1940 was a particularly hopeless year in Great Britain. Having easily conquered France and signed a temporary treaty with the USSR, Adolf Hitler turned his full attention towards the conquest of the United Kingdom. As the Battle of Britain commenced, Prime Minister Winston Churchill, against this bleak backdrop, memorably addressed his people, and the world:
“…if we fail, then the whole world…including all that we have known and cared for, will sink into the abyss of a new dark age…. Let us therefore brace ourselves to our duties, and so bear ourselves, that if the British Empire…last for a thousand years, men will still say, ‘This was their finest hour.’”
Many metaphors have been put forth to help us wrap our minds around the scope and implications of the COVID-19 pandemic, however the analogy of a world war is the most illuminating and appropriate. For we face a common enemy which will not be vanquished easily nor rapidly, and certainly not without collective and unified focus.
Much like World War II (WWII), everyone, regardless of age or profession, has been and will continue to be affected by this crisis for years to come. For some, it is suffering from the infection itself, for others grief over the loss of a loved one, and for all, financial hardship and austerity. To continue with this metaphor, healthcare workers (HCW), especially those who deal with acute illness, can be thought of as the soldiers deployed to the frontlines.
The duty of soldiers is to bravely risk their personal well-being for the common good when the time of need arises. Those who support the troops, as well as the soldiers themselves, always hope that the most necessary equipment will be available in abundant supply when heading into battle. However, this is never the case. The infantry must be deployed when the circumstances demand their service rather than when they are ideally equipped to perform the task that is asked of them.
We, the soldiers waging this battle against the SARS-CoV-2 virus, face similar circumstances of imperfect preparedness, especially regarding shortages of personal protective equipment (PPE) and testing supplies. And knowingly or unknowingly, this is the job we signed up for when we chose the profession of medicine. For many of us, it is easy to have lost sight of this, as such public health disasters have not occurred for many generations. Much like members of the army reserves during peacetime, we’ve not considered that our work could demand us to put our own safety on the line in tangible ways for some time.
I too was lulled into this false sense or perpetual stability; thinking that the status quo state of clinical practice would continue indefinitely. Frankly, I was actually quite comfortable with medicine changing at glacial pace. It made it easier to keep up-to-date and to have a life outside of work. But like the soldiers drafted into WWII, we clinicians have largely lost the luxury of a pleasant work-life balance.
Despite this reality, I’ve been tremendously impressed with how my colleagues have unflinchingly accepted this (hopefully temporary) new norm without complaint—everyone’s definition of triumph and defeat recalibrates somewhat during wartime. And while it is certain that the global and, more specifically, the U.S. preparation and response to the COVID-19 pandemic have been frustratingly inadequate, we have not used this as an excuse to fail to show up when needed. There has been a universal and implicit understanding among HCWs that bemoaning the shortsightedness of our leaders, despite ample warnings from infectious disease experts, is counterproductive to our mission of protecting the lives of our patients and communities.
Yet as we persevere in our mission, we must simultaneously demand appropriate assistance on the home front. While the outpouring of moral support from the public for HCWs has been encouraging, the provision of more tangible support from our nation’s leaders has been disappointing.
During WWII, President Roosevelt rapidly pushed the War Powers Act through congress, which compelled factories to shift from producing commercial goods to manufacturing supplies needed for the war. Despite having slow and minimally automated means of production by modern standards, these facilities quickly and willingly pivoted from manufacturing radios and cars to making planes, guns, and tanks. Therefore, in 2020, there is simply no valid excuse for this shortfall in the production of the comparatively basic and necessary PPE supplies for this war at hand.
Consequently, all HCWs should speak up and demand support from organizational and governmental leadership to take immediate steps to remedy this situation. This should be done both by directly asking for necessary PPE from our administrators, if facing a shortage, and by supporting the work of advocacy groups towards ensuring sufficient PPE supplies for all HCWs (for example, a simple first step is signing the petition at getusppe.org/advocacy).
Yet such solutions will take time, and we must realize this. When responsible soldiers face a “mission critical” task, deserting is not an option. Rather, they accept that they must hold off the enemy, often through unproven and unorthodox methods, while awaiting reinforcements. Similarly, we are forced to dutifully show up and creatively find ways to care for patients until this problem of inadequate PPE resolves. However, even though duty calls, we must still exercise caution. Even without maximal PPE, we can take reasonable steps to avoid becoming casualties ourselves—both for our sake and for the sake of our families and future patients.
Thankfully, the imperative for sophisticated PPE may be less than initially believed. While respirators, such as the N95 mask, are in critically low supply in many places most affected by COVID-19, we do not have abundant evidence to suggest that such masks are required in most UC settings. For example, Singapore and Hong Kong were able to keep nearly all of their HCWs safe through the use of only surgical masks (except when performing highly aerosolizing procedures) in conjunction with good hand hygiene, social distancing, and increased use of telemedicine services.
Another story of hope comes from the Korean experience. South Korea experienced an early surge in cases, but was able to “flatten the curve” quite effectively by rapidly expanding the amount of drive-thru, point-of-care (POC), PCR testing available to the general public. We should feel hopeful that we will experience similar diminution of spread if our leaders take steps to make POC PCR testing more easily accessible for patients.
Expanding serology/IgG testing is also crucial as we press further into the pandemic. Identifying previously infected HCWs who’ve developed protective antibodies will prove extremely valuable in allowing us to determine who can serve on the frontlines with the least risk to personal safety.
Finally, we in the healthcare community must look after one another by ensuring those among us who fall into higher risk categories, either by age or health history, are sheltered from the most dangerous roles. A successful war effort requires much more than just combat boots on the ground. The engineers, medics, and communications specialists of WWII played an integral role in the allied victory without coming directly under enemy fire. Similarly, we must find support roles, largely through the use of telemedicine, which allow our most at-risk comrades to participate in the fight without unnecessary exposure to the heat of battle.
I have been encouraged by the valor and commitment my fellow HCWs have shown during these fearful times and I pray that their sacrifices will not have been in vein. Rather, it is my hope that COVID-19 will force many of society’s new behaviors to become habitual and normalized in perpetuity to reduce the likelihood of a pandemic of this scale from happening again. I hope that the lessons we are all learning about our preparedness and our vulnerabilities as a nation and species will endure long after this crisis resolves. And if we in the healthcare community are able to bravely persevere as we have thus far (and I believe we will), those who look back at our service during these uncertain times will rightfully say: “This was their finest hour.”
Joshua W. Russell, MD, MSc, FAAEM, FACEP
Editor-in-Chief, JUCM, The Journal of Urgent Care Medicine
Email: [email protected]