Medical Examiner

We Should Have Treated COVID as a Natural Disaster, Not a Public Health Emergency

After six months working in an ER during a pandemic, I have some thoughts about how this went.

Doors to a hospital emergency room, with chairs outside
Photo illustration by Slate. Photo by Getty Images Plus.

This is part of Six Months In, a Slate series reflecting on half a year of coronavirus lockdown in America.

Everyone has a moment when the pandemic started for them. For me, it was dropping a friend off at a nearly deserted Dulles Airport on March 5 without having to fight for a space to park by the curb. Six months later, I sometimes think we are no better off than we were that day, even though I had little idea of what was about to hit us then. We know a lot more now. And yet we are not much further from where we started in progressing toward taming, if not vanquishing, the beast.

When I talk to friends who work in emergency rooms across the country, some in hot spots, the general feeling is of exhaustion and abandonment. For a while, we were lauded as front-line heroes (how I have grown to hate that term) and given free meals, but that didn’t stop our pay from being cut with most of the rest of America’s; nor did it stop the endless litany of indignities that characterize the normal workday in an emergency department. We still have to manage patient complaints; criticism from colleagues in other specialties; statewide shortages of psychiatric beds even as mental illness is on the rise; and, once the patients started coming back, hospital overcrowding and incredibly long wait times. Plus, there’s a new one: patients under our care refusing to wear masks. Still, we should have seen this coming. Early on, as food was arriving for us by the truckload, a nurse friend mused: “This job has been grueling for the last 10 years, and it will continue to be grueling after COVID. It’s just that in this moment, people care, but they won’t forever.”

Working in medicine has always been loaded with emotion, even as we strive to be rational. In his book A Young Doctor’s Notebook, Mikhail Bulgakov writes about how one night a young girl is brought to him, dying, with a mangled limb he has to amputate, an operation he has never done before and barely has any idea how to do. He thinks to himself, Let me get out safe and sound from this terrible event in my life. The irony is that the event is terrible for the girl (who survives) and her worried father, but Bulgakov makes it about him. For us doctors, it’s hard not to do that. We don’t want to detach from the people we treat, and we can’t if we are to do our jobs well—but there is a fine line between absorbing the tragedy of others and making it our own. For the past six months, we have been making the tragedy of COVID our own. And how could we not? Our role in it is constantly in the news, in texts and calls from friends and family, both expressing concern and asking for advice. It seems impossible to escape. In a pre-COVID world, one of the beauties of emergency medicine was being able to leave it all behind. I had always felt that I lived a strange double life: At work, the horrors that humans inflict upon themselves and others were front and center—gunshot wounds, car crashes, domestic violence, homicide. At home, my life wasn’t perfect, but it was most definitely not harrowing. Now, COVID has blurred the lines between those worlds. I can’t hug my children as soon as I walk into my house. I worry about bringing COVID to my parents. I generally don’t discuss the details of my work with my family, but now my children ask every day: “How many COVID patients did you see?” The ritual of leaving work behind by sitting in my car for a moment before walking into my house is replaced by a different one—of showering, of a daily laundry load of work clothes, of taking shoes off outside. But it doesn’t wash COVID out of my life, or even let me leave it at the door.

We have to remember, though, that COVID didn’t just happen to us. It happened to everyone in the world. Everyone has suffered, not least the families of those who died. And while many of the problems we face are unique to our profession, many are shared by others. PPE shortages? Turns out they hurt factory workers just as much. Children stuck at home with no child care? We weren’t the only ones considered “essential.” The loneliness and social isolation, the feeling of being let down, the difficulties of continuing our work despite COVID are experiences common to many workers outside of medicine. When this crisis was framed as something happening to the medical system—a framing that we as medical providers perhaps did not create, but certainly accepted—we left too many other people out.

While it’s true that much of the drama unfolded in hospitals, the focus on this as a medical crisis, rather than a more general disaster, caused us to fail in a couple of important ways.

Our messaging wasn’t completely wrong, but it was just enough off the mark to hurt. When we hectored the public about social distancing (early on) and mask-wearing (later), we told them to do it for health care workers. But people don’t respond to this kind of messaging on other dangers; they don’t stop buying guns so their accidentally shot child won’t traumatize a doctor who has to pronounce a 4-year-old dead. We knew that. We should also have known that appealing to people’s sense of altruism—“my mask protects you”—wouldn’t work when people won’t even wear seatbelts to protect themselves.

