logistical information, without a lack of robust health workforce, the pandemic could not be contained. Health workers are the bottleneck in health service provision. A government, and by extension institutions and employers, that do not protect, support, and empower their health workers fail in their obligation to uphold the Right to Health.
The issues that we are facing during this pandemic are not vastly different than many of the previous ones, except maybe in scale and location. For those, like me, that grew up in the Global South, we witnessed these dynamics in a resource strapped setting during the HIV/AIDS “global epidemic”. During the 90’s, the mainstream public health debate was the stigma and discrimination faced by HIV/AIDS patients while obstacles faced by health workers were hardly recognized or only as an afterthought. The main disincentives being no hazard pay, lack of protective equipment, or no investment in safer workplace initiatives, sometimes as basic as gloves and retractable needles. These are repeated in subsequent pandemics, with Ebola claiming the lives of hundreds of health workers. Yet, health financing prioritized patient care and quality of services without sufficiently supporting, protecting, and empowering health workers and viewing them solely as vehicles to be utilized to achieve these desired patient care results. This was the driving force behind founding the Health Law Institute (HLI).
During this pandemic, it is evident that poor and unsafe working conditions of health workers are not only restricted to the Global South. Health workers have been on the frontlines without sufficient planning or protection, all the while putting their patients’ lives before theirs. Working long hours, often times unremunerated, with inadequate or no personal protective equipment (PPE) seems to be the norm. In many cases, they have been threatened with disciplinary actions or even fired when they speak out about lack of gear or bring their own masks and at times banned from wearing protective masks in hallways. Employers have put forth a variety of reasons for their actions including the idea that PPE needs to be conserved and used as minimally as possible to the notion that it scares patients. Unfortunately, these non-transparent ways utilized by management to address these issues along with shifting protocols are meant to preserve a dwindling supply of protective gear and are not from the point of view of protecting health workers. Health workers have been forced to use protective gear for longer than recommended, share with colleagues, or reuse PPE, intended for one-time use, over periods of time while storing them in paper bag between shifts. Some National public health institutes have even suggested the use of scarves and bandanas when stocks are depleted.
This lack of control over personal safety can be traumatic as they fear becoming infected and expose their patients, other health care staff, and even family members. Some have taken to using social media with tags #GetMePPE and even set up websites to obtain PPE directly. The emotional toll of being exposed and exposing others to the virus is compounded by having to isolate partially or completely from family members, seeing colleagues sick and on ventilators, knowing that hospitals may have been transformed into incubators for the virus, physically struggling through shifts when infected and being forced to operate below the normal standard of care. Having to take excruciating decisions on rationing ventilators and other lifesaving care and pondering blanket do-not-resuscitate orders for coronavirus patients adds to these mental scars. On top of all these, many health workers have faced harmful verbal and physical abuse in the larger community while performing daily errands, as individuals fear they are infected. Furthermore, the stigma associated with seeking mental health, the uncertainty of its effect on licensing with professional boards, and the already slim mental health infrastructures and coverage make it even harder for health workers to access required counselling and appropriate mental health interventions. Older health workers and those with underlying medical conditions, many of whom have been recalled back from retirement, face an even harsher predicament.
Getting enough protective gear is among the cheapest, most effective things to slow down the pandemic and stall the unnecessary loss of health workers. No compromise should be made on established protocols for treating patients during a pandemic. One has to wonder that if health workers took a stand not to treat patients without proper PPE, would the PPE magically “appear”. Does being a health worker mean that one has to give up one’s instinct of self-preservation? An earlier HLI blog touched upon the right of health workers to remove themselves from situations which they believe present a risk to their own life/health or the life/health of their family members and the competing duties of care to themselves and the duty to care for their patient. As the pandemic rolls on, these will remain to be pertinent along with what is the duty owed to future patients. However, what we do definitely know is that even the loss of one health worker creates a ripple effect on the already limited trained professionals. Accelerated graduations or calling health workers back from retirement may help the situation but still may not be able to compensate for these losses both in terms of number or experience.
My ten key takeaways on what needs to be done to prioritize the health and well-being of health workers so that they can continue to provide quality patient care not only during this pandemic but beyond.
Health workers should not have to work without PPE: This would apply to all health settings and all health workers including support staff. It is necessary to provide training on using PPEs appropriately and limit situations that can lead to exposure. Also, whistleblower protections to prevent employers from retaliating against frontline health workers who raise health- and safety-related concerns should be implemented.
Health workers should be duly compensated: This would apply to all work provided, including overtime, and allowed time for rest and quarantine if necessary. Though non-monetary forms of compensation may be uplifting and boost morale, it cannot replace fair monetary compensation, especially in a situation where they are risking their own lives to provide care.
Health workers should have access to priority testing and be accorded preferential vaccination when it becomes available
Mental health counselling and coverage should be made available without repercussion on ability to practice or maintain licensure.
Limit liability during the current pandemic as health workers are forced to operate below the normal standard of care.
Raise awareness, prevent, and prosecute discriminatory and harmful acts against health workers, both on the job or during daily community interactions
Empower and support health workers to better identify incidences of domestic violence and child abuse which has spiked during the pandemic.
Be inclusive of all categories of health workers. In all health settings, be it a hospital, community pharmacy, private practice, dentist office etc., health workers are prone to being exposed. Therefore, guidelines should be developed keeping all these practice areas in mind. Also, staff from all hierarchies, age groups and those with underlying medical conditions should be considered depending on risk of exposure. Further, disaggregated data, reflecting these parameters, should be systematically collected and reported.
Funding. Investment in our health workforce and health systems is crucial not only when we are faced with a crisis but should be ongoing so that we are able to rapidly contain or avert a future crisis. The resulting effect on our economy shows how it is inextricably linked to our well-being.
Better policies to foster safe and decent working conditions. Including health workers in the discussion and being aware of the global interconnectedness as we design these policies will be of utmost importance. Also, continuing to harness technological advancements, as we have done during this pandemic, will drive greater participation, reduce carbon footprint, and help to level the playing field between organizations by allowing greater accessibility.