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The moral injuries in store for NHS workers

Research is revealing invisible injuries beyond the traditional diagnosis of PTSD, with important applications for healthcare staff caught up in battling Covid-19

Artillery Row

Just your average, mundane, run-of the-mill ordinary life is riddled with excruciating choices which can change everything for good or bad. There’s many a choice that can come back to haunt you like one of the avenging Greek Furies. It’s a lesson I got to appreciate more than I wanted during my tour in Afghanistan, and it’s one which NHS staff working on Covid-19 wards are now wrestling with.

During one of my first meals after the C-130 transport plane had deposited us at Camp Bastion in Helmand Province, I was given a stark indication of the types of choices that lay beyond the perimeter wire. The main cookhouse tent was heaving with hungry soldiers as I managed to find a free chair at a table next to a random sergeant. We got talking and discovered we were both qualified as a Joint Terminal Air Controllers (JTAC), a specialist trained soldier who directs combat aviation in close air support (CAS) of troops fighting on the ground. With the sergeant heading out with the departing brigade that we were replacing, I asked what his tour had been like as a JTAC. By way of summary, he explained, he would describe one particular firefight after the Taliban ambushed his patrol.

Nearly half of intensive care staff reported symptoms of PTSD, severe depression or anxiety

The ensuing battle escalated quickly, he said. The patrol became pinned down, unable to withdraw. The sergeant spotted a small Afghan girl—he reckoned she was about four years old—on the roof of a compound. She was holding a mobile phone to her ear and had an excellent line of sight to the patrol’s position. The sergeant said he assessed she was acting as the Taliban’s equivalent of a mortar fire controller—and doing a sterling job of accurately directing intense enemy fire onto the patrol. With the patrol unable to extract, the sergeant said it was only a matter of time before they started taking casualties due to the weight of fire. He got on the radio and requested a jet for CAS that soon turned up in the heavens. The sergeant directed the pilot to drop a bomb on the building with the girl. The building was obliterated, after which enemy fire subsided and the patrol withdrew. “I did what I had to do,” he said. “Don’t get me wrong, I didn’t feel good about it—I’ve got four kids at home. But what the fuck else was I to do. My kids want to see their dad come back.” He shrugged, smiled ruefully, and went back to eating his dinner.

I have no idea if that choice has come back to haunt him in subsequent years. His experience and choices, along with my own in Afghanistan, come to mind when considering and reading about the travails of NHS staff dealing with rising infection rates due to the latest Covid-19 variant strain.

A 15 January article by The Times about the intense physical and emotional pressures on medical staff having to deal with another wave of infections highlighted how, after dealing with the first wave of infections, nearly half of intensive care staff reported symptoms of post-traumatic stress disorder (PTSD), severe depression or anxiety, according to a study in the journal Occupational Medicine. Researchers also found, the article notes, that 40 per cent of staff surveyed after the first Covid-19 crisis had probable symptoms of PTSD, with one in seven clinicians and nearly one in five nurses working in Intensive Care Units (ICU) reporting thoughts of self-harm or suicide. In the face of the latest barrage of hospital beds filling up with Covid-19 patients and accumulated burnout among staff, this has prompted warnings from some experts that NHS workers are now “suffering more than combat troops.”

These are valid, genuine comparisons, and counterweighing concerns about and exasperation with the “Protect the NHS” mantra and how we have found ourselves, as Rob Sutton’s recent article for The CriticHow Covid paved the Road to Serfdom, describes, “in a situation in which every facet of public life has been redirected to protect an instrument of the state”, should not blind us to the bravery, endurance and emotional suffering of NHS staff. Though the catch-all label of PTSD misses the nuance of the particular mental health phenomenon many NHS staff could be most vulnerable to.

Healthcare workers are finding themselves in positions similar to combat medics on a battlefield

Due to the size of its military and veteran population who have seen active combat over a sustained period from Vietnam to Afghanistan, America appears to be much further along than the UK in parsing the depths of psychological trauma experienced by its combat troops and veterans, and also in appreciating how such trauma can be just as prevalent among the likes of emergency and healthcare workers, especially given the torrid circumstances and decisions having to be made during the Covid-19 outbreak. There is increasing recognition of invisible injuries beyond the traditional diagnosis of PTSD, with increasing focus on so-called moral injury. This has been described as an injury to the soul that results from having to make a choice—or a failure to make the right choice—that you can’t tolerate at a moral level within the ethical framework that comprises your conscience and, with that, your self-identity. While this can manifest PTSD-related symptoms—anxiety, despair, flashbacks, social isolation and suicidal thoughts—guilt and shame have been identified as hallmark factors that distinguish a moral injury. This can lead to an inability on the part of the individual with a moral injury to self-forgive, and to consequently engage in self-sabotaging behaviour, such as feeling like you don’t deserve to succeed at work or relationships, according to the US National Center for PTSD.

“Moral injury is an affliction of conscience,” says Rita Brock, co-author of Soul Repair: Recovering from Moral Injury after War, and the director of the US-based Shay Moral Injury Center. “It happens especially in high stakes situations where no good choice is possible or when emergency situations require rapid responses by instinct or training with no time to weigh a decision.”

