Moral injury

Physicians are quitting. So are other health professionals, I’m told. Across hospitals and specialties, health care workers are quitting the programs they tried so hard to enter. Each story is different, but people speculate. Are they simply weak, not durable, or not resourceful enough? Should they just, in the spirit of Cynthia Villar’s words, do better? Should they just rest until they’ve recovered from burnout? The problem is that it isn’t just burnout. It isn’t a lack of resilience, grit, or altruism. It’s moral injury. Psychologist Brett Litz and colleagues, writing on the experiences of war veterans, describe it as “perpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” — in other words, a lasting wound on a person’s psyche as a result of exposure to, or participation in, unjust or unethical circumstances.

Moral injury in the context of health care has long been seen as a symptom of a broken health system. How do we allocate scant resources? How do we continue to care for patients knowing that we end up discharging them into homelessness, malnutrition, poverty, unemployment? The fact that physicians are taught to work for the holistic welfare of their patients, only to be met with the infinite barriers that the average Filipino faces in receiving care, is a moral injury — a sense of betrayal by a society that should do better — that health workers have had to live with for a long time. Its causes and effects are deeper than burnout.

The pandemic brings this moral injury to the fore, and magnifies it, makes it visible even to the fortunate few who have never had to worry about access to health care. I will not waste more space here on the incompetencies, insensitivities, inequities, and lies that have been served to us since the beginning of the pandemic. Suffice it to say that this injurious reality, this feeling of betrayal from officials who continue to gaslight and deliberately misunderstand or ignore the pleas of the poorest and most vulnerable as well as the health care workers speaking for them, is not new, but this is the looking glass through which we will look back on the experience of the pandemic in the Philippines.

So health care workers go on, some to other paths, some to continue in the difficult position which the pandemic has forced them into. They have no answers to the questions asked them by patients and families who have nowhere to go, or no money with which to pay. So while others are sitting home… while corrupt individuals line their pockets… while spokespeople downplay COVID-19 statistics… while senators denigrate professions of which they know next to nothing… while the government continues to red-tag those who would clamor for better, these health care workers continue to suffer these soul wounds. They and their patients bear the brunt of the system’s failures. Because there is no centralized referral system for COVID-19 hospitals, workers call hospital after hospital looking for vacancies. They shell out money for their own protective gear, to fund patient procedures, to help patients to recover financially once discharged. These soul wounds are made a thousand times worse by the news of corruption within PhilHealth. These health care workers now find themselves looking deep into the chasm of corruption where a few benefited from what could have helped millions of Filipinos. Moreover, doctors to the barrios have been working in their communities fighting against both COVID-19 and non-COVID-19 illness while underfunded and undermanned, only to be guilt-tripped about their concerns about deployment to COVID-19 response efforts elsewhere. It’s injury upon injury upon injury.

When one is exposed to enough of this reality, one cannot help but be radicalized; as Massachusetts physician Emily Moin wrote on Twitter recently, “if you made it out of med school without becoming a socialist, you were not paying attention.” Those who have climbed the ranks in politics and in the Department of Health have become so far distanced from these daily, soul-destroying struggles. Why are these leaders so out of touch? Do we not deserve leaders able to empathize with the fears of the sick and poor instead of mistaking every cry for change as rebellion?

Health is political. The conditions — and persons — that create and perpetuate unequal access to good, appropriate care are political. One does not have to be a rebel or a subversive to demand better. One merely has to have seen the moral injury our countrymen are suffering, and to have the empathy, understanding and desire to serve, of which so many in power seem completely bereft.

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