For the Greater Good II

Since I am on the subject of service to the Greater Good I thought perhaps a follow up would be helpful. 

I don’t think there is any argument about who the most in demand group of people will be in a PanFlu event, and who, as it happens, will also be the most at risk, Health Care Workers, commonly shorthanded to HCW’s. 

The risks HCW’s assume during a time of a public health crisis is nothing new, below is a paragraph from Daniel Dafoe’s fictionalized telling of the Great Plague in London written in the early 1700′s. 

So the plague defied all medicines; the very physicians were seized with it…men went about prescribing to others and telling them what to do…and they dropped down dead, destroyed by that very enemy they directed others to oppose. This was the case of several of the most skilful surgeons.


A WHO Working Paper from Sept 14, 2006 The role and obligations of health-care workers during an outbreak of pandemic influenza attempts to address the ethical issues of HCW’s reporting to work during a pandemic as well as the ethics of not properly protecting them when they do so.  It quotes a paper addressing the HCW response to the outbreak of SARS written by Ezekiel Emmnuel: 

The history of physicians’ responses to … contagions is mixed. Galen is reported to have fled from Rome during a plague in 166. Although in the 14th century some physicians stayed and cared for the sick, most responded to the Black Death by fleeing. Defoe indicates in A Journal of the Plague Years—a novelistic chronicle about London’s great plague of 1665—that most physicians were called “deserters”. In the mid-19th
century, nascent professional organizations began to articulate the physician’s ethical obligation to care for the sick during epidemics. The SARS epidemic tested the dedication of a medical profession that might have been weakened by increasing commercialization, poor morale, an emerging preference for easier professional lifestyles,
and the pervasive self-cantered individualism of the larger society. Emmanuel 2003


The WHO paper goes on to state:

HCPs have responded with admirable courage and self sacrifice in response to communicable diseases such as SARS and Ebola. One might ask, therefore, whether an ethical problem truly exists.  There is little doubt that the vast majority of HCPs performed their jobs effectively admirably under considerable stress and sometimes at significant personal risk. Many HCPs provided exemplary care, and still others behaved in truly heroic fashion. Scores of nurses, doctors, respiratory technicians, other professional and non-professional health workers laboured extremely long hours at personal risk. This demonstration of going above and beyond the call of duty, which proved necessary to control the disease, was morally commendable. It can be expected, though not guaranteed that a similar response would be evident globally in the case of an influenza pandemic.

At the same time, however, serious concerns did surface during SARS about the extent to which HCWs would tolerate risks of infection to themselves. (Bevan and Upshur 2003) Some baulked at providing care to those infected with the unknown virus. In some circumstances, staffing became an issue in SARS wards and assessment centres; indeed, failure to report for duty during the outbreak resulted in the permanent dismissal of some hospital staff. As a consequence, the risk that was faced during SARS was not distributed equitably, and those HCWs who volunteered to provide care faced the greatest exposure. (Ruderman et al, 2006) Similarly, in Ebola outbreaks, there are reports of
doctors and nurses fleeing their posts for fear of contracting the disease or because of pressure from family members. (Hewlett and Hewlett, 2005)

Following such outbreaks, many HCWs who care for patients with serious communicable diseases raised concerns about the protections that were provided to safeguard their own health and that of their family members. Conflicting obligations were another significant concern. HCWs are bound by an ethic of care. Therefore, obligations to the patient’s well-being should be primary. At the same time, however, HCWs have competing obligations to their families and friends, whom they feared infecting, in addition to obligations to themselves and to their own health (particularly those with special vulnerabilities, such as a co-morbid condition). HCWs have faced stigmatization and serious threats to their families as a consequence of providing care. (Singer et al, 2003; Hewett and Hewett, 2005) During outbreaks, some HCWs questioned their choice of career; subsequently, some decided to leave their profession and pursue new ventures, indicating an unwillingness or inability to care for patients in the face of risk. Recent survey data from the U.S. indicate that there exist mixed views concerning the duty to care for patients during infectious disease outbreaks. (Alexander and Wynia,

The 2003 outbreak of SARS is our modern benchmark for how the health care system and the world at large will handle an infectious disease outbreak that carries a high degree of danger of death for those inflicted. 

Depending on whose figures you wish to quote SARS had a CFR of between 12-20%, staggering and frightful for a modern medical system to face.

During the SARS outbreak in Toronto Canada the hospitals treating patients had a reported 30% refusal to show from the nurses.  It must be remembered that nurses were especially hard hit by SARS in Toronto.  This was due in part to the abysmal handling of the administration and doctors early on and partly to the aerosolizing of the virus during intubation of the patients.

The reasons for the nurses high risk are not important to my point at this time however.  What is important is that the nurses knew that they stood a goodly chance of becoming infected and a risk of dying that was not insignificant, and I’m sure the prospects of a prolonged, debilitating illness also weighed in the decision processes of those who chose not to report to duty.

Given the level of danger I greatly admire the 70% of nurses that did report to care for those in such desperate need of their skills. However, I do not fault those that chose the opposite.  Self preservation is a powerful instinct.


AMA policy document “Physician Obligation in Disaster Preparedness and Response” adopted in June 2004:

National, regional, and local responses to epidemics, terrorist attacks, and other disasters require extensive involvement of physicians. Because of their commitment to care for the sick and injured, individual physicians have an obligation to provide urgent medical
care during disasters. This ethical obligation holds even in the face of greater than usual risks to their own safety, health or life. The physician workforce, however, is not an unlimited resource; therefore, when participating in disaster responses, physicians should balance immediate benefits to individual patients with ability to care for patients in the future. (AMA 2004)

The last sentence is an argument I have seen raised in response to the threat of a severe PanFlu.  It is an argument that I find difficult to refute.  While we will need our physicians during a health crisis of the scope feared we will also need them for all the other, normal, everyday and life-threatening health issues that will continue to occur and will continue to occur post pandemic.

There is good reason to believe that if a severe pandemic comes about any time within the next several years we will see our health care system overrun, overwhelmed and reduced to early twentieth century conditions and treatments within two or three weeks, four at the most.  There won’t be much a doctor will be able to do for patients of PanFlu (assuming severe).  The care that our medical system will be reduced to providing could easily be provided by non-skilled care givers.

How unreasonable is it to think that loosing 30% of our HCW’s due to unwillingness to work, and adding another 30% that will be removed from the labor pool due to illness, their own or a family members will quickly reduce the remaining 40% to little more than walking zombies if that 40% will have to supervise the care of possibly hundreds of cases each?

It may be wise to consider saving our skilled nurses and doctors for The After once a certain "tipping point" is reached.

As with most things related to a severe pandemic….there are no easy answers.

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