Of heroes and working safely in a dangerous time

“Where are the enemy?”

Benjamin waved his hand expansively. “Over zere.” (Benjamin spoke English – terrible English).

“But where?”

Benjamin, a Polish Jew whose mother-tongue was French, must have deflated George Orwell’s enthusiasm in Homage to Catalonia; an enthusiasm driven – one may assume, by the purest of motives when he signed up as a volunteer to defend the nascent Spanish republic against the military revolt led by General Franco.

Soon after arriving in Barcelona in the early part of the civil war, he was quickly sent to the frontline near Zaragoza.

The “front” was not as what he had imagined – trenches in straight lines, with a mere 50 to 100 yards across no man’s land separating him from the enemy.

Here the frontlines were ridges and hilltops, and across hundreds of meters of barren ravines all he could see were the tiny parapets and flags of the fascist positions.

His heart sank further when the weapon he was handed was a German Mauser dated 1895 while the best rifle was given to, in his own words, a half-witted little beast of fifteen (half of the “men” in his company were teenagers from the backstreets of Barcelona).

The narrative of the Covid-19 pandemic has been invested, not surprisingly, with the metaphor of war – the enemy, frontlines, heroism, sacrifice.

The emergency departments, the ward floor and the ICU are our battlegrounds.

The civilian population in turn must contend with the inconvenience of confinement. More stringent curbs on matter-of-fact liberties and uncertain economic future are to follow should this war drag on.

I could not help harking back to Orwell’s account of the enemy he could not see and also the mess he observed when one entered into battle woefully unprepared.

Doctors and other healthcare professionals readily accept that their job often requires them to serve beyond the call of duty even in “peace time”.

We are of course cognizant of the fact that occupational death is a risk in some fields of medicine such as one that deals with new, little known infectious diseases.

Of this, the late Dr Carlo Urbano comes to mind. A WHO infectious disease expert, he contracted the disease and succumbed to it while working to unravel the mystery of SARS in 2003.

But needless deaths in frightening numbers is something else.

Among doctors alone, Covid-19 has claimed the lives of 61 doctors in China and Italy each, 24 in Indonesia, 10 in the UK, days before I started writing this.

That is an indication of what is very frightening to healthcare workers about this pandemic.

Frightening but also humbling for we mistakenly thought that modern medicine has at last conquered many of the big diseases that man has long struggled with to find relief and freedom from.

We did not see that in the Spanish flu pandemic of 1918, half a million died, and that too, in an era of medicine when antibiotics and ventilators had not yet existed.

Over a short period of time we have better understood the enemy – what it is and its genetic make-up and have baptised it with a name.

We know how it is transmitted and we can accurately diagnose infected persons even if they do not show any symptoms of the disease.

But the few unfortunate enough to be inflicted the full severity can die even in the best ICU of the best hospital.

The word tragic does not describe enough the sad fate of healthcare workers who lose their lives in the line of duty when we now know that this can be prevented by having the right personal protective equipment (PPE), appropriate for the level of risk in patient encounters.

The recent death of a Jakarta doctor is one such heartbreaking story just as we read about fallen doctors in the Philippines paraded as heroes.

Working in such an underfunded healthcare environment, we wonder if doctors, despite being aware of the dangerous odds against them, feel pressured into carrying out heroic deeds by societal expectations rather than out of their own volition.

Heroism does not adequately describe their ultimate sacrifice.

But this is not just about an underfunded healthcare system in a third world country where underfunding of basic infrastructure is just one of a myriad of other interconnected problems.

The tenth National Health Service (NHS) doctor to die of Covid-19 had earlier warned Prime Minister Boris Johnson that frontline workers did not have enough PPE.

Except for powered air-purifying respirator (PAPR) which is used in procedures that carry the highest risks of transmission, PPE for obtaining diagnostic specimens and general ICU care of infected patients are not expensive even for the standard of developing countries.

The problem is unpreparedness, logistical issues and lack of concern borne out of ignorance for the safety of those who have to work at the frontlines.

Many of these are junior doctors and nurses who dare not articulate their fears of having to work without adequate PPE.

If the shocking number of doctors who have died in the line of duty is not enough to jolt those in authority to do the right thing, we hope the protests by healthcare workers from New York to Quetta in Pakistan and the Zimbabwe government being taken to court over its failure to provide doctors on the frontline with masks, will.

Apart from the great personal cost to the families of the fallen, what is going to happen to society if the ranks of frontliners are depleted to the point that the entire system collapses?

We can be certain that the ethics and legal dimensions of this will soon enter the narrative of the Covid-19 pandemic.

Those who do not know Dr Musa Nordin in person are apt to be a little disturbed by the tone of his impassioned open letter to the director-general and the leadership of the Health Ministry.

But his message is a timely reminder before we lose a healthcare worker in the line of duty.

That would be a devastating blow not just to the frontliners but the entire medical and its allied professions.

And unlike our neighbours, ours is not for the lack of funding, infrastructure and dedicated personnel.

Dr Musa is a respected doctor in the paediatric fraternity who has distinguished himself at the forefront of neonatology. But his other passion is advocacy on vaccines and the prevention of infectious childhood diseases.

He has the right credentials and the welfare of fellow workers and the people of this country in his heart.

If there is such a term as Corona Crusaders, he would be among them, urging the government to do extensive testing, protect the frontliners and guard our borders to prevent a new wave of infections from neighbouring Indonesia.

On the other hand, the director-general and the Health Ministry leadership have earned the respect and trust of the Malaysian public in the handling of the Covid-19 pandemic.

Of all the government officials, he is the only one every citizen looks up to with hope in this time of crisis.

At the beginning of March, we were like Spain and France in terms of statistics. Short of calling it a miracle, we have not followed suit in the explosion of new cases and the number of fatalities.

And not to forget, all this was unfolding when we had no functioning cabinet for two weeks. Still, we should not drop our guard for the safety of the shore is still some distance away.

In the novel about a fictional plague that took place in the Algerian city of Oran before independence, Albert Camus wrote of hundreds of city dwellers falling victims to it and the ensuing chaos, fear and the tensions brought about by closure of the city gates.

The main protagonist, Dr Bernard Rieux, is a physician of supreme clinical detachment who assembled a team of volunteers of disparate individual characters to fight against the plague, bringing and treating the sick in a makeshift hospital and dealing with the dead.

As the plague began to be tamed, in a moment of reflection Rieux spoke to his assistant Tarrou:

“I feel more fellowship with the defeated than with saints. Heroism and sanctity don’t really appeal to me.”

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DR MAZENI ALWI is senior consultant paediatric cardiologist at the National Heart Institute (IJN). - Mkini