Abstract
To Be Who or What? To Be Doctors
In the present climate, there is much talk about “heroes.” “Doctors are the heroes of this war” is a recurring trope in Italy and the rest of the world these days. 1 However, doctors wonder about this label; they do not see themselves as heroes, but simply as medical workers, just like the nurses and all of the other health workers who continue to do their work well aware of the high risk of contagion in healthcare settings.
This is how they have always worked, for their patients' benefit. They have always faced exhausting shifts, made do with limited resources, and risked their lives at work. Yet, before today, few had noticed. Have they really become heroes, or is it simply that the public's view of them has changed?
Perhaps they truly are heroes, because they work hard and risk their lives without worrying too much about their safety, despite the glaring inadequacy of the personal protection equipment given to them, 2 and because some have given their lives to help others. In Italy, to date, about 200 doctors, nurses and pharmacists have fallen victim to the pandemic. 3
Perhaps, as clearly indicated by Caitriona Cox, 1 as a society, we need to critically examine what duties we think healthcare workers should have in this pandemic, what the reasonable limits to these duties are, and how we can provide them with better support rather than simply clapping for them every Thursday.
They are heroes because they have to face a fight that, until a few months ago, they could not have predicted: the fight with their own conscience. Today, doctors must make life-and-death decisions about many patients. As the resources are not enough for all patients, the “first-come, first-served” criterion crumbles under the weight of the overwhelming demand for treatment. 4
Consequently, they can no longer make treatment decisions based only on proportionality and clinical appropriateness criteria. They must take into account the availability of resources and prioritize patients with “the longer life expectancy.” This amounts to saying that “the weakest will die,” with the doctors' consent. While the guidelines issued by scientific societies on the best treatment procedures for patients according to patient status may well protect doctors from lawsuits, the choice of who to treat and who to let die is left to the conscience of the individual doctor; and it is a choice that sharply clashes with the Hippocratic oath and with professional and personal ethics. This is an important lesson for all healthcare workers that emphasizes the need to make every effort to care about every life, even when we must choose whom to save.
To Be or Not to Be…Policymakers?
Political leadership positions, once prestigious and coveted, have now become burdensome, risky, and unpopular. This is because past policy choices are coming back to haunt us. Over the past 10 years, the Italian National Health System has suffered budget cuts of about €37 billion. According to Organisation for Economic Cooperation and Development (OECD) data updated in July 2019, Italy ranks below the OECD average in terms of total per capita health expenditure (US$3,428 versus US$3,980) and public per capita health spending (US$2,545 versus US$3,038), and only ranks above the Eastern European countries and Spain, Portugal, and Greece. Between 2009 and 2018, the percentage increase in public healthcare spending in Italy was 10%, against an OECD average increase of 37%. 5
Similarly, according to the United Nations Economic Commission for Latin America 2018 report, 6 16 Latin American countries dedicated less than 4% of their gross domestic product to healthcare—the novel coronavirus disease 2019 (COVID-19) pandemic is a critical test for already overburdened public healthcare systems.
Evidence from the United States is even more striking: mismanagement and years of inadequate funding of the nation's federal, state, and local public health agencies hampered the early response to the epidemic. 7
In Italy, healthcare education planning, developed by universities in agreement with central and regional governments, has been no more farsighted. As a result, we now have a serious shortage of doctors and nurses, made worse by a deliberate cut in scholarships. 8 Additionally, the fields of medicine, research, and science have been despised, neglected, and humiliated by politicians.
The whole political spectrum is responsible for the present state of things. Over the past years, at one time or another, all political sides have had a go at managing public health, and all have decided to cut funds and resources. The inexorable and unrelenting axe of budget cuts has been sugar-coated as an “efficiency drive,” an inhuman policy that has sacrificed the health service through choices increasingly linked to profit, political patronage, and, let's not forget, too often, to corruption. 9
To Be or Not to Be…Able to Manage the Pandemic?
In Italy, we have witnessed the creation of “task forces,” with lavishly paid “super experts,” whose number grows day by day, making the miracle of the loaves and fishes pale in comparison. 10 The attitude towards these super experts has been one of anxious expectation, followed by bitter disappointment.
It is like watching the race between a cheetah and a snail. Pandemic control measures were implemented a bit too late and lost much of their effectiveness. As a result, many of the dedicated private and public COVID-19 treatment facilities that were created, ended up being scarcely used. In contrast, little was done to strengthen primary healthcare in the community. From the start, 80% of the patients admitted to hospital with COVID-19 had an average age of 79 to 80 years and should have been protected as a priority age group, to avoid putting undue pressure on intensive care units, which is what inexorably and tragically happened. General practitioners (GPs) faced the pandemic without precise guidelines and personal protective equipment, paying a high toll in terms of human lives. The same happened in the United Kingdom, where GPs called for practices to be given the appropriate personal protective equipment to protect themselves. 11 This notwithstanding, they managed to provide the frontline filter against the pandemic. Even today, despite the fundamental role of primary medicine, GPs have as their only allies in the trench their professional skills, morals, and ethics, while the support of the authorities is yet to come.
Nonetheless, countries like South Korea have provided successful strategies to mitigate the impact of the epidemic among GPs through employment of technology and holistic education of its physician community, which led to rapid testing of suspected individuals with little to no contact with healthcare staff, thus decreasing the chance of viral transmission. 12
The snail is falling behind, the cheetah is far ahead.
To Be or Not to Be… Psychopaths?
Some reflections on the personality traits of elected officials seem appropriate. We should be aware of the successful psychopaths who are widely represented in society and in positions of power. 13 These are individuals who suffer no psychopathological alterations but have a serious alteration of moral compass. The lack of moral compass is accompanied by narcissistic traits that prevent them from seeing others as equals, since they are convinced that “they are the best.”
They have a marked ability to manipulate individuals and the public, which enables them to rise to power. They use lies and half-truths to their advantage, and they have a versatile ability to change opinion, to state something and then its opposite without compunction for their lies and deception. People can be easily fall under the spell of psychopaths, hailing them as “saviors.”
Due to their psychological makeup, these individuals are unable to learn from experience and their mistakes. They use various techniques to avoid taking responsibility. They will use 2 methods in particular: the first is finger pointing, that is, pinning the blame for the failure of a project or scheme on others; in the case of the pandemic, healthcare workers are scapegoated. The second technique is to identify an external enemy as the target of anger and allegations: Europe, China, the World Health Organization, … why not the Martians?
These personality traits can be found in many officials who have so far managed national and regional health policy, with the tacit and not entirely innocent complicity of many of us, the citizens, as we often made our voting choices based on the expectation of personal advantages.
What is astonishing is that similar dynamics can be seen in other countries, too, and that no one is apparently learning from their own or others' mistakes.
The perfect storm, the tragedy we are witnessing is like a jigsaw puzzle of faults and ineptitude, of which we are all guilty by action or omission but in which, fortunately, there are also many heroes.
We often repeat the mantra: “everything is going to be alright.”
And it is true that this pandemic will end eventually, but at what cost!
And let us not delude ourselves that we will have learned our lesson…
To be or not to be?
We are human beings in Italy and the world.