The war narrative is in full swing as Healthcare Workers (HCW) are rechristened frontline warriors and thrown into battle with an invisible, merciless enemy. And like true warriors they are expected to keep on fighting until either martyred, or victorious. Either way, these HCWs are hailed as heroes of the nation.

And as is always the case, heroes are elevated to dizzying heights, and then expected to play their part and live up to the societal expectations. After all, the Eiffel tower isn't lit up for everyone, nor the Burj Khalifa. Everywhere in the world, people are "clapping for carers", applauding from balconies, banging pots and pans on rooftops and singing for them on curbsides. And it was indeed an emotional sight for us to see our policemen saluting HCWs who, hands on hearts, accepted this recognition with gratitude and teary eyes.

The front line 'warriors'

Who are these frontline warriors? While news generally focuses on physicians, those at the forefront also include nurses, paramedics, and technicians in radiology, labs, theater, dialysis units and in other areas. Several non-medical people are also included among healthcare workers, like janitors, security personnel, receptionists, and ambulance drivers who are as important to the battle but mostly go unnoticed. All of these people run the risk of contracting the virus that does not discriminate.

As a febrile patient arrives at a health facility, he/she will first probably encounter a security guard who will direct the patient and accompanying relatives to the designated room. If he’s lucky, the guard will be wearing a non-regulation mask, and that's all the protection he has. A receptionist, probably also armed with an improvised cloth mask, will register and take down the patient's details, as the patient stands perhaps two feet across. Subsequently, the patient will be assessed by a doctor in a designated screening area, assisted by a nurse.

Sicker patients, thankfully the minority, will need to be admitted while the rest will be sent home with instructions on isolation. Those sent home are not necessarily free of the infection; they are just not sick enough to merit admission.

Patients admitted in hospitals' isolation wards or ICUs are looked after by staff that is now somewhat better equipped. According to the World Health Organisation (WHO), the minimum requirement for those involved in direct care of a Covid-19 patient is the use of an impermeable gown, gloves, a medical mask and eye protection. Access to these are gradually increasing for healthcare providers and the ancillary staff within designated 'red zones'.

Real fears

Healthcare workers all over the world have fallen to this deadly virus. Pakistani physicians too have unfortunately joined the ranks of these fallen heroes, the first being a young man from Gilgit-Baltistan armed with little more than his enthusiasm to serve, who contracted the disease while screening potential patients, and the latest, a senior physician who had established a facility for affected patients in a remote area of Karachi.

In this scenario, fear becomes a very real emotion, and paralyses all alike, including doctors. We have already seen mounting evidence of dissent among the ranks of these very frontline HCWs. There are reports from several institutions across Pakistan, as well as from abroad, of health workers refusing to report for duty, because of lack of protective gear.

Diversity of health facilities

There is a great deal of diversity in the operational scope of the healthcare institutions in Pakistan. People working in all these facilities, whether or not they are government-designated Covid-19 centres, are unsuspecting and largely unprepared frontliners. And while some institutions have devised mechanisms to limit exposure, others have not. These unsuspecting health providers have at the most masks and gloves to ward off the threat of infection. There have been reports that some institutions had even refused to provide routine surgical masks in the initial few weeks of the outbreak and had asked HCWs to arrange their own.

At this time, high profile tertiary healthcare centres will be the obvious focus for PPE distribution, providing required protection to their staff. But smaller government, private, not for profit, and community run hospitals are in danger of missing out.

WHO recommends hand hygiene with alcohol rub if not visibly soiled, and washing with soap and water if dirty, as the primary measure for protection for everyone. And while some of the more prominent centres have these facilities, finding a tap with running water and a nubbin of a calcified soap is an accomplishment at many of the smaller hospitals and clinics. Even the minimum is not always available, let alone meeting WHO recommendation underlining the requirements for HCWs in this situation.

The proposed Pakistan Occupational Hazard Safety Act 2018 aims at protecting workers and other persons against harm to their health, safety and welfare through the elimination or minimisation of risks arising from work, but there is no independent legislation looking at occupational safety for healthcare workers in Pakistan. While pandemic situations can understandably cripple any system, even during 'normal' times, many of our health facilitates lack basic safety equipment to protect workers.

In reality, departments of Infection control, if they exist in hospitals, have classically been treated as orphan departments, with their advice being flouted by all ranks. Hospitals have shied away from investing in infection control measures, not realising the importance of these often simple measures. Hand hygiene is one of the sorest topics for infectious disease experts.

Against this backdrop, HCWs are still expected to go to war for society.

HCWs' expectations from society

While society has high expectations from HCWs, those working at the frontlines also have some justifiable expectations from members of the public. Even though most OPDs have been shut down to redirect the focus of personnel and facilities towards Covid-19, people have not stopped having acute appendicitis, heart attacks, or labour pains. And in several cases, unsuspecting hospital staff have actually been infected by patients with other ailments simply because the patient did not reveal their travel or contact history. An honest history regarding exposure and symptoms is essential for the protection of HCWs. One team member getting infected means the entire team has to be quarantined, and as a result innumerable patients suffer due to the sudden drop in available HCWs.

With the scarcity of equipment for protection, and while the real frontliners cover their faces with improvised, low quality masks which do nothing in terms of virus protection, it is not an uncommon sight to see members of the general public walking around wearing surgical masks while shopping for groceries, or even the precious N95. All of us have seen government functionaries sporting these coveted masks, often worn around their chins so that the cameras do not miss the concerned expressions on their faces.

