As an emergency medicine physician and director of emergency management, I have taken part in disaster and humanitarian responses in Sri Lanka after the Indian Ocean earthquake and tsunami, in Haiti during the height of the AIDS epidemic, and elsewhere. I often experienced “reentry” afterward — the disjointed feeling of returning to the place and activities I had left behind. I never expected to experience reentry from working in my own hospital in Northern California, yet that’s what I am feeling today.
I know from experience that reentry often feels like an assault. Disaster relief workers experience stringent and unpredictable environments, and they may witness gruesome scenes or experience personal deprivation. The return home can be as jarring as it is a relief: responders often have haunting memories and feel profoundly changed, and they are prone to culture shock and post-traumatic stress.
This is what many of the estimated 22 million health care workers around the U.S. are now facing nearly two years into the Covid-19 pandemic. For the good of the country’s ongoing pandemic response and long-term health, American health care workers must urgently address how effectively to reenter what is decidedly a new normal.
Emergency managers think of disasters as having four phases: mitigation, preparation, response, and recovery. Mitigation and preparation represent the careful planning, the relationships forged, and the guidelines created before a disaster. The response phase is characterized by quick thinking and action in the midst of a disaster.
The recovery phase — comprising the transition back to normal operations and regular duties — is extremely complex, yet it is frequently a less-appreciated part of the cycle. Recovery is the process of negotiating short-term needs with long-term goals and of balancing the desire to return to normal with the goal of decreasing future vulnerability.
It’s during the recovery phase that individuals and nations begin to truly comprehend the tangible losses of a disaster and its hidden costs.
It is a mistake to view the four phases as linear, because short- and long-term recovery should begin even as the response phase is underway. The length, breadth, and speed of change of the recovery phase require disaster responders to tend to recovery even in the context of an ongoing response.
The Covid-19 pandemic has brought unprecedented challenges and changes for everyone. For health care workers, it initiated a deployment into a disaster response that seemingly has no end. In the early months, doctors, nurses, respiratory therapists, paramedics, hospital food service workers, and others suffered from fear, isolation, and shortages of personal protective equipment and other supplies. They battled the dual anxieties of treating this perplexing and potentially deadly new disease while worrying about bringing it home to their families.
The later months were about exhaustion — physical, mental, and moral. Patients in tents, patients in hallways, entire families lined up in cars to get tested or seated in chairs hooked up to oxygen tubing. One day I spent eight hours under a pop-up tent treating patients with an ice pack strapped to my neck as temperatures soared to 108 degrees. Then came midwinter, when it didn’t seem possible that more patients could be treated, yet still they came. Later on, I often felt empty because of the never-ending onslaught, experiencing the same burnout and compassion fatigue felt by so many frontline responders during the Covid pandemic.
Relief workers are at risk of mental health disorders following disaster deployment. The risks are even higher when the deployment is prolonged, when relief workers experience risk of personal harm, and when responders identify with disaster victims as their neighbors or community — all factors that health care workers experienced during the Covid-19 pandemic.
In its “Tips for Supervisors of Disaster Responders” fact sheet, the U.S. Substance Abuse and Mental Health Services Administration describes a range of reactions that returning responders may experience, including unrelenting fatigue, cynicism, dissatisfaction with routine work, easily evoked emotions, and difficulty with colleagues and superiors. Some responders become stuck in this stage — they go on to experience severe stress and may exhibit symptoms of disorientation, anxiety, and hopelessness.
The U.S. now finds itself in the complicated recovery phase, and Americans have only begun to contend with the pandemic’s moral and psychological fallout. Many exhausted clinicians are experiencing vicarious trauma, anxiety and depression, moral outrage, and compassion fatigue even as the country is confronting a fourth wave of Covid-19, a startlingly transmissible variant, and patients who have declined disease-preventing and life-saving vaccines.
How do health care workers heal? How do they find the resilience to lean in again? It can start by Americans acknowledging the inspiring work of health care workers throughout this transformative experience and the toll the pandemic has had on them. It continues with health care workers and their communities having open conversations about the effects of trauma after disaster deployment and the creation of safe spaces for clinicians to share, reflect, and process.
Post-disaster social support on the part of relief workers’ communities and employers is essential for successful reintegration. Health care organizations can address barriers to care by normalizing the need to seek mental and emotional health support. Clinicians should be provided with the necessary and evidence-based tools to rebuild themselves, such as practicing self-compassion, participating in peer support, and being intentional about sleep, nutrition, movement, and connectedness with other people. Finally, the nation must listen and provide health care workers with the respect, compassion, and support they have provided to their patients and communities throughout this extraordinary time in our history.
Most health care workers will experience some form of reentry during the recovery phase of the pandemic. As a society, we are all accountable to health care workers and their recovery, as we expect them to be accountable to us.
Mary Meyer is an emergency medicine physician and regional medical director of emergency management for The Permanente Medical Group, Kaiser Permanente Northern California.