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Salting the Earth

John J. Frey III is an emeritus professor of Family Medicine and Community Health at the University of Wisconsin School of Medicine and Public Health. He is on Twitter: @jjfrey3MD

The combination of the US election “season” and the devastation from the pandemic has left the country exhausted and in shambles. The emotional and political wreckage from recent times has worked its way into the national character of America. Physicians, nurses and staff have been particularly traumatized and exhausted after a year of constant death and uncertainty while living behind masks, shields and other PPE with no real relief in sight.

The emotional and political wreckage from recent times has worked its way into the national character of America.

Clinicians and hospital employees feel a rising rage as they watch a lack of national leadership, health systems crumble, colleagues die, and their careers being permanently affected by circumstances. No clinician trains to be a pandemic doctor but they are nevertheless. Meanwhile, the newspapers are full of demonstrators and politicians who demand the freedom to infect their neighbors and families but will, of course, also demand the best of medical care when they are ill. Health professionals are being asked to save the lives of some people who seem determined to kill them.

Clinicians … feel a rising rage as they watch a lack of national leadership, health systems crumble, colleagues die.

My colleague Will Miller MD refers to what we are experiencing as professional moral distress, which is a more profound concept than the overused term burnout. Moral distress reflects the conflict we feel between what we know we need to do and what institutions will permit us to do. Interestingly, the literature on moral distress is primarily from nursing. Recovery from it will require radical institutional changes, more clinician autonomy but will affect physicians for the rest of their careers.

The doctor patient relationship is built on trust. We need to accept that the patient is telling us their truth and we believe that beneficence, working for those patients’ wellbeing, is one of the principles of public health ethics.1 We believe in the mutual positive regard that patients and doctors should have for each other. But the cognitive dissonance of communities that appear grateful for the sacrifices of health professionals yet engage in behavior that completely disregards the safety of those same health professionals will not be forgotten easily. This time in history will leave scars.

General trust in the US has been shattered by the numbing repetition of lies and conspiracy narratives. Any hope that neighbors will learn to collaborate for the common good is undermined by the malignantly narcissistic figure of Donald Trump who spreads hatred and paranoia everywhere. The pandemic has amplified the literal and figurative distance between neighbors and among family members, between teachers and students, between doctors and patients , inflicting a kind of collective psychological trauma that can be summed up by asking an older person when they think they will feel safe going to a movie or going out to dinner or seeing their grandchildren again. The answer is, despite vaccines beginning to be rolled out, a sad look followed by “maybe never.”

General trust in the US has been shattered by the numbing repetition of lies and conspiracy narratives.

The federal government, which has resources and expertise, has undermined trust in science and avoided rational suggestions for prevention. States and health systems fight over supplies and will undoubtedly fight over vaccines. In normal times, 50% of people are vaccinated at their primary care physicians’ offices and 90% of family doctors provide immunizations as part of their practice. So as the coronavirus vaccines become available to the general public, generalists will be the front lines in the campaign. They know their patients and communities and they are trusted. They are distributed along the lines of the general populations in rural and urban communities. They have experience negotiating with those hesitant for whatever reasons to get vaccinated. 2,3 So, unless the practicing community is at the center of vaccine distribution, the country will fall short of its goals. At the moment, there is little talk of how the primary care workforce is central to the first wave, never mind that this will most likely be an annual process.

The exit of Trump – and he will go – will be a final act of pique and governmental destruction which will salt the earth of the country in a way that may make any rehabilitation and reckoning seem impossible. He has unleashed campaigns against voting rights, health care, the environment, education, housing, relationships with other countries in the world, left cities and states with irreconcilable differences and created levels of intolerance not seen since the civil war. Thousands of physicians nationally are signing statements published in their local newspapers asking their neighbors to exercise some civic restraint and decrease risky behavior. But the record numbers of deaths shows that the warnings are not having an effect.

Cooperation, collaboration and unified movement toward a national health system is the only way to not be crushed again.

So what will rise, afterward. One can hope, some civility and understanding, collaboration and a search for the common good – at the local and state level if not at the federal government. It depends on how widely Trumpism has metastasized. Family medicine will have to be reinvented both from a structural and educational perspective. Things worked moderately well in the half century before the deluge, but the combination of the political violence visited on the country, the concomitant destruction of trust and the glaring inadequacies revealed by a merciless pandemic have pointed out the urgent need for massive reform. President Joe Biden has to clean out the Augean stables full of the shit left by Trump and his brown shirts but also has to reinvent a health system focused on stewarding resources rather than pursuing greed. Cooperation, collaboration and unified movement toward a national health system is the only way to not be crushed again when the next pandemic comes along. As Benjamin Franklin has been quoted “we must all hang together or we shall each hang separately.” This is the time for physicians and the public to take that to heart.

References

1. Schröder-Bäck P, Duncan P, Sherlaw W, Brall C, Czabanowska K. Teaching seven principles for public health ethics: towards a curriculum for a short course on ethics in public health programmes. BMC Med Ethics. 2014;15:73.

2. Campos-Outcalt D, Jeffcott-Pera M, Carter-Smith P, Schoof BK, Young HF. Vaccines provided by family physicians. Annals of family medicine. 2010;8(6):507-510.

3. Hurley LP, Bridges CB, Harpaz R, et al. U.S. physicians’ perspective of adult vaccine delivery. Annals of internal medicine. 2014;160(3):161.

 

Featured photo by Alex Iby on Unsplash

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