Disclaimer: The opinions expressed are solely that of the authors who take full responsibility for this content. There are no conflicts of interest to report.
It is often said that we are at war with an “invisible enemy” during the COVID-19 pandemic. Despite the recent history of similar outbreaks (i.e., SARS, H1N1), failures in government and its leadership left the U.S. grossly unprepared for battle. Front line providers including EMS, nurses, nurse practitioners, physician assistants, ancillary staff, and physicians serve as “soldiers” caring for the deluge of patients overwhelming our health system. Structural racism unfairly places the poor and minorities at increased risk of exposure since they over-represent the critical work force in the food service, transportation, and health industries, and often live in communities where it is difficult to socially distance.
Shortages in personal protective equipment (PPE) have compounded the stress for front line providers, with those exposed becoming ill or even dying from this devastating disease, or living in fear of transmitting it to their families and colleagues. For the first time in our lives, we fight with the injustice of having to recycle PPE – placing ourselves and patients in danger. We willingly join the fight because of our duty to care for all those in need, whether or not there is a pandemic. Shortages have also forced others considered part of the critical workforce to fight this war without any or inadequate PPE, resulting in unnecessary illness and casualties.
Televised governmental briefings recount how there is enough PPE, whereas those of us on the frontlines experience shortages and rationing. As we struggle in unimaginably horrible conditions, decentralized purchasing causes states to compete against each other, driving prices for medical equipment unnecessarily high. We cannot imagine why this is permitted by a federal government that needs to protect all citizens equally as we compete against ourselves, driving up budget deficits that were already at critical levels. Meanwhile it seems as if a stockpile of goods owned by the federal government is being allocated as personal favors to garner support for re-election rather than prioritizing locations having the greatest need.
Ethically, the failure to provide for frontline providers was as complete as the failure in providing physical protections. When COVID-19 began to surge in NYC, discussions were held about how this would impact hospitals that already work at maximal capacity with constrained resources. At that time, discussions were not only about the impact this crisis would have on our patients, but also about providers who would be forced to make the most difficult of choices, that of rationing care.
Just as soldiers going into battle, providers would deal with the impact of those decisions – determining who lives or dies – with short- and potentially long-term mental health consequences, most notably PTSD. Writing was on the wall: would there be enough ICU beds, staff, ventilators, and medicines to care for the influx of patients? How would providers deal emotionally with being the persons responsible for making these choices? Some of these concerns were initially eased, knowing that experts had determined rationing policies in reports published by the National Academy of Medicine and the New York State Task Force on Life and the Law., Staff were reassured that guidelines based on sound ethical principles would guide us through the terrible decisions should they be faced. That, of course, never happened. Rumors were that the New York State Department of Health had guidelines ready to help not only with the distribution of ventilators, but also with wrenching decisions about resuscitation for patients on admission or for those on ventilators who might continue to deteriorate. Among the recommendations is having an on-call panel of ethicists who would make final decisions about who would receive resources or who might be removed from a ventilator – in a fair and just manner. That would have been so helpful. In lieu of that we had intellectual dislocation, feelings of ethical inadequacy and panic at any moment about how to proceed.
In the first wave of the pandemic, rationing of ventilators was unnecessary, in part from community willingness to practice social distancing and creative repurposing of similar equipment (i.e., BiPAP machines). Yet, demand also reduced from rationing patient care in other ways. Deaths at home increased because fewer patients were sent to hospitals by emergency medical services, or they waited until it was too late to seek care. Patients were also sent home who would have otherwise been admitted due to bed shortages, risk of contracting the virus in the hospital, and constrained capacity to perform life-extending diagnostics and therapies. Without a uniform guideline in place directed by a national, state, or city public health agency, the entire weight of rationing decisions is on those under the most stress during this crisis.
This leads us to consider the failure of government to provide sufficient mental health services. Frontline providers are witnessing an 84% death rate among intubated patients, exacerbating depression experienced by some who are living separately from their families to protect against spreading the disease. Our dedication to our mission – to care for our patients regardless of constrained resources and stress working in this pandemic – is visible and appreciated among all those cheering every evening. But what did providers sign up for when they joined this cadre? Did they expect a dysfunctional government that cannot provide the necessary equipment to protect themselves and care for their patients? Did they expect federal leadership to ignore rationing policies that were developed thoughtfully after the SARS epidemic?
The case curve in New York has bent, but the war is far from over. New fronts are surfacing in other cities and states with local government interpretation of need and expectations for social distancing. Moreover, uncertainty as to what will transpire when the economy reopens leaves us vulnerable to the same devastating scenarios predicted by models of disease spread and severity. What is needed, now more than ever, is to operationalize a comprehensive rationing policy that was developed by the New York State Task Force on Life and the Law. Having a comprehensive rationing policy to lean on would ensure that just care is provided during this crisis, should care rationing be required, and also would go a long way to prevent PTSD among our frontline “soldiers.” The federal government should expand health benefits to include mental health parity so that it is covered and not stigmatized for all those dealing with the stress from this pandemic. A centralized, fair PPE and ventilator allocation system needs to be operationalized to coordinate and deploy these scarce resources to areas in greatest need, rather than leaving states in direct competition for purchasing and allocations.
When this crisis is over, as a society, we need to learn from these failures, and recognize that public health infrastructure and addressing health and social inequity is akin to insurance for our country, to protect against an upcoming and devastating economic depression that will linger long after this epidemic is contained. We need to seize this opportunity to address health, social, and occupational inequities that encompass pervasive structural racism. Only then may we resuscitate ourselves and prevent further tragedies for all those being asked to fight for our lives and economic well-being. A commitment to public health was our contract to care for all those impacted by this crisis, but without an accompanying universal economic contract, the U.S. is doomed to repeat the same mistakes that led to this current devastation.
Stephen P. Wall is a Tenured Associate Professor in the Departments of Emergency Medicine and Population Health at the NYU Robert I. Grossman School of Medicine, a bioethics researcher and an emergency physician who practices at Bellevue Hospital, NY, NY.
Nancy N. Dubler is a bioethicist at NYC Health + Hospitals and the NYU Robert I. Grossman School of Medicine, and attorney who co-authored the NY State Task Force on Life and the Law Ventilator Allocation Guidelines.
Lewis R. Goldfrank is Professor and former Founding Chair of the Department of Emergency Medicine at the NYU Robert I. Grossman School of Medicine, who co-chaired the National Academies of Sciences (Institute of Medicine) Committee on Personal Protective Equipment for Healthcare Workers During an Influenza Pandemic. He practices at Bellevue Hospital, New York, NY.
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