Margaret Walton-Roberts, Professor, BSIA and Geography and Environmental Studies
The unprecedented global shut down due to the pandemic of COVID-19 is exposing public health system weakness globally. In COVID-19 we are facing a virus to which we are immunologically naïve, and for which it is complicated to determine an accurate case fatality rate, but we do know it is higher than influenza and more serious for the elderly and those with comorbidities. There has been some variability in national government responses to the epidemic depending on public health resources, but contact tracing and containment using quarantine and isolation of the infected, and social distancing to limit spread are the main approaches. The relative effectiveness of these approaches can be seen in the data on national infection and death rates.
It is clear that in the chaos and confusion of shut-downs and shut-ins the public have become acutely aware of what is important to them. Jobs that are deemed low paid and low valued have become essential to the public’s sense of security. Grocery store clerks, care workers, nurses, hospital cleaners have all suddenly been seen for the important work they do to maintain human systems of biological survival. In this moment of unprecedented crisis, health care workers, the equipment they need to do their work and a coordinated international response have become the frontline in coping with the pandemic. As countries struggle to flatten the curve, it is worth examining the roles and struggles of these heroes of the current pandemic in more detail.
The World Health Organization’s primary role is to direct and coordinate international health within the United Nations system, including health systems; health through the life-course; noncommunicable and communicable diseases; preparedness, surveillance and response; and corporate services. Health systems include human health resources—the number, qualifications and distribution of appropriate health workers. Numerous studies show evidence of a direct and positive link between numbers of health workers and population health outcomes. Nurses represent the largest occupational group in health globally, 2/3 of whom are women, and their role is fundamental to achieving various global health and development strategies. Considering this, it is prescient that the World Health Assembly has designated 2020 the year of the nurse and the midwife.
Understanding the importance of the work of nurses also means we need to recognize how they are made vulnerable by policy decisions. Toronto’s experience of the SARs pandemic in 2003 revealed how austerity policies turned nurses into vectors of the SARs virus, since the majority of nurses’ were not employed full time and in order to earn an adequate wage they had several part time jobs. In moving between different hospitals the nurses transmitted the virus. Mike Davis has discussed a similar case related to Seattle’s first COVID-19 outbreak at a Life Care Center nursing home. These nursing homes are some of the US’s most understaffed and underfunded where care workers typically work several jobs in nursing homes across the city. Early spread of the virus may have been linked to workers moving between these locations: underinvestment in health and long term care effectively undermines infection control and exposes health workers to increased risk.
Front line health workers are some of the most vulnerable in this pandemic. In Spain 14% of COVID-19 cases are health care workers and 10-15% have been infected in Brescia, Italy. When the surge of COVID-19 patients hit hospitals, reports indicate a war like environment, with staff exhausted, terrified and facing PTSD as they cope with the horrific reality of having to ration lifesaving ventilators. In New York nurses are wearing garbage bags in place of gowns, and reports of nurses contracting and dying due to COVID-19 exposes how dangerous this lack of personal protective equipment is. We are even seeing tragic news of nurses committing suicide after being infected by COVID-19 because they fear they may have infected patients. While health workers have been praised in various public displays of support, there have also been disturbing reports of NHS nursing being subjected to discrimination and violence, and US nurses and Indian doctors being evicted from their homes because of COVID-19 fears.
To fight the global pandemic many OECD (high income) nations are calling upon what is effectively a global health workforce. According to recent report by MPI migrants make up 29 percent of physicians, 22 percent of nursing assistants in the USA. In the UK 13.3% of NHS workers report a non-British nationality, and in Canada in 2018 8.5% of nurses and 26.4% of physicians were internationally educated. This supply is sometimes at the expense of source regions, typically lower income nations that experience out-migration as a form of brain drain. It is worth remembering, that while the British are rightly proud and protective of the NHS, its formation in the 1950s was built on the contribution of thousands of Commonwealth and Caribbean Windrush migrants, and some of their families were later subjected to appalling treatment by the UK government, including denial of government services and deportation. The importance of immigrants’ contribution to the health care systems of many high income nations becomes more ironic when we think about the xenophobic and nationalistic reactions of some political leaders in response to the pandemic.
In the aftermath of this unprecedented global pandemic and its associated economic, social and political effects, we need to remember the gratitude we have expressed for health workers. We must remember this at election time when we consider political party platforms that boast mandates of tax cuts and ‘small’ government. These promises generally result in cutbacks to health investment, and nurses and other feminized health workers are often disproportionally impacted by these fiscal actions. In addition, the place of international migrants in OECD heath care systems reveals the global sourcing of workers that wealthy countries have long enjoyed, and that demands a mutual responsibility to promote and protect global health initiatives that boost the public health capacities of all nations.
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