My career as a hospital epidemiologist has been based on science and evidence, which I believed to be the touchstones of my work. But Covid-19 has taught me that fear — gut-wrenching, all-consuming fear, like the fear of dying from a horrific respiratory virus — can be much more powerful than science.
We can’t conquer this fear unless we acknowledge and respect it.
I’m no stranger to my work keeping me awake at night. In pre-pandemic times, I sometimes lost sleep over issues like a spike in staph infections in a particular intensive care unit.
Now I lie awake worrying about keeping patients safe from Covid-19. But there’s an equally powerful and constant worry: How do we keep our staff safe? After all, we can’t take care of our patients without healthy staff. Do we have enough personal protective equipment (PPE)? Have we adequately trained and retrained frontline workers on how to avoid becoming contaminated with the virus? Is there anything more I should be doing to prevent workers at the hospital from becoming infected with SARS-CoV-2, the virus that causes Covid-19?
Every positive test in a worker makes me feel like I’m not doing my job.
I have trained for a pandemic situation like this, and have long felt that my colleagues trusted my judgment and decisions. Covid-19 has challenged that faith. When we watched the news coming out of China in January, I explained that the high case-fatality rate (the rate of deaths in people being treated for Covid-19) would almost certainly be orders of magnitude lower once expressed as the infection-fatality rate (the rate of deaths in people infected with SARS-CoV-2, many of whom never have symptoms of Covid-19 or require treatment). “Are you sure about that?” I was asked. Perhaps I was minimizing the risk to prevent panic, some implied.
By March, we had read about and seen footage from Bergamo, Italy, and from New York City. Health care workers were getting sick and dying. Our hospital had its first Covid-19 patient. We knew we were heading into a surge and there was nothing we could do to stop it.
We were so low on supplies that we were urging staff to avoid using N95 masks when caring for patients who weren’t suspected of having Covid-19. Then the situation got worse, and we limited N95 masks to staff caring for Covid-19 patients undergoing treatments at high risk for aerosolizing the coronavirus. These masks were so precious that they had to be stored and distributed centrally.
What I wanted the staff to understand from this distribution method was, “I care about you, so I want there to be enough N95s available when the hospital was full of Covid-19 patients undergoing high-risk procedures.” What they heard was, “I don’t care about you, so I make up rules that compromise your safety.”
We desperately tried to get more masks and other types of personal protective equipment, but simply could not do so. The demand far outweighed the supply.
Some staff members pointed to pictures of health care workers in other countries wearing full hazmat suits and wondered why we were not recommending and purchasing the same level of protection. When my team members and I cited guidance on personal protective equipment or other safety measures from the Centers for Disease Control and Prevention, the World Health Organization, and the Infectious Diseases Society of America, all of which we tightly adhered to despite the severe supply shortages we faced, the response from some workers was that they no longer trusted those organizations. And the unspoken implication was that they no longer trusted me or the hospital administration.
Give us more protection, workers seemed to say, to show us you care about us. To make matters worse, nearly every day our recommendations and protocols changed, either due to new science, new public health guidance, or new shortages of supplies. Every email communication I sent was met with new expressions of despair: It’s too complicated. How can anyone keep up with all the changes?
And what I heard was, “Do you actually know what you’re doing?”
I was doing everything I could to make sure everyone working in the hospital was safe. But many didn’t feel safe. And in the end, perception is what matters. My training and scientific backing gave me a wealth of experience in treating and preventing disease, not panic or terror. I was ill-equipped for the emotional impact of a disease like Covid-19, even though I understood better than most the science of its transmission.
It was no consolation that the nation’s top experts, like Anthony Fauci of the National Institutes of Health and the scientists at the Centers for Disease Control and Prevention, were experiencing the same reactions from the public. Nearly every U.S. infectious disease physician and epidemiologist had advised the public not to wear masks in the early days of the pandemic. Then we changed our tune.
That’s how science works. Research advances knowledge and public health and medical guidance change to follow. But that simply doesn’t play well when you are being closely analyzed by a frightened and distrustful public.
In April, at the peak of the surge in Massachusetts, I took a different approach. There was too much information to disseminate, and our daily emails and constantly refreshed website were not effective ways to communicate. Because all non-essential surgical and outpatient activities had been canceled, I requested access to underutilized clinical staff and built a “Personal Protective Equipment Support Team” of more than 70 redeployed physicians, nurses, therapists, and technologists. The goal was to bring the information, education, and emotional support directly to the frontlines.
The team attended daily briefings to stay abreast of practice changes then supported the frontline staff by fanning out throughout the hospital, speaking to and demonstrating protection techniques to doctors, nurses, housekeepers, transporters and anyone else who was likely to interact with Covid-19 patients.
What we soon learned was that staff members were not necessarily looking for solutions to their fears but for acknowledgement of them. So our PPE support team began providing more than just information. We listened. We commiserated. We validated the feelings and the fear.
I continued to communicate with the staff in a daily email, which eventually became weekly and then biweekly, but rather than just giving them clinical information about new rules and guidance, I began share more personal and human information. I also learned, gradually and the hard way, to avoid dogma. I admitted that I was wrong about masks and recommended wearing them both inside and outside the hospital. I have become more careful when I speak about controversial topics like airborne spread and herd immunity, leaving open the possibility that new science could prove me wrong.
Without exception, every frontline health care worker in our institution showed up every day and did their jobs. The fact that they did so while fearing for their health and well-being made that even more commendable.
Today, I see the story that has played out in hospitals over the past 10 months repeating itself in schools. Teachers are understandably afraid to return to their classrooms. Like most health care workers, they did not sign up to risk their lives for their work. Proponents of in-person schools, mostly parents, argue with teachers in public forums and on social media, and quote scientific experts, health authorities, and government officials who say that schools should be open. They share articles and studies hoping to convince parents that in-person learning is safe enough.
None of those approaches will work. My experience has shown me that fear must be acknowledged, not dismissed in the name of science. Getting to a point of relative comfort with what one perceives to be a dangerous situation cannot happen overnight. For teachers to become comfortable being in the classroom, they actually need to be in the classroom and come out unscathed, as hospital workers have learned. Parents should thank them and applaud them like people did for health care workers in the spring. Administrators must educate them on safety strategies and give them access to expert advice, while accepting that some of them will remain skeptical and distrustful.
Respect the fear individuals have about Covid-19. Acknowledge it. Listen to what they have to say. Support them. Be patient and compassionate. And we can overcome the fear together.
Shira Doron is an infectious disease physician and hospital epidemiologist at Tufts Medical Center in Boston.