Health workers become unexpected targets during covid-19

Editor’s note: The Economist is making some of its most important coverage of the covid-19 pandemic freely available to readers of The Economist Today, our daily newsletter. To receive it, register here. For our coronavirus tracker and more coverage, see our hub

ONE WAS punched in the face on a Chicago bus. Two were stoned by a mob in the Indian city of Indore. Five men doused another in the Philippines with bleach. At least 21 in Mexico have been assaulted. At a time when politicians lionise them and homebound citizens cheer them on with claps and pictures of rainbows, doctors, nurses and other health workers around the world are finding themselves under threat of violent attack, and under terrible psychological strain. From Australia to China, governments and hospitals have had to take extraordinary measures to ensure the safety of their staff, even as they battle to control the global pandemic.

Covid-19 has left health-care workers more visible—and vulnerable—than ever. With a third of humanity having been locked down over the past few weeks, they are some of the only travellers on roads or public transport, conspicuous in brightly coloured scrubs or white robes. Doctors are easy targets for the frustrated, aggrieved or scared. Attacks are often treated as isolated incidents, but highlight a mounting problem: health-care systems across the world have struggled in recent years both with rising violence and the psychological toll on staff.

The figures are stark. The World Health Organisation estimates that as many as 38% of physicians worldwide have suffered physical violence at some point in their careers. In many places it is worse. In 2019 one in seven NHS staff in England said they had been physically attacked by a patient or member of the public in the previous 12 months. One in three Australian doctors reported similar abuse in the period of a year. Over 75% of India’s physicians say they have faced the threat of violence at work. After a female doctor was stabbed to death at a hospital in Beijing in late 2019, China introduced a new law banning threats against medical workers.

Fear of contagion, amplified by misinformation, appears to be prompting more violence during the pandemic. Often physical attacks are preceded by verbal ones, as doctors and nurses are singled out for supposedly spreading the disease. Others seem borne of frustration. Staff at hospitals in Australia reported being deliberately coughed and spat on by anxious patients waiting to be tested for the disease.

Yet deeper problems leave doctors and nurses vulnerable to attack. In many countries, perceptions of doctors have deteriorated over recent decades. China ended state subsidies for its hospitals in the 1990s, after which they quickly commercialised. This led to declining trust, as doctors were suspected of caring more about making money than looking after their patients. A similar phenomenon has been seen in India. Certainly, some doctors have abused the system. But tropes of corrupt, negligent physicians have become easy narratives to fall back on for politicians and sensationalist media outlets. In countries where people lack faith in the justice system, attacks in hospitals may appeal to patients who feel they may never get their day in court. An expanding middle class across the globe now demands more from medical professionals than they may be able to give. Even the architecture of modernised hospitals—such as emergency rooms that are easily and quickly accessible—also makes them more vulnerable to attack.

In response, health-care systems have taken extreme measures to protect their staff. Some hospitals in China now teach them self-defence. India’s government updated laws in April to deny bail to those accused of violence against health-care staff. Some emergency rooms in America have installed metal detectors. And administrators in Australia have started telling staff not to wear their scrubs outside hospitals.

These concerns come on top of the mental and emotional toll the pandemic is exacting. In hard-hit areas, many medical staff are working even longer hours than usual. Front-line workers have a high risk of catching covid-19, made worse by chronic shortages of personal protective equipment. Many have lost colleagues to the virus. Some, afraid of infecting their loved ones, have isolated themselves from their families for long periods of time. In a study of 1,257 health-care workers who treated covid-19 patients in China at the height of the country’s crisis, more than 70% experienced psychological distress. And in several countries, doctors and nurses have been fired or threatened after speaking out about poor leadership and the lack of equipment. In Russia, three doctors have fallen from hospital windows after making public complaints; two of them died. Local media reported these as either accidents or suicide.

Health work can be difficult at the best of times. More than 40% of American physicians experienced symptoms of “burn-out”—characterised by emotional exhaustion, withdrawal and cynicism—in 2019. According to Dr Colin West of the Mayo Clinic in Minnesota, burn-out often stems from overwork, stress and bureaucracy that limits interaction with patients; doctors feel less able to help those in their care.

The pandemic has created acute horrors. In some areas, a lack of resources means doctors have had to ration life-saving care. In Italy—where 10-25% of hospitalised covid-19 patients required ventilation, sometimes for several weeks—there were reports of doctors weeping in hallways over the choices they had to make. Many have spoken about the pain of watching patients die alone. Such traumas can cause “moral injury”, the term used for psychological distress caused by action, or inaction, that violates one’s beliefs. First applied to the experience of certain soldiers in wartime, moral injury can contribute to problems including depression and post-traumatic stress disorder (PTSD).

Struggling medics can find help hard to come by. Worldwide, doctors and nurses take their own lives at rates significantly higher than the general population. Dr Clare Gerada, who chairs “Doctors in Distress”, a British charity, attributes the problem, in large part, to a lack of time and space afforded to doctors and nurses to discuss the emotional impact of their jobs.

Many health officials, conscious of the strain on medics, have tried to provide helplines and other support. Many experts worry that such measures will be phased out once normal service is resumed. Dr Andrew Molodynski, a psychiatrist who oversees mental-health policy for the British Medical Association, notes that many conditions such as PTSD require consistent face-to-face treatment. The economic damage sustained during the crisis will hinder the provision of such treatment, and other mental-health care, over the longer term.

Even as covid-19 cases fall, the workload for medics is likely to stay high, as hospitals scramble to provide the care suspended during the response to covid-19. The threat of violence will only add to the burden. For those who would assault doctors, Brad Hazzard, the health minister of New South Wales, summed it up bluntly. “When you see that person in a uniform in a hospital might be actually putting a tube down your throat to keep you alive, you will wish you hadn't actually done what you did.”■

Dig deeper:
For our latest coverage of the covid-19 pandemic, register for The Economist Today, our daily newsletter, or visit our coronavirus tracker and story hub