Cynthia M.A. Geppert, MD

The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.

For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.

From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.

During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.

fdp03807298_t.png

The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.

For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.

From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.

During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.

fdp03807298_t.png

The COVID-19 pandemic put unparalleled strain on US health care systems and individual health care providers (HCPs), which has been well documented. Like all other medical peer reviewed journals, Federal Practitioner relies heavily on the generosity and dedication of federal HCPs. As the pandemic unfolded, we questioned whether HCPs would have the time and energy to write new articles, complete research projects, and review the work of their peers. To assess the impact of COVID-19 on the journal, we compared data from a full year during the COVID-19 pandemic with that of the previous year to determine whether and how the pandemic reshaped the peer review and publication process.

For the purposes of this review, we will compare a full year of COVID-19 journal performance with the prior year. Since COVID-19 infections spiked at different times in different places, there is no clear starting point for the pandemic. Similarly, states varied widely in their vaccination rates and opening procedures. Nevertheless, the period from May 1, 2020 to April 30, 2021, most of the country experienced COVID-19 restrictions, and the number of cases rose dramatically.

From May 1, 2020 to April 30, 2021, Federal Practitioner received 208 submissions, 110% increase over the previous year (189 submissions from May 1, 2019 to April 30, 2020) and a 28% increase over a 2-year period. After submission, it took an average of 9.0 days to the first reviewer invitation compared with 10.3 days in the previous year and 4.7 days 2 years prior. Time from the initial submission to the first decision (ie, accept, reject, or revise) took 72.8 days in the COVID-19 year compared with 91.1 days in the previous year and 69.6 days 2 years prior. In both periods it took reviewers a mean 9.5 days to complete a review from the date invited, and the rate of late reviews was unchanged as well.

During the COVID-19 pandemic year, 1481 reviewer invitations were sent to potential reviewers and 498 reviews were completed (33.6%) by 195 individual reviewers: an average of 2.4 reviews per manuscript. Most reviewers recommended to accept the manuscript, and just 14.7% of reviewers recommended to reject the manuscript (Table). The previous year 1295 invitations were sent to potential reviewers and 460 reviews were completed (38.1%) by 181 individual reviewers for an average of 2.4 reviews per manuscript.

fdp03807298_t.png

The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.¹ Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.² In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.^3,4

In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.⁵

Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.⁶

For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.

1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts

There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.⁷ Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.⁸ Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.

Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.⁹

2. Utility: Necessary But Insufficient

Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.

First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.

This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.

However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.^10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).

Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).

In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.

There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).¹² There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.

The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.¹ Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.² In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.^3,4

In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.⁵

Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.⁶

For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.

1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts

There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.⁷ Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.⁸ Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.

Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.⁹

2. Utility: Necessary But Insufficient

Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.

First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.

This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.

However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.^10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).

Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).

In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.

There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).¹² There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.

The Veterans Health Administration (VHA) COVID-19 vaccine allocation plan showcases several lessons for government and health care leaders in planning for future pandemics.¹ Many state governments—underresourced and overwhelmed with other COVID-19 demands—have struggled to get COVID-19 vaccines into the arms of their residents.² In contrast, the VHA was able to mobilize early to identify vaccine allocation guidelines and proactively prepare facilities to vaccinate VHA staff and veterans as soon as vaccines were approved under Emergency Use Authorization by the US Food and Drug Administration.^3,4

In August 2020, VHA formed a COVID-19 Vaccine Integrated Project Team, composed of 6 subgroups: communications, distribution, education, measurement, policy, prioritization, and vaccine safety. The National Center for Ethics in Health Care weighed in on the ethical justification for the developed vaccination risk stratification framework, which was informed by, but not identical to, that recommended by the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices.⁵

Prioritizing who gets early access to a potentially life-saving vaccine weighs heavily on those leaders charged with making such decisions. The ethics of scarce resource allocation and triage protocols that may be necessary in a pandemic are often in tension with the patient-centered clinical ethics that health care practitioners (HCPs) encounter. HCPs require assistance in appreciating the ethical rationale for this shift in focus from the preference of the individual to the common good. The same is true for the risk stratification criteria required when there is not sufficient vaccine for all those who could benefit from immunization. Decisions must be transparent to ensure widespread acceptance and trust in the vaccination process. The ethical reasoning and values that are the basis for allocation criteria must be clearly, compassionately, and consistently communicated to the public, as outlined below. Ethical questions or concerns involve a conflict between core values: one of the central tasks of ethical analysis is to identify the available ethical options to resolve value conflicts. Several ethical frameworks for vaccine allocation are available—each balances and weighs the primary values of equity, dignity, beneficence, and utility slightly differently.⁶