In a paper that Brock co-authored with HC Palmer, a former battalion surgeon during the Vietnam War who now counsels American veterans with moral injury and PTSD, it states that, “the fight against the coronavirus is strikingly similar to battlefield medicine: desperate and unrelenting encounters with patients, an environment of high personal risk, an unseen lethal enemy, extreme physical and mental fatigue, inadequate resources and unending accumulations of the dead.”

I’ve mentioned moral injury previously in a number of The Critic articles about Afghanistan and Iraq, and the parallels with the particular situations that NHS workers are now in because of Covid-19 are striking. Healthcare workers are finding themselves in positions similar to combat medics on a battlefield—conducting triage to prioritize who gets treated and who doesn’t, in essence deciding who might live and who dies.

“Few people in healthcare have had real-life experience with triage in which a significant number of life-and-death decisions had to be made because of equipment shortages,” says Arthur Markman, a psychology professor at the University of Texas at Austin. “That increases the chances that they may experience moral injury as a result of their jobs.”

Another noteworthy aspect of the situation for NHS workers is that many of the most effective counter measures to moral injury and PTSD or to any form of stress and anxiety—such as talking it through with someone, ideally a colleague who can relate to your experience or to a professional counsellor, or through just experiencing the balm of ordinary human interaction, touch, a loving embrace, or at the least the chance to get laid—are much harder to achieve due to lockdown restrictions.

Many effective counter measures to moral injury are much harder to achieve due to lockdown restrictions

“Medics are missing the pub like everyone else,” notes The Times article. “They have nowhere to decompress” while the “coping mechanisms” that staff could normally rely on—ranging from that trip to the pub to talk and laugh with friends to watching a favourite sports team to a thorough workout at the gym—are no longer there. In the kitchen of a hostel near Lisbon in Portugal during my latest Camino adventure, I found myself talking with an NHS worker who had been working in an ICU dealing with Covid-19 patients in a city in central England’s Midlands region. He explained he had come to work in Portugal at the start of January after being offered a job in a local hospital’s operating theatre—presumably freeing up local medical staff to move to the ICU and Covid-19 ward—because his NHS work was simply getting too much for him. He described leaving his home, where he lived alone, in the dark of winter to go and work on a Covid-19 ward that had no windows for a 12-hour shift in which he took two short breaks totalling one hour—usually spent in a room with no natural light—before returning, again in the dark, to an empty house. He said the final straw was when he and a small group of friends—most of whom were fellow NHS workers—met in his home at the start of January in defiance of local restrictions to celebrate his birthday, and the police turned up after a neighbour presumably called.

“We weren’t making any noise because of the lockdown and there was no music,” he says. “We all live on our own and just wanted to get together to celebrate my birthday on my day off.” He notes the police were relatively sympathetic but insisted they had to do their job—which including fining him and each of his friends £200.

On various levels all of the above may well be worse than what combat troops endured—we at least had Afghan blue skies and sunshine while always being in close contact with people amid a busy camp full of energy and life—if that be the right word—while buttressed by the British squaddie’s unfailing sense of humour, the type of which appears increasingly absent in modern Britain, especially with Covid-19-related finger wagging and snitching justified in the name of public health.

Another moral injury parallel between military personnel and healthcare workers is the potentially damaging role played by a sense of having been betrayed by authorities and those in charge. For many veterans—and I can certainly vouch for this—the pride in serving one’s country and belonging to a particular regiment or unit collides with a feeling of disappointment, if not disgust, about what their service achieved, with the ongoing turmoil in Iraq and Afghanistan acting as further indictment of their efforts and the wars they were involved in, all of which is compounded by a sense, if not knowledge, that military and political leaders failed or deceived everyone beneath them. The resulting sense of violation, and even of having been naïve and duped, can further stoke the internal clash with conscience and spirit—deepening the moral injury and the scar running through the soul.

“Betrayal wrecks trust, profoundly disrupts identity and destroys relationships,” Brock says. “It’s also suspected of causing or aggravating post-traumatic stress symptoms—nightmares, intrusive memories, hypervigilance, irrational angers, and depression.” She notes how US healthcare workers are working to save people but have “been betrayed by the government’s inadequate response”—a judgement that may well chime with how some NHS workers feel in relation to the UK government’s response. This sense of betrayal by figures and institutions of authority can compound the moral injury to provoking reflexive distrust of anyone, with all the negative ramifications that can have for familial and personal relationships.

It’s inevitable that those at the coalface get sick and face enormous pressure

While the American and British characters differ in marked ways, it is still worth looking to the American experience, because, as ever, it tends to achieve a level of intensity and scale beyond anyone else, and because there is always going to be a limit to that British stiff-upper-lip-type of resolve. Of the 2.7 million American men and women who deployed to Iraq and Afghanistan, an estimated 11 to 20 per cent have received a diagnosis of PTSD, according to the US National Center for PTSD. The percentage of former service members coping with moral injury is judged to be comparable, though some experts warn that the prevailing emphasis on PTSD means moral injury can often go unrecognized and ignored. The perils of this are illustrated by research indicating a link between moral injury and a higher risk of suicide among active-duty troops and veterans who also have PTSD.