Covid-19, for some, has presented with opportunities to profit. Hoarding of essential items to create false shortages and flooding the market with fake hand sanitisers are just two examples. While unscrupulous elements will always be there, one hopes that society will play its due role.

What our healthcare workers need from society is more than just empty salutes. In addition to responsible behaviour from members of society, like the simple enough act of staying home to help plank the now infamous curve, all potential frontliners have to be equipped with the correct protective equipment. It is the responsibility of the government and of healthcare institutions to ensure that this happens.

Realistic capacity-building efforts

The government is working hard to obtain from abroad and manufacture our own ventilators. But machines alone do not save lives, not without the humans who know how to operate these machines. Pakistan already has a shortage of skilled expertise to run these machines, and this will only be amplified in the days to come. These ventilators, significantly more than just plug and play machines, cannot simply be parked anywhere and a patient hooked up. And the sad part is, even in the most advanced centres around the world, the mortality rate of Covid-19 infected people on ventilatory support has been reported to be over 80%.

So while we do need to procure more ventilators, our primary focus should be on the optimum utilisation of the human resource available, the unwitting warriors on the frontlines. And our best bet still lies in trying to flatten the curve. Increased testing and then contact tracing is key to the process of identifying and isolating carriers. China had 18,000 teams of five people each entrusted in this massive effort. But here we hardly hear any mention of strengthening this critical level of defence. Similar concerns are being raised in neighbouring India.

How are we preparing our workforce for this war? Due to reduced elective out-patient activity, many HCWs are actually facing layoffs and salary deductions. There is a very real fear that HCWs employed with private health institutions and quarantined after exposure may end up facing pay cuts.

The Sindh government has reportedly enforced a mandatory pay deduction on all its employees, including HCWs to fund the Covid-19 effort. Such measures are bound to demotivate the workforce, particularly when it comes to staff that already makes very little. For example, how much will be left to take home after deduction for someone on cleaning duty at a government hospital's Corona ward.

Meanwhile, as the government imports regulation of PPEs from abroad, we are a country tuned to jugaarh (innovation) even in the best of times. This skill is coming in handy as the unlikeliest of providers are coming forth with what appear to be appropriate PPE coveralls and face shields being mass produced, on their own initiative, and pro bono.

These efforts must be supervised by those who know the requirements so that it is not wasted, and health workers are not provided with a false sense of security. Along with PPEs, the staff needs proper training in their appropriate use including donning and doffing procedures.

Reciprocity, not claps

In addition to equipping and training of frontline workers, the society needs to acknowledge the contributions of the HCWs and ancillary staff in tangible terms. If the need arises, HCWs must be guaranteed preferential access to scarce medical resources, over and above everyone else.

All health workers must be prioritised to tests in case of possible exposure. A negative test will obviate the need for quarantine which will deplete the workforce, and also reassure the HCW and her/his family. This preferential treatment must be extended to the immediate family members of the HCW, especially those who share the same living space with them, keeping in mind the importance of their peace of mind. The testing kits at present are in short supply, but they must be made preferentially accessible to HCWs and other frontline staff.

In case a member of the frontline staff gets Covid-19 and requires hospital resources, he/she should be prioritised over another patient presenting with the same requirements. This is based on the principle of reciprocity, with society honouring its HCW heroes with more than just banging pots on rooftops. This is also in line with their 'instrumental value' since getting the HCW back on her/his feet is essential so that the workforce is not depleted in the long run even if he/she takes up to six months to regain full capacity to work.

Society also owes HCWs to extend the right of preferential treatment and access to the health workers' immediate family members. No doctor, nurse, or paramedic can come to work and give her/his 100% if distraught about a sick family member whom he/she has possibly infected. In the event of an immediate family member contracting the disease, there should be reassurance that the same preferential access to healthcare will be available for HCWs.

Mental health challenges

Fatigue, long working hours, and physical violence are some of the risks which exist for HCWs given the morally distressing decisions they often have to make along with witnessing the suffering of human beings, with or without Covid-19.

Along with this, HCWs and ancillary staff will now be carrying a huge psychological burden on their shoulders. In addition to personal health worries, there would be the ever lurking fear of transmitting the virus to loved ones. However, the biggest cross they would bear is that of their patients, many of whom they may lose, not because they could not save them but due to insufficient resources. Such pressures can lead to depression, insomnia and distress. Already, there have been several reports of nurses ending their lives because they could not cope with the mental stress of seeing patients die around them. This is expected to worsen and these people will require ongoing and perhaps long term mental health help. However, mental health continues to be an area which is sorely neglected in our healthcare system and by our society at large.

HCWs are no warriors

Calling HCWs warriors in the times of Covid-19 and glorifying the situation is hugely problematic. Healthcare workers are certainly in the forefront, but unlike soldiers, they did not sign up for this and neither were they trained on how to deal with this. Healthcare workers were also never equipped for such a war unlike a soldier who would never be sent to the front without proper training and equipment. Here, our HCWs are applauded as they march bravely towards uncertainty, armed with little more than a worn out facemask.

A soldier's response to an enemy attack is exactly in lines of his duty. The oft mentioned 'oath' that medical practitioners take at the time of graduation nowhere mentions risking their lives for their patients. A doctor's or a paramedic's response in the times of disasters, be it earthquakes or floods or this pandemic, is well beyond the call of her/his duty. They are responding, not because they were trained and obligated to respond, but because they believe they can help.

Applaud them not as warriors going to the battlefront, but as conscientious professionals and staff who are rising to the occasion because if they do not, then who will?