You may be thinking: But wait, I thought the thing about masks is that they mostly protect others, so how else could it have been communicated? I think this underlines some of the ways our focus on this as a public health crisis has harmed us. As doctors, we encouraged the response to be driven solely by public health considerations and standards, but those turned out to be wrong on several important points—most notably mask-wearing and asymptomatic spread. What if we had treated this as a complex disaster, and let the expertise of disaster planning machinery be used to furnish the immediate crisis response we needed? When an earthquake happens, we don’t rely on geologists to sort out how to dig people out of the rubble. Perhaps disaster planners wouldn’t have been so hung up on whether there were randomized controlled trials on the efficacy of mask-wearing before suggesting them. As a colleague remarked, we don’t ask for evidence on hurricane shelters when there’s a hurricane. With masks, we knew that other countries that have been through this before use them, and were using them again. We could have let that guide us, framing masks as a possible preventative measure that could help slow the spread, with little downside. But we didn’t, because the evidence didn’t meet public health standards. Until it did—and more recent research suggests that masks, even cloth ones, actually do contribute some protection to the wearer.

Another reason I wish we hadn’t felt that the world was relying on us as doctors to point the way out of this mess is because I think it pressured us to respond in ways that haven’t been helpful. We’ve decided it’s our role to scold anyone who makes a decision we don’t agree with—universities, school systems, the Food and Drug Administration. We’ve been so worried that people wouldn’t take this seriously that we swept the fact that the vast majority of people who get COVID don’t get very sick at all under the rug. These days, in my ER, I’m seeing more and more people who don’t even realize they have COVID because their symptoms are so mild. And these people are a key piece of the puzzle—because they go back to work, and to backyard barbecues, and to grocery stores, not even realizing they are sick. But we failed to educate the public accurately about this disease, at first because we just didn’t know about it, and later because we were afraid of seeming as though we were downplaying it.

On a more personal level, I worry that this is hurting us because we are letting it. Our preexisting anger at so many of the problems that plague the health care system is now deflected onto problems that seem, and often are, related to COVID. But those problems aren’t new. COVID didn’t suddenly turn a beautiful world harsh, and no one should be able to see that more clearly than us. An emergency department in America was a microcosm of everything that was wrong even before COVID—racial disparities, economic inequalities, domestic violence, child abuse, international conflict, disregard for the rights of others, unfair labor practices—and these are just a few of the reasons people end up with us. COVID was a magnifying lens on the role those factors play in human illness.

I want to be clear that I am not minimizing the impact that COVID has had and will continue to have on medical providers. For those who worked in hot spots, the post-traumatic stress alone will likely eat up the meager mental health resources that are available. For the rest of us, we at the very least already know we will continue to deal with this disease long after the pandemic is over. For many, it will change their view of medicine forever. Some will leave. Some, I hope, will shift their energy into forward-looking policies. It may be too late to salvage this pandemic, but there will be others, and while our hindsight is still not perfect, I hope we can eventually learn from our mistakes. Nor do I think any of these mistakes were really our fault. Ultimately, our responsibility is to take care of patients. It’s because we felt responsible for those patients, and because it also felt like no one else was looking out for them, that we had to step into roles we were unprepared for. I worry about the long-term impact of that on my friends and colleagues and the residents I train. If we don’t find a way to absolve ourselves of a responsibility that shouldn’t have been ours in the first place, the next six months will feel even longer than the last.

In March, I took a picture of my children on a bike trail in front of a sign that said “END.” I thought to myself that I would post it on social media the day the pandemic was declared over. I realize now how silly that was. One day, the pandemic will officially cease to be a pandemic. But COVID will likely continue to show up in emergency departments for years after that. We will be wearing masks at work for a very long time after the rest of the world can go maskless. And in America’s ERs, well after the disaster porn of COVID is gone from the headlines, we will still be mopping up the mess of economic destitution COVID is leaving in its wake, serving, as we always have, as America’s safety net.