The potentially destructive and lethal impact of this complex mix that is so hard to parse is illustrated by the numbers of US veterans who kill themselves. Between 2005 and 2018, a staggering 89,100 veterans took their own lives, according to the Department of Veterans Affairs, which estimates that seventeen US veterans commit suicide each day. In the civilian realm, the US National Institute of Mental Health estimates about 8 million civilians suffer from some form of PTSD during a given year. Both Brock and Palmer fear there will be healthcare workers who will take their own lives because of moral injuries experienced during the pandemic, having been crushed by the decisions they had to make and swamped by unrelenting grief, compounded by a sense of fury and humiliation at the authorities who failed them. According to reports coming from the US, it is already happening.

But others caution against our increasing recourse to diagnosing the likes of PTSD and moral injury. There is an argument that the salaried, benefitted employees of US national organizations generating those stark PTSD numbers have something to gain by if not exaggerating then promoting those numbers that they themselves generated. It is also argued that the bar for trauma severity set by the mental healthcare industry is getting lower and lower, thereby enabling almost anyone to join the trauma-suffering community. It does seem that increasingly we are being told by some expert or commentator from some organisation—in keeping with the trend whereby we are instructed in how we must think about every aspect of our lives—that we must have some form of trauma based on our experiences.

I’m acutely conscious of that trend in relation to my own reactions and decade-long navel-gazing endeavour over Iraq and Afghanistan. I harbour a hope that its stubborn duration might indicate there is more to it than it just being some self-regarding, narcissistic exercise in self-pity. But, undoubtedly, if the military is sent to fight overseas, soldiers and civilians are going to die. It should come as no surprise. The same with the NHS dealing with a nasty infectious disease. It’s going to happen that those at the coalface get sick and face enormous pressure. It’s sad, lamentable and measures must be taken to prevent staff getting sick and unduly suffering psychologically. But doctors and nurses have always dealt with death—and continued working afterward without comment, recognising the nature of the job. The level of hand wringing and emotive manipulation around the NHS’s situation, with the predicament of its workers appearing to be used as an emotive sledgehammer to justify quashing civil liberties and closing down society, is causing society, our political leaders, and perhaps even some NHS staff, to lose perspective.

Brock notes an advantage that healthcare workers might have over combat veterans when facing any reckoning over their actions is that the majority of the populace can more easily relate to healthcare workers and empathize with the conundrums they’ve endured. Throughout the pandemic around the world, healthcare workers have been applauded for their bravery and sacrifices, including many who have died after catching Covid-19. But some veterans see a parallel between this lauding of healthcare workers and the thank-you-for-your-service culture in America that can often prove so frustrating for many active-duty military and veterans.

“One of the hardest things is being told you’re a hero yet feeling anything but a hero—it creates a disconnect,” says Adam Linehan, who served as a combat medic in Afghanistan in 2010 and endured a mixture of PTSD and moral injury after he left the military. “You are perceiving me as one thing, but I know I am the opposite: that’s at the root of why so many veterans feel alienated.”

Engaging in collective conversations about moral injury can strengthen societies

The emotional and psychological plights of healthcare workers resulting from the conundrums they face both when dealing with Covid-19 but also at any given time, represent important lessons for all of society, says Nöel Lipana, who was left with a moral injury from his 2008 Air Force tour in Afghanistan and now works as a social worker while promoting better understanding of moral injuries both in the military and beyond. He explains that too often the situations that healthcare and emergency workers find themselves in and the suffering that then ensues point to a deficit of empathy at all levels—within their organizations and among the general public—about the realities they face. “Veterans are typically the focal point of a trauma discussion that needs be much wider,” Lipana says. “We know where these injuries occur, and there is a language for it, so we can find solutions and change the norms that hold these problems in place.”

Brock’s book Soul Repair finishes by noting how the act of engaging in collective conversations about moral injury can strengthen the moral fabric of society and the connections that tie its members to the rest of the world. “Our collective engagement with moral injury will teach us more about the impact of our actions and choices on each other, enable us to see the world from other perspectives, and chart pathways for our future,” Brock says. “If we achieve deeper and more open ways to grasp the complexities of human relationships, we’ll be able to understand power and the complex ways we can misuse our power.”

There has already been ample discussion throughout 2020 about how the impact of Covid-19, with so much tragedy and loss occurring, could shake up society in myriad ways. There’s even talk of how we may emerge as better people for our pandemic experience, with a restored sense of the importance of family and community, of the value of the simpler virtues in life rather than belting through the years in pursuit of wealth, career progression, a gorgeous Instagram feed; a better appreciation of nature and the environment. Here’s hoping. Any meaningful shift in that direction doesn’t appear to be happening that speedily yet, if events and developments of the past few months are anything to go by. But at least such weighty societal and global concerns are one thing that NHS workers are unlikely to be as troubled by as they set off for another gruelling shift.

“I would wake up at night thinking: Have I checked that patient! Has the ventilation tube come out of their mouth!” the NHS worker in Portugal told me, before being unable to suppress a smile. “I hadn’t even cut my birthday cake when the police barged in, can you believe it.”

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