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Chris Feehan and Judy Illes | May 7, 2020

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At 7 o’clock local time, shouts of support and banging of pots can be heard far and wide as Canadians show their appreciation for the efforts of our country’s essential workforce. As we proudly proclaim our support, we imagine healthcare providers in particular in a state of war, overwhelmed by a storm of suffering. In some regions of Canada – Quebec and Ontario where infections rates are the highest – this is indeed the case. However, in others such as British Columbia, healthcare workers may be experiencing more of a calm than a storm, and their anxiety may be mounting alongside their anticipation of a surge of patients that may or may not materialize. The significance of this pre-traumatic or anticipatory stress may be no less profound than its post-trauma counterpart. We must address it head on.

As the COVID-19 pandemic has expanded around the world, it has not done so evenly. Wuhan, Milan, and then New York became poster-cities for what we fear—uncontrolled spread of the virus leading to healthcare systems strained past their limits. In these epicenter cities, narratives emerge of the heroic efforts of essential healthcare providers working all hours with faces chapped from masks rarely removed. They risk their lives and, in keeping with their ethical and professional duty to care, expose themselves to great personal risk. In addition to the tragic death toll from the virus, at least one doctor in New York has died from suicide as a result of the stresses of this pandemic. 

So far, thankfully, these stories have been the exception. Whether through luck or prudent action, many areas have been given a window of opportunity to prepare. For some, the anticipation may be as troubling, or even more so, than action itself.

Anticipatory anxiety can occur as the body reacts to perceived future dangers. Real or imagined, these dangers activate the nervous system in preparation for a burst of activity potentially necessary for survival. These fight-or-flight responses are well matched to short-lived dangers, such as running from predators in our evolutionary past. They are less ideal for preparing for the consequences of a worldwide pandemic but for these, humans have the ability to reason and develop adaptive strategies beyond the primitive fear responses more appropriate to our mammalian ancestors. We can refocus attention on tractable problems and on helpfulness over helplessness; we can reframe negative projections of the future into positive ones; and, we can develop coping skills for relaxation and mindfulness. In the context of fighting a pandemic that is characterized by immense uncertainty and an open timeline, these strategies can equip healthcare providers to prepare for the worse and strive to keep anxiety from overcoming them as they wait for the other shoe to drop.

The strategies will not work in isolation, however. Consider the general mental health of healthcare workers even before this pandemic. Many studies have shown high levels of dissatisfaction, distress, and burnout.  For example, a 2017 survey of Canadian doctors by the Canadian Medical Association revealed that 30% experience burnout, 34% screen positive for depression, and 13% describe their psychological well-being as low. Similar rates are seen in other health care professions and in surveys around the world.  It is from this unstable baseline that the unique stresses of the pandemic are overlaid. 

For some, the baseline is particularly unstable and waiting is more agonizing than for others.  Research has shown that workers with pre-existing mental illness are less resilient to stress and less able to employ adaptive coping strategies. A tendency toward negative emotions can predict many different mental and physical disorders, and place people at a higher risk of anticipatory anxiety and a higher and longer lasting risk of post-traumatic stress. 

Pre-traumatic stress in front-line workers has not received as much attention as its post-trauma syndrome counterpart. While there are some risk factors for PTSD that are mostly unavoidable in crises, such as exposure to extreme suffering or violence or an inability to help everyone where situations necessitate triage or rationing, there are aspects of the workplace environment that can be modified to reduce anticipatory trauma. Lack of viral therapies and ventilators aside, health systems can help our healthcare workers by moderating high workload intensity and downtime between shifts for rest and recovery. Task repetitiveness and a low sense of control can be addressed to give a sense of purpose. Emotional resilience can be prioritized as an explicit goal. We can all listen to the fears of our essential workers, reach out when they signal for help, and plan together to restart and come out of this crisis stronger than before.

There is a paradox in this story: the regions of Canada that reacted most quickly to the pandemic are the ones that may never see the large volumes of cases for which they prepared. We must not overlook the opportunity to assure our essential workers that their efforts were not futile or paranoid.  We should not miss the real psychological impact of waiting and preparing for a fight which may or may not come. We should make every effort to reach out and support our healthcare workers who may be struggling with guilt or fragility as they wait, rather than provide the care for which they were trained. They deserve respect consistent with the diverse cultural and religious beliefs represented in our country. We must honor the sacrifice being made by the everyday heroes doing their best to protect us as we carry on and as we restart, no matter what that looks like. 

See you at 7 pm tonite.

Dr. Chris Feehan is a third year Neurology Resident at UBC. Dr. Judy Illes, CM is Professor of Neurology, Canada Research Chair in Neuroethics, and Director of Neuroethics Canada at UBC. She is Fellow of Royal Society of Canada, Division of Life Sciences.