Long before coronavirus swept the globe, Jim Harper had seen his share of devastation. As battalion surgeon for the 101st Airborne in Iraq, his sole mission was saving lives. But there were some injuries he could do nothing about. Behind his field hospital sat the “death bin,” where soldiers’ bodies, and pieces of them, were gathered.
Jim, whose name I’ve changed to preserve his anonymity, left the Army after the Iraq war, and now serves as an emergency room physician in a large U.S. hospital. He never imagined that the prolonged trauma he endured in a combat zone could happen to civilian doctors working stateside. Then came coronavirus. “It’s no less frightening looking down the throat of someone breathing vapors that could kill you,” he told me, “than strapping on body armor and driving down airport road in Baghdad.”
The tension and fear that dominated Jon’s days overseas are now part of everyday life for health-care workers on the front lines of the fight against COVID-19. Emergency rooms across the country have become trenches. We know that the casualty count will be catastrophic, and that health-care workers and first responders will be the ones who witness the deaths and gather the bodies. What we have not accounted for, however, is the long-term psychological impact of their efforts. Americans are right to laud the bravery these responders demonstrate by simply showing up for work. What we have failed to appreciate is the price they will pay for that courage in the years to come.
I have some sense of the trauma these conditions can inflict. I served with a disaster response organization, and deployed as a medic to refugee camps and disaster zones. I will never forget the sight of bodies stacked by the side of the road after Typhoon Haiyan swept through the Philippines. For those on the front lines of the battle against coronavirus, that grim reality is with them every day.
“When a Corona patient suffering from silent hypoxia rolls in,” Jim told me, “it’s very similar to the Charlie Foxtrot that unfolds when an IED blasts up your convoy.” The difference with coronavirus, however, is that the patient brings the threat with them. Every infected individual is carrying a personal IED into the hospital.
Because the front lines of this pandemic cut through our communities, coronavirus responders, unlike combat medics, have no easy way to rotate out of the hot zone. If a potentially infectious interaction does force them to isolate, they are denied the very thing that helps most when dealing with trauma—contact with other human beings.
Daily exposure to the dead and dying, feelings of helplessness, the moral injury that comes from making decisions about who should live or die—these are already exacting a heavy toll on our responders. A New York doctor and a medic recently died by suicide. They will not be the last.
The coming deluge will overwhelm our existing mental health infrastructure. As any veteran will tell you, we have seen this movie before, and it does not end well. Among those who served in uniform after the September 11, 2001, terrorist attacks, deaths by suicide now eclipse combat deaths. It is possible, even likely, that a similarly gruesome statistic will eventually apply to coronavirus responders.
Unless we prepare.
As horrific as the epidemic of veteran suicides has been, it contains valuable lessons. When the Departments of Defense and Veterans Affairs failed to adequately address mental health care, leaders from across our community devised their own solutions. Team Rubicon, the disaster-relief organization I helped lead, was founded to give veterans a renewed sense of purpose through service. Even as it evolved into a world-class disaster-response organization, it maintained a focus on the mental health of its front-line responders. When my relief team returned from the Philippines after the deadly typhoon, among the first people we spoke with upon arriving at Los Angeles airport was a counselor. It made a difference.
Eventually, veterans learned to advocate for themselves, and to demand accountability from the same government that sent so many of us to war. The Clay Hunt Suicide Prevention Act, named after one of Team Rubicon’s original members, was signed into law by President Obama and expanded access to mental health care, while increasing the supply of licensed psychiatrists through a scholarship program. Clay Hunt lost his own battle with depression years earlier, but the bill that bears his name saved countless others.
Additional laws followed, but not until the epidemic of veteran suicides reached more than 20 per day. We cannot let the same thing happen among those battling COVID-19. As a nation, we must understand the long-term effects of their time in the trenches. Then, we must innovate, build capacity, and hold government accountable.
We can take the following five steps immediately:
- Activate a hotline for health-care workers in crisis, modeled after the Veterans Suicide Prevention Hotline. This would be staffed by counselors who understand the unique pressures those battling COVID-19 face, and who can provide urgent interventions or simply offer guidance about additional resources.
- Establish a dedicated fund, similar to the September 11 Victim Compensation Fund, to ensure that COVID-19 workers have the resources necessary to access the health services they will need. After 9/11, first responders waited nearly 18 years to see their health care guaranteed. We cannot subject COVID-19 responders to the same agonizing delay.
- Establish presumptive eligibility for COVID-19 responders to access the above fund when private insurance falls short. The burden of proof cannot rest with those who risked their lives—anyone suffering a mental-health crisis should not be forced to endure a lengthy application process, because delays cost lives. For responders who do contract COVID-19, the same presumptive eligibility should apply, particularly given the uncertainty about long-term physical consequences of the disease.
- Enforce parity for private insurance plans, to ensure that mental-health issues receive the same level of coverage as physical illness. It makes no sense to receive care for a sprained wrist, but be denied for a mental injury. The brain is just another organ, subject to trauma. With appropriate treatment, it can heal from psychological wounds.
- Create standards to encourage those who employ COVID-19 responders to focus on mental health. These might include regular self-assessments, annual screenings, and peer-support networks. Where appropriate, workplaces should adopt and formalize the veteran community’s “buddy system,” one of the best ways to counter self-isolating behavior.
Over the longer term, America must radically expand its mental-health infrastructure. We will need a dramatic increase in the number of mental health-care providers, along with much broader awareness that mental health is every bit as essential as physical health.
Military veterans have long felt that those who sent them to war could never fathom what they’d seen. The idea of “death bins” behind field hospitals seemed like something few people would believe. Now, we have mass graves in New York City, and freezer trucks in parking lots. The immediacy of this crisis is clear to anyone who can see. We must also appreciate its longer-term effects, and the burdens that our COVID-19 responders will carry for years to come. Unless we act now, we will lose an unacceptable number of those fighting on our behalf.