4. The frontline under stress and requiring protection

As the COVID-19 pandemic progressed, graphic news footage was broadcast of thousands of distressed patients overwhelming health facilities across the world, many of which were woefully unprepared for the surge. Ambulances waited in line, emergency rooms overflowed, and hospital beds were dangerously oversubscribed. In Spain, to give just one example, many intensive care units (ICUs) operated at 200% to 300% of capacity, and other countries were under similar strain. 

Holding it all together were health professionals and other essential workers on the frontline—medical technicians, doctors and nurses, border and quarantine staff, midwives and community workers, food suppliers and cleaners—working hour after hour, often lacking adequate PPE and patient supplies, watching helplessly while patients died without loved ones by their side, and worrying about their own health and their families. Response measures added to their stresses—as schools and day-care centres closed down, parents who were essential workers found themselves having to juggle impossible demands on their time.

“In the beginning of the pandemic, there was a lot of confusion. It was total chaos. Nobody knew. There were no guidelines. There was nothing.” Health worker participating in an Independent Panel focus group

The COVID-19 pandemic has taken an enormous physical and emotional toll on the world’s health workers. While there is a lack of globally representative data, Amnesty International, Public Services International and UNI Global Union drew on a wide range of sources recently to estimate that at least 17,000 health workers died from COVID-19 in the first year of the pandemic.  In addition to the unacceptable death toll, health workers have suffered extreme and sometimes debilitating stress. A recent analysis of 65 studies enrolling nearly 100 000 health workers in 21 countries found a high prevalence of moderate depression, anxiety and post-traumatic stress disorder.  Research shows increases in substance abuse and even suicides.   Experts predict the strain on caregivers during COVID-19 could result in high levels of burnout and exacerbate human resource shortages.

A woman in blue scrubs puts on a disposable face mask.

Preparing for the worst Dr. Alia Dharamsi remembers the exact moment she heard a person had been admitted with the novel coronavirus in a Toronto hospital. "I texted my firend and said 'I don't want to die from this." Alia, six months out of residency and one of the youngest doctors on her team, made a decision to learn all she could. She set up in-situ simulation exercises with her colleagues, which partly involved a medical mannequin to "cough" out phophorescent dust. Using a glow light, the team could then see where the dust was landing including "on our necks, on the walls, and in the ventilator ducts".

Through these exercises, she and her colleagues determined how to organize resuscitation teams, what safety/PPE precautions were needed, and how to prepare. "We built protocols from the ground up", she says. She shared everything the team learned on an open blog site that encourages peer-reviewed cases, and the case has been viewed by thousands of times by doctors from around the world.

"This was very purposeful. It was a way for us all to prepare, at a time we weren't sure if we would even need to use the skills." By mid-March, with cases spreading around the world, Alia knew the simulations had been essential. "We walked into a fire everyone was trying to escape from. We walked towards our patients, as prepared as we could be."

Countries adopted a range of measures to provide health worker surge capacity. In Europe, 75% of countries allowed early recruitment of health professionals who were finishing their formal training, 71% asked professionals to work additional hours, and nearly half have allowed retired personnel to re-enter the workforce. Community health workers were engaged in some countries to help with prevention and ensure continuity of services other than COVID-19 care.

“Nurses do so much of the work in patient care, yet we are undervalued and not heard. My submission is to encourage those of us in areas of evidence-based research to influence the policies and change the old narrative.” Comment from Uzoma, a nurse in Nigeria, during an Independent Panel exchange with nurses

Countries adopted a variety of strategies in an effort to reduce the extent to which COVID-19 disrupted services. In Kenya, for example, highly targeted COVID-19 restrictions were coupled with efforts to mitigate negative impacts on the health system, including home-based malaria visits with community health workers, vaccine catch-up campaigns, and the use of telemedicine and phone-based consultations.  Redesign of delivery can reduce the strain, for example introducing triage systems in primary health care that can direct patients either to routine services or to dedicated pandemic management facilities. 

Telemedicine, multi-month medicine dispensing and expanded home visits can reduce pandemic impacts on essential health services. In a sample of 46 countries, UNAIDS found that accelerated use of multi-month dispensing of antiretroviral medicines for people with well managed HIV had reduced clinic visits by half by mid-2020.  In addition to health system reconfigurations, essential service disruptions can be minimised by targeting lockdown policies in a way that ensures access to needed care.

In addition to health workers, the pandemic has also affected other essential workers, including those working in food shops or delivery and transportation, cleaning staff and others. Those involved in meat processing were at particular risk of infection. Meat-packing plants provide favourable conditions for viral transmission, given their low temperature, metallic surfaces, dense production of aerosols, noise levels requiring workers to shout, crowded working conditions and, often, limited access by employees to sick leave.

The nature of the frontline and the degree of risk to workers reflects an income gradient, both between and within countries. While those who could (and could afford to) worked from home during the crisis, others kept food supplies, transportation and deliveries functioning. These largely lower-income workers themselves were at risk of infection.

A United States study found that between 56.7 and 74.3 million adults who lived with people who were, or who were themselves, at increased risk for severe COVID-19 outcomes had positions that did not accommodate working from home. 

Early in the pandemic in New York City, 120 employees of the Metropolitan Transportation Authority died from COVID-19, and nearly 4000 tested positive. In London, 28 bus drivers died.  Especially early on, those forced to go to work and associate with possibly infected co-workers and members of the public lacked proper protective equipment and government guidance. Those who quit to protect themselves and their families faced long-term unemployment in depressed economies.

A US study found that between 56.7 and 74.3 million adults who lived with people who were, or who were themselves, at increased risk for severe COVID-19 outcomes had positions that did not accommodate working from home.
A man wearing a KN95 mask and white shirt looks to the side. Credit: Rosem Morton

In Summary

Health systems were not prepared, and health workers have not only been put under enormous stress, but also at personal risk.

Health systems will be prepared to meet the needs of a crisis only if they have preplanned across multiple dimensions, including for supply and use of proper protective equipment, adequate staffing, childcare support, mental health support, and income support for those for whom continuing to work is too risky. Those capacities need to be in place well in advance of the point when a crisis hits.

Nurse Mali Johnson describes the impact of COVID-19 on her work and personal life.Credit: Rosem Morton
Dr. Juliia Zhirnova explains the stress she’s felt throughout the last year. Credit: Katya Rezvaya
Endnotes