Covid-19 is not only playing havoc in the lives of patients, it has also impacted the lives of caregivers, the multitude of healthcare professionals who are at the frontlines of this battle, all across the world. Pakistan too is increasingly feeling the pressure as we steadily ascend this steep upward swing of the curve to wherever its peak may be. While doctors and nurses and the other ancillary staff are doing what they can, in the Covid-19 crisis they are confronted with much more than what they were ever trained for, or perhaps even signed up for.

This article examines not only the health risks involved but also the emotional impact that this mounting crisis is bound to have on what may be a highly motivated but often grossly ill-equipped health workforce.

The physical risks to doctors, nurses and other ancillary workers are all too apparent. Already, several health workers across Pakistan have been infected by their patients, and one young physician has lost his life.

As we try and flatten this curve by social distancing measures, the higher the upward stroke of this now infamous curve goes in Pakistan, the greater will be the challenge for healthcare workers as our capacity to care for the sick is exhausted. We are witnessing in real time how much more robust health systems have been brought to their knees by the ravages of this disease in other parts of the world.

Limited resources in a resource-constrained setting

Pandemic or no pandemic, healthcare resources in Pakistan are already inadequate to cater to our usual requirements. Even in times of normalcy, healthcare professionals in Pakistan face chronic shortages of even the most basic equipment and supplies. Shortage of Intensive Care Unit (ICU) beds is almost a daily occurrence in tertiary care hospitals, with junior doctors constantly phoning other hospitals to find available ventilators so that a critically ill patient can be shifted and saved. Often, they do not succeed.

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These chronic shortages are about to expand manifolds in the coming weeks, if the number of Covid-19 cases increases in Pakistan. The shortage of resources is not strictly limited to equipment and supplies, but also the human resources required to deal with this challenge.

The government is scrambling to get the needed equipment including ventilators from China. The chief of National Disaster Management Authority of Pakistan (NDMA) has assured the nation that by early April, we will have planeloads arriving in the country. These machines need skilled operators and an ordinary health professional without proper training cannot use them and can actually inflict more harm in their misuse. We may not have sufficient qualified personnel who are available and also willing to do the job.

While we are quite confident that healthcare workers will be eager to serve at the proverbial frontlines, the fear of the virus is very real and we have already seen media reports of physicians refusing to go to report for "Corona duty" because they fear for their lives and that of their loved ones.

From the more developed parts of the world, including the United States, shortage of human resources has become evident as healthcare workers have contracted the virus, and are now in quarantine. With our resources at a stretch in peace times, how will we deal with these challenges in times of crisis?

Who gets to live, and who does not?

It is not difficult to imagine a situation, in which there is one ventilator possibly available, and four very sick patients in one hour, and perhaps 12 more equally sick and deserving ones in the next hour. How is the decision to be made to allocate this one available life saving device to a patient?

In normal times, especially where there are adequate resources to go around, "First come, first served" usually works very well in allocating hospital beds and resources, the patient who arrives first generally gets admitted first, provided it is medically indicated. In a chronically overstretched health system such as ours, our physicians generally juggle factors such as age, quality of life and the estimated utility of life years after recovery. This is not an easy calculus. These criteria however have become more crucial in the present situation.

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Consider the now-not-so-hypothetical situation in which there are two patients, an 80-year-old and a 40-year-old, both needing the machine to breathe. How about a 60-year-old who is a major donor to the hospital, or a 30-year-old fruit vendor who pushes his cart in streets all day long? What if a 65-year-old professor has a better shot at quality life for the next decade if he survives, versus a 35-year-old man with colonic cancer with an unknown outcome?

Throw into this analysis the situation when a 77-year-old patient with several other medical issues occupies an ICU bed, and after fighting several weeks, walks out of the hospital, to live a healthy retired life for perhaps another four years. During the time of his ventilation, perhaps four other younger patients who are now dead may have been saved by using this one machine with shorter periods of ventilation, and perhaps lived for decades, contributing to society.

These are the kind of decisions exhausted, terrified and sleep-deprived healthcare workers may have to be making soon, with little or no training in ethical decision-making.

The triage system and its challenges

A system however currently exists for sorting out patients for treatment prioritisation. The system dates back to 1792, when the Surgeon in Chief to Napoleon's Imperial Guard applied a process known as "medical triage". In this system, the wounded during war were divided into three different categories: those who will recover without treatment, those who will die whether or not they are treated, and those for whom treatment will make the difference between life and death. It is the third category that requires urgent care, particularly in situations of resource shortages, like as in war or today in a pandemic situation.

While the majority of Covid-19 patients can fortunately be treated at home safely, it is the 15-20% sick ones that will overwhelm existing resources, as is amply evident in how the virus has crippled the much more robust heath systems in European and American hospitals. It is these patients who will face triage for hospital and ICU beds, and ultimately for ventilators.

However, there is a difference when it comes to applying triage in a pandemic. As the situation escalates, healthcare workers will be forced to make choices and decisions which will literally boil down to life and death. They will be the ones who will be choosing who may be given a chance to live, and also those who will be left to die.

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Those being triaged out and excluded from ventilation are not because it is clear that they will die despite this intervention (category 2 in the above mentioned categorisation of triage). The doctor triaging out Corona patients would many times know that the patient he just turned away may have lived if intervention was provided; but there were too few ventilators to be hooked up.

