Doctors as soldiers in times of pandemic.

The medical profession has been considered a ‘noble’ profession and usually enjoys a high level of trust from the general public. Despite this position of trust, doctors as the face of an often inadequate healthcare system, occasionally bear the brunt of attacks by patients and their families who are frustrated by the failures of the healthcare system.

With the advent of Covid-19, doctors are finding themselves in an unusual situation of being hailed as soldiers and heroes in the ‘war’ against the virus. With the accolades, there has been a demand and an expectation that doctors should live up to this tag. This can create an awkward position for doctors. Are they happy being the focus of this adulation, which is very likely to be temporary, whilst trying to live up to the public demands? Use of such militaristic language to describe the medical profession can be a double-edged sword. Public opinion can easily turn against its heroes. There have already been accusations that some doctors have not been turning up for work and demands have been made to force any doctors to return to work, using the ‘soldier’ analogy against them.

Being a ‘hero’ involves (a) going beyond the expected duties; (b) at a personal risk to oneself; (c) with a desire to help others and (d) with no expectations of any advantage in return. This is not entirely the role of a doctor even in the course of a pandemic. Doctors do have a ‘duty of care’ to patients but this duty is not limitless. We can be expected to take care of the patients but cannot be expected to put our own lives at risk in the care of the patients. Nobody would expect a surgeon to donate his or her kidney to save the life of a patient; similarly, without adequate personal protective equipment (PPE), we cannot expect doctors to treat highly infectious patients. Yet healthcare workers are still expected to go to work, whilst the rest of the population is asked to protect themselves by limiting any external contact.

The duty of care of a healthcare professional can best be described as a ‘social contract’ between the profession and society at large. By this contract, healthcare workers get a certain privilege in society and in return, they have a ‘duty to treat’ patients, even at a degree of risk to their personal wellbeing. The privileges bestowed by this social contract are accompanied by certain responsibilities. One of them being that doctors are held to a greater accountability and higher threshold of conduct compared to the other professions. Inherent in this social contract model, however, is a reciprocity from the society. In return for the doctor’s duty to treat, society is expected to treat them with respect and to do their own part, including adherence to social distancing guidelines. The use of militaristic language, portraying doctors as soldiers or heroes, takes emphasis away from the reciprocal nature of this social contract. This risk leaving healthcare workers embittered and disillusioned, as they may feel that they are alone in fulfilling their side of the mutual obligation.

Even before this pandemic, doctors have been battling systemic issues in the health economy, issues that foster unhealthy work environments, with expectations of a 24/7 availability leading to a life-work imbalance. The COVID-19 pandemic has increased the demand on physicians’ time, along with an increased intensity of work. Physicians must deal with concerns relating to their own and their families’ wellbeing, whilst dealing with ever changing roles and expectations.

Doctors have often put others health and wellbeing over their own but now have to make a decision between protecting their family’s health over treating a highly infectious patient. As more knowledge about the disease is gained, physicians have had to adapt to everchanging guidelines and to incorporate it into their practice at short notice. Many had to adapt to different work roles, with which they often found themselves uncomfortable. Alongside this, many physicians had to deal with the mental trauma of illness affecting their colleagues or family, as well as being witness to a tragedy affecting their patients by a disease where patients often are denied the support blanket of their families for reasons of infection transmission, leading to health professionals often being the sole provider of emotional comfort, whilst also managing their medical needs. Even doctors who are not on the forefront of this ‘war’ are still affected, for example, financially, by an almost complete absence of fee-paying patients requiring elective surgery. This is likely to lead to long-term psychological and personal effects on the medical professionals. Being called a ‘hero’ and applauded in public is not going to put a salve on this wound. Doctors are humans too. They are entitled to their own fears and anxieties. If public and authorities don’t support them, they would not be able to carry out their important role in serving people.

Amnesty International in its July, 2020 document ‘Exposed, Silenced, Attacked: Failures to protect health and essential workers during the pandemic’, report that over 3000 health care workers (HCWs) have lost their lives due to COVID-19 during the current pandemic. Besides physical harm, HCWs treating patients during a pandemic are at increased risk of psychological distress and posttraumatic stress, as shown a recent metaanalysis. Risk factors for psychological distress included being younger, being more junior, being the parents of dependent children, or having an infected family member. Longer quarantine, lack of practical support, and stigma also contributed. Clear communication, access to adequate personal protection, adequate rest, and both practical and psychological support were associated with reduced morbidity. Surveys of HCWs from different nations have reported high levels of anxiety, depression and insomnia during this pandemic. There is an added risk of ‘moral injury’ where doctors have to take decision on the allocation of scarce resources to a large number of severely unwell patients. This ethical conflict adds to the psychological distress.

Health care workers speaking about the working conditions have faced restrictions or reprisals. There have been reports in at least ten countries of health workers being evicted from where they live, there being attempts to evict them, them finding it hard to find a place to live or facing stigma where they reside. Amnesty International recorded instances in at least eleven countries, where health and essential workers have even been attacked or subjected to violence on the way to work, in their workplaces, as well as by their community or neighbours, and in their homes. Further, in May 2020, 13 medical and humanitarian organisations representing 30 million healthcare professionals issued a declaration condemning “over 200 incidents of COVID-19 related attacks [against health workers] – a trend that endangers these vital frontline responders and the communities they serve”. , Recently, in a first case of its kind, a healthcare professional in United kingdom has been reported for a ‘fitness to practice’ investigation for allegedly delayed attendance to patient because of inadequate personal protective equipment.

This Covid crisis has shone a light on inadequacies in health care systems in every country. Whilst doctors appreciate the clapping, it would be even better to have clarity on testing, isolation and proper availability of PPE. In the long term, it would be best to be able to work in healthcare systems which are adequately funded and where the staff is valued, both by the people and by the government. Doctors don’t want short term plaudits to suit the current media narrative. They want a society where they feel confident to be able to provide best possible care for their patients, irrespective of the health care system or patients’ financial situation. This is a job of the governments and for the societies which vote for these governments. Doctors and their patients deserve better !