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June 09, 2020

Healthcare workers ‘at the frontline’ of COVID–19

Doctors

Image created by Kevin Kobsic. Submitted for United Nations Global Call Out To Creatives - help stop the spread of COVID-19.

Written by Dr Sharifah Sekalala

In Susan Sontag’s seminal essay on ‘Illness as Metaphor’ (1978), she argued that military metaphors profoundly shape our responses to public health crises. ‘Fighting’ against a disease positions it as an ‘enemy’ that must be defeated, and risks stigmatising those who ‘lose their battle’ as weak or lacking courage. In the same way, describing healthcare workers at the ‘frontline’ of an offensive invokes warlike language, and the gendered nature of this discourse may lead us to misperceive the complexity of caring during a crisis.

There has been no shortage of military metaphors relating to Coronavirus (COVID-19) pandemic in the United Kingdom (UK). The prime minister, Boris Johnson, talked of a fight in which everyone is directly enlisted, and, on his return from hospital after contracting COVID-19, he referred to the coronavirus as “an unexpected and invisible mugger”, which he praised for being “suitably muscular”. Likewise, the Queen, in a rare speechin April 2020, drew on the phrase “We’ll meet again”, taken from the 1939 British song popularised by singer Vera Lynn, which invokes the idea of soldiers leaving their families to go and fight in a war.

However, these metaphors are a blunt instrument. They are designed to garner public support, and tend to emphasise the part played in the response to COVID-19 by men, overlooking serious and structural gendered inequities in healthcare. Many speeches have mentioned doctors and nurses, but, as in war, the generals at the top are valorised for their heroism, while those in the trenches at the frontline are forgotten. These most vulnerable and exposed healthcare workers are (unlike frontline troops in war) predominantly female and are overrepresented by those from poor socio-economic and racial backgrounds. For many weeks the UK government even refused to release data on BAME deaths, making it harder to know who exactly was dying. Carers in care homes were also not given Personal Protective Equipment (PPE) until there was a public outcry.

In the UK, healthcare workers have been hailed as heroes, and the country is out on the streets every week clapping for them. The prime minister has even named his newly-born son after one of them, and they have been given preferential treatment by many retailers, with some restaurants even providing them with free meals. But who exactly are the people shouldering the sharp end of the burden of COVID-19? Occasionally, we read headlines about particularly brave surgeons or nurses – far less often about healthcare workers, who constitute the vast majority of those risking their lives every day to support the healthcare system. The entire system is also being sustained by largely women carers who are now doing much more caring at homeas children are off school even when they are still working remotely.

Care work in the UK is grossly underpaid and largely unrecognised. Many cleaners and healthcare workers are no longer directly paid by the NHS, and therefore do not enjoy the same employment rights as NHS workers. They are not unionised and therefore they cannot demand health and safety measures that many other workers take for granted. Many are migrants and consequently in a weak position to articulate their rights when they are violated. By celebrating carers as heroes we may make ourselves feels better while overlooking society’s responsibilities to them. Warlike rhetoric portrays the noble togetherness of a fight against this great evil, but many of the most vulnerable foot-soldiers would be better served by focusing attention on structural changes that would help the most disadvantaged of these people.

The way in which the aftermath of caring has been dealt with illustrates the erasure of some of these categories of carers. A UK backed scheme in which dependants of NHS carers who died from COVID-19 were automatically given indefinite leave to remain free of charge (giving dependants the right to remain in the UK without any time limit on their stay and allowing them to take up employment or study), had been limited to certain occupations such as doctors, radiographers, nurses, biochemists and phycologists leaving social care workers, hospital cleaners and porters ‘out in the cold’. It was only after an extensive outcry that the government relented and added these carers to this scheme.

The valorisation of certain kinds of carers is not unique to the UK and is a global problem. In the Ebola crisis in West Africa many international discussions focused primarily on the risks of violence faced by frontline health workers ‘in the field’, and the scarcity of professionally trained health workers. In so doing, the international community failed to recognise that caring during complex emergencies often necessitates that caring not only falls to professional carers but relies largely on non-professionals. This care work was gendered, and it often fell on women to provide it. Just as in the COVID-19 crisis, the Ebola crisis had different hierarchies of carers from those most protected from harm, to those least protected. The first category comprises international aid workers, primarily employed by humanitarian aid agencies (e.g. Oxfam, Mercy Corps, Doctors Without Borders (MSF), International Committee of the Red Cross, and foreign public health agencies such as Public Health England and the Centre for Disease Control. These international health workers retained a high level of autonomy in that they had clear contractual terms about the kind of work that they could reasonably be expected to do, and always had the option of leaving the country.

The second category, medical professionals at the domestic level, consisted of doctors, nurses and other highly trained domestic health workers, such as nurse aides, nurse assistants and midwives, referred to here as domestic nurses. In both West Africa and the Democratic Republic of the Congo, a severe shortage of domestic health workers, especially in the public health system, created an overreliance on nurses. In global health crises, domestic nurses are often the first responders, due to a shortage of local doctors. The nurses often worked in very poor conditions, lacked sufficient knowledge of haemorrhagic fevers, and in the early days of the epidemic often worked without PPE. Their vulnerability to infection was borne out by a systematic review(Selvaraj et al, 2018) of research on health workers in West Africa, which found that nurses and midwives — predominantly women — were particularly vulnerable to Ebola because of the intimate care they provided during the epidemic. In the West African crisis, nurses accounted for more than fifty percent of infected health workers. As employees of the state, the nurses had low bargaining power, though some managed to negotiate more lucrative employment with humanitarian aid agencies. Others had no choice but to remain at their stations in low-paid government hospitals, thereby, suffering differential and disadvantageous economic reward compared to the higher remuneration packages paid to foreign humanitarian workers and nurses who worked for humanitarian agencies. The third category was Community volunteers, such as Water and Sanitation (WASH) staff, who performed the highest risk jobs: cleaning and disposing of blood, vomit, waste, burying bodies, and educating local communities about the epidemiology of the disease. Many worked as cleaners in hospitals and treatment units, some washed clothing, while others (primarily traditional healers) helped wash and bury bodies. In the West African Ebola crisis, many of these staff were volunteers, and, although they received training, their lack of experience, and their poor work conditions, placed them at greater risk of contagion. As non-medical professionals, these community health workers fell between the category of professional workers and citizens. Due to their legal status as volunteers, their pay and working conditions were less favourable, making them particularly vulnerable.

Finally, there were individual carers in homes – who were predominantly women - who looked after families during and after the crisis. In a patriarchal culture, women’s primary designation as carers meant they were more likely to have responsibility of nursing and caring for extended families. They performed various care roles in homes, and sometimes, as a result of quarantine, had to leave their own home to reside near Treatment Units to care for loved ones in isolation — and then had to manage the precarity posed by living in temporary accommodation in a male-dominated environment.

The comparisons between the hierarchies in West Africa and those in the UK are startling and they must make us seriously rethink the ways in which caring is organised, recognised and compensated. We use the language of heroism to obscure; the very nature of the ‘hero’ identity requires that only a few people can be identified as such, and those that do meet the criteria require self-sacrifice in order to do so. In reality, both in the UK and globally, the group of people who provide care is much bigger. At the bottom are people who we have severely oppressed, and we owe it to these carers to move beyond the metaphors, and to examine and document the experiences of the categories of carers in the COVID-19 crisis if we are to remove the structural barriers to caring for them.


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