Such decisions will take an immense psychological and emotional toll on healthcare professionals who will be left to bear the "dreadful burden of choice".

Another very real aspect linked directly to having to turn away patients is that of personal risk or violence by outraged relatives. In a culture of mistrust, the person on the frontline may be in harm’s way in such situations.

Italian experience and other guidelines

Italian doctors have been grappling with exactly these kinds of dilemma and recommend that in these desperate Covid-19 inflicted times, the "first come, first served" rule does not apply.

They have recommended that "priority should be given to those who have, first, greater likelihood of survival and, second, who have more potential years of life". Applying the utilitarian philosophical theory which talks about the rule of maximising benefits for greater numbers, the application of this analytical framework advocates that healthcare workers utilise limited resources to "save more lives, and more years of life".

Operationalising this rule would mean that people who are sick but have a greater chance of recovery would be given priority, and those refused would include in addition to the category 2 patients noted above, also those who if saved are considered too old to benefit for a meaningful period of productive life, even if they arrived early and a ventilator was available. This exclusion from treatment is beyond the framework of classical triage to which health systems are accustomed.

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The moral burden in making such choices, albeit aided by guidance documents and expert opinions, does not lessen the enormity for the decision-maker.

More complexities

Even with these guidelines in place, ought a fellow physician or a nurse be given priority for a ventilator bed if she requires it, over and above another patient who fits the criteria? Most would say they should, based on the principle of reciprocity. Expert opinions also suggest that because of the instrumental value of healthcare workers (i.e. they are essential for providing emergency care services in times of pandemic) they may be given priority for treatment.

But ought an ICU bed be kept vacant in order to accommodate a stricken healthcare worker who may need it? Even beyond a sense of camaraderie, this may be a pragmatic necessity to keep the system functioning.

Also worth considering is the scenario in which the next day, the ER receives a 70-year-old mother of a physician who works at this hospital. Her son has brought her, riddled with guilt since sequestered tightly in the house, the only way his mother could have contracted the infection is through him. Even though she may not fit the age criteria (which, let us assume, has been set at 65 years) should she be given a ventilator, using the same principle of reciprocity? After all, human beings do not live as atomistic, isolated units, they are very much part of the family system. What are the responsibilities of healthcare professionals to their families in such times?

Personal risks

Hospital beds and ventilators are not the only things in short supply. The personal risks of handling patients with a deadly contagious disease can be mitigated somewhat by the use of Personal Protective Equipment (PPE) which, at present, is a rarity. Using a mask and a pair of gloves offers very limited protection and does not constitute PPE.

Does the society expect healthcare professionals to rush to "combat" in the absence of such equipment? In other words, is the duty to treat by healthcare workers' absolute, no matter what the context?

Immanuel Kant would certainly say it is. But Kant is criticised because his analysis does not take the context into consideration, the context that the individual lives in. Would a 25-year-old physician be well within his rights to refuse to report for duty in the Corona ward where no PPE is being provided, especially now that one 29-year-old physician from Gilgit-Baltistan contracted the disease while screening suspected patients and subsequently perished?

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Do healthcare professionals have the same duty to treat, as say soldiers do to carry out orders from his superiors? A soldier is expected to stand his grounds, under any circumstance, even after running out of ammunition, if told to do so. The oath that physicians take at the time of graduation from medical colleges talks of service without prejudice, and practice with his patients' health as his first consideration. However, nowhere does it state that a physician should risk his own life for the sake of his patient. Of course, it can be argued that it is within such dire situations where the greatest servitude to humanity is required. However, these would count as supererogatory acts rather than something that may be expected as a norm.

Healthcare leadership also has considerable issues to contend with. Would it be justifiable for the medical superintendent of a hospital to use coercive means to make sure that the Corona Unit at her hospital is staffed? The fear of personal peril of contracting the disease is very real, but the fear of taking the disease home is even greater.

Consider the hypothetical case of a young general practitioner in a government dispensary in a small Pakistani town. He is told to report for Corona duty by the District Commissioner. Having never managed a patient in a ward since his house job 18 years ago, he may not even be able to start a drip, let alone manage fluids for a very sick patient. He wonders what use he will be at the frontlines, with or without PPE. Is he a disgrace to his profession if he refuses to go?

Mental health of frontline workers

In addition to the very real physical risks that they run, there is also the inevitability of considerable mental distress. Refusing to allocate precious life-saving resources to a gravely sick person who may be having even the slightest chance of living is a heavy cross to bear: "He died because I decided he should not be given a chance."

With mental health enjoying the lowest rung in our healthcare priorities, ironically somewhere near public health in our medical education system, the mental scars these healthcare workers will develop can have long reaching consequences for themselves, their families and their medical practice.

Amidst the joys of seeing a patient recover from the throes of Corona and walk out, there will be the devastating lingering images of those who died gasping for breath. Or the parent they blamed themselves for infecting and ultimately losing.

As a society, when we examine the role played by these men and women, our doctors, nurses, physical therapists, ancillary and support staff, the security guards and the janitorial staff, let us not criticise them for their failings, for there will be plenty of those, but for the immense burden they carry on their shoulders each day, in the hope that lives of complete strangers can be saved. The scars from the battles to come will be etched on their lives forever. As members of the public, it is our collective duty to exercise patience, and have faith, in these heroes, most of whom will remain unsung.