For example, utilitarian ethics looks to produce the most good and avoid the most harm for the greatest number of people. Within this framework, there can be different notions of “good,” for example, saving the most lives, the most life years, the most quality life years, or the lives of those who have more life “innings” ahead. The approach of the US Department of Veterans Affairs (VA) focuses on saving the most lives in combination with avoiding suffering from serious illness, minimizing contagion, and preserving the essential workforce. Frameworks that give primacy to 1 notion of the good (ie, saving the most lives) may deprioritize other beneficial outcomes, such as allowing earlier return to work, school, and leisure activities that many find integral to human flourishing. Other ethical theories and principles may be used to support various allocation frameworks. For example, a pragmatic ethics approach might emphasize the importance of adapting the approach based on the evolving science and innovation surrounding COVID-19. Having more than 1 ethically defensible approach is common; the goal in ethics work is to be open to diversity of thought and reflect on the strength of one’s reasoning in resolving a core values conflict. We identify 2 central tenets of pandemic ethics that inform vaccine allocation.

1. Pandemic Ethics Requires Proactive Planning and Reevaluation of Continually Evolving Facts

There is an oft quoted saying among bioethicists: “Good ethics begins with good facts.” One obvious challenge during the COVID-19 pandemic has been the difficulty accessing up-to-date facts to inform decision making. If a main goal of a vaccination plan is to minimize the incidence of serious or fatal COVID-19 disease and contagion, myriad data points are needed to identify the best way to do this. For example, if 2 doses of the same vaccine are needed, this impacts the logistics of identifying, inviting, and scheduling eligible individuals and staffing vaccine clinics as well as ensuring that sufficient personal protective equipment and rescue equipment/medication are available to treat allergic reactions. If the adverse effects of vaccines lead to staff absenteeism or vaccine hesitancy, this needs to be factored into logistics.⁷ Tailored messaging is important to reduce appointment no-shows and vaccine nonadopters.⁸ Transportation to vaccination sites is a relevant factor: how a vaccine is stored, thawed, and reconstituted and its shelf life impacts whether it can be transported after thawing and what must be provided on site.

Consideration of the multifaceted factors influencing a successful vaccination campaign requires proactive planning and the readiness to pivot when new information is revealed. For example, vaccine appointment no-shows should be anticipated along with a fair process for allocating unused vaccine that would otherwise be wasted. This is an example of responsible stewardship of a scarce and life-saving resource. A higher than anticipated no-show rate would require revisiting a facility’s approach to ensuring that waste is avoided while the process is perceived to be fair and transparent. Ethical theories and principles cannot do all the work here; mindful attention to detail and proactive, informed planning are critical. Fortunately, the VA is well resourced in this domain, whereas many state health departments floundered in their response, causing unnecessary vaccination delays.⁹

2. Utility: Necessary But Insufficient

Most ethical approaches recognize to some extent that seeking good and minimizing harm is of value. However, a strictly utilitarian approach is insufficient to address the core values in conflict surrounding how best to allocate limited doses of COVID-19 vaccine. For example, some may argue that prioritizing the elderly or those in long-term care facilities like VA’s community living centers because they have the highest COVID-19 mortality rate produces less net benefit than prioritizing younger veterans with comorbidities or certain higher risk essential workers. There are 2 important points to make here.

First, the VHA vaccination plan balances utility with other ethical principles, namely, treating people with equal concern, and addressing health inequities, including a focus on justice and valuing the worth and dignity of each person. Rather than giving everyone an equal chance via lottery, the prioritization plan recognizes that some people have greater need or would stand to better mitigate viral contagion and preserve the essential workforce if they were vaccinated earlier. However, the principle of justice requires that efforts are made to treat like cases the same to avoid perceptions of bias, and to demonstrate respect for the dignity of each individual by way of promoting a fair vaccination process.

This requires transparency, consistency, and delivery of respectful and accurate communication. For example, the VA recognizes that lifetime exposure to social injustice produces health inequities that make Black, Hispanic, and Native American persons more susceptible to contracting COVID-19 and suffering serious or fatal illness. The approach to addressing this inequity is by giving priority to those with higher risk factors. Again, this is an example of blending and balancing ethical principles of utility and justice—that is, recognizing and remedying social injustice is of value both because it will help achieve better outcomes for persons of color and because it is inherently worthwhile to oppose injustice.

However, contrary to some news reports, the VHA approach does not allocate by race/ethnicity alone, as it does by age.^10,11 Doing so would present logistical challenges—for example, race/ethnicity is not an objective classification as is age, and reconciling individuals’ self-reports could create confusion or chaos that is antithetical to a fair, streamlined vaccination program. Putting veterans of color at the front of the vaccination line could backfire by amplifying worries that they are being exposed to vaccine that is not fully tested (a common contributor to vaccine hesitancy, particularly among communities of color familiar with prior exploitation and abuse in the name of science).

Discriminating based on race/ethnicity alone in the spirit of achieving equity would be precedent setting for the VA and would require a strong ethical justification. The decision to prioritize for vaccine based on risk factors strives to achieve this balance of equity and utility, as it encompasses VA staff and veterans of color by way of their status as essential workers or those with comorbidities. However, it is important to address race-based access barriers and vaccine hesitancy to satisfy the equity demands. This effort is underway (eg, engaging community champions and developing tailored educational resources to reach diverse communities).

In addition, pragmatic ethics recognizes that an overly granular, complicated allocation plan would be inefficient to implement. While it might be true that some veterans who are aged < 65 years may be at higher risk from COVID-19 than some elderly veterans, achieving the goals of fairness and transparency requires establishing a vaccine prioritization plan that is both ethically defensible and feasibly implementable (ie, achieves its goal of getting “needles into arms”). For example, veterans aged ≥ 65 years may be invited to schedule their vaccination before younger veterans, but any veteran may be accepted “on-call” for vaccine appointment no-shows via first-come, first-served or by lottery. Flexibility of response is crucial. This played out in adding flexibility around the decision to vaccinate veterans aged ≥ 75 years before those aged 65 to 74 years, after revisiting how this prioritization might affect feasibility and throughput and opting to allow the opportunity to include those aged ≥ 65 years.

There will no doubt be additional modifications to the vaccine allocation plan as more data become available. Since the danger of fueling suspicion and distrust is high (ie, that certain privileged people are jumping the line, as we heard reports of in some non-VA facilities).¹² There is an obvious ethical duty to explain why the chosen approach is ethically defensible. VA facility leaders should be able to answer how their approach achieves the goals of avoiding serious or fatal illness, reducing contagion, and preserving the essential workforce while ensuring a fair, respectful, evidence-based, and transparent process.

Some who read Federal Practitioner regularly may recall that since 2017, I have been dedicating the December and January editorials to a more substantive version of the popular best and worst awards that appear in the media this time of year. Everything from the most comfortable slippers to the weirdest lawsuits is scored annually. In an effort to elevate the ranking routine, this column has reviewed and evaluated ethical and unethical events and decisions in the 3 federal health care systems Federal Practitioner primarily serves. In previous years it was a challenge requiring research and deliberation to select the most inspiring and troubling occurrences in the world of federal health care. This year neither great effort or prolonged study was required as the choice was immediate and obvious—the year itself. A year in which our individual identities as health care professionals serving in the US Department of Defense, US Department of Veterans Affairs (VA), and US Public Health Service is subsumed in our realities as citizens of a nation in crisis.

The opening lines of A Tale of Two Cities have become such a literary platitude taken out of the context of the novel that the terror and fascination with which Dickens wrote these oft-quoted lines has been diluted and dulled.¹ In citing the entire paragraph as the epigraph, I hope to recapture the moral seriousness of its message, which is so relevant in 2020. While protesting the widespread injustice that fueled the progress of London’s industrial revolution, Dickens also feared such discontent would ignite a bloody uprising as it had done in Paris.¹ This passage is a classic example of the literary device of parallelism that so perfectly expressed Dickens’ reflections on the trajectory of the unprecedented historical impact of the French Revolution. A parallelism that also aptly captures the contemporary contrasts and comparisons of the best and worst of 2020.

It is estimated that at least 66% of those eligible to vote did so on November 3, 2020, the highest turnout in more than a century, demonstrating the strength of the United States as a representative democracy.² It is not about partisan politics, it is that more than 150 million citizens braved the winter, the virus, and potential intimidation to cast a ballot for their values.³ Still, America has never been more divided, and Dickens’ fear of political upheaval has never been more real in our country, or at least since the Civil War.

As I write this editorial, manufacturers for 2 vaccines have submitted phase 3 trial data to the US Food and Drug Administration for Emergency Use Authorizations and a third consortium may follow suit soon. Scientists report that the 2 vaccines, which were developed in less than a year, have high efficacy rates (> 90%) with only modest adverse effects.⁴ It is an unparalleled, really unimaginable, scientific feat. Americans’ characteristic gift for logistical efficiency and scientific innovation faces daunting administrative and technical barriers to achieve a similar viral victory, yet we may have faced even more formidable odds in World War II.

As of December 4, 2020, Johns Hopkins University reports that more than 275,000 Americans have died of coronavirus.⁵ The United States is on track to reach 200,000 cases a day with the signature holiday season of family festivities brutally morphed into gatherings of contagion.⁶ Hospitals across the country are running out of intensive care beds and nurses and doctors to staff them. Unlike the Spring surge in the Northeast, cases are rising in 49 states, and there is nowhere in the land from which respite and reinforcements can come.⁷

Thousands of health care professionals are exhausted, many with COVID-19 or recovering from it, morally distressed, and emotionally spent. Masks and social distancing are no longer public health essentials but elements of a culture war. Those same nurses, doctors, and public health officers still show up day after night for what is much closer to war than work. They struggle to prevent patients from going on ventilators they may never come off and use the few available therapies to keep as many patients alive as possible—whether those patients believe in COVID-19, wore a mask, no matter who they voted for—because that is what it means to practice health care according to a code of ethics.

In March 2020, I pledged to devote every editorial to COVID-19 for as long as the pandemic lasted, as one small candle for all those who have died of COVID-19, who are suffering as survivors of it, and who take risks and labor to deliver essential services from groceries to intensive care. Prudent public health officials wisely advise that the vaccine(s) are not a miracle cure to revive a depleted country, in part because it may undermine life-saving public health measures.⁸ And so the columns will continue in 2021 to illuminate the ethical issues of the pandemic as they affect all of us as federal health care professionals and Americans.

The Tale of Two Cities chapter that begins with the “best of times, and the worst of times” is entitled “Recalled to Life.” Let that be our hope and prayer for the coming year.

Some who read Federal Practitioner regularly may recall that since 2017, I have been dedicating the December and January editorials to a more substantive version of the popular best and worst awards that appear in the media this time of year. Everything from the most comfortable slippers to the weirdest lawsuits is scored annually. In an effort to elevate the ranking routine, this column has reviewed and evaluated ethical and unethical events and decisions in the 3 federal health care systems Federal Practitioner primarily serves. In previous years it was a challenge requiring research and deliberation to select the most inspiring and troubling occurrences in the world of federal health care. This year neither great effort or prolonged study was required as the choice was immediate and obvious—the year itself. A year in which our individual identities as health care professionals serving in the US Department of Defense, US Department of Veterans Affairs (VA), and US Public Health Service is subsumed in our realities as citizens of a nation in crisis.

The opening lines of A Tale of Two Cities have become such a literary platitude taken out of the context of the novel that the terror and fascination with which Dickens wrote these oft-quoted lines has been diluted and dulled.¹ In citing the entire paragraph as the epigraph, I hope to recapture the moral seriousness of its message, which is so relevant in 2020. While protesting the widespread injustice that fueled the progress of London’s industrial revolution, Dickens also feared such discontent would ignite a bloody uprising as it had done in Paris.¹ This passage is a classic example of the literary device of parallelism that so perfectly expressed Dickens’ reflections on the trajectory of the unprecedented historical impact of the French Revolution. A parallelism that also aptly captures the contemporary contrasts and comparisons of the best and worst of 2020.

It is estimated that at least 66% of those eligible to vote did so on November 3, 2020, the highest turnout in more than a century, demonstrating the strength of the United States as a representative democracy.² It is not about partisan politics, it is that more than 150 million citizens braved the winter, the virus, and potential intimidation to cast a ballot for their values.³ Still, America has never been more divided, and Dickens’ fear of political upheaval has never been more real in our country, or at least since the Civil War.

As I write this editorial, manufacturers for 2 vaccines have submitted phase 3 trial data to the US Food and Drug Administration for Emergency Use Authorizations and a third consortium may follow suit soon. Scientists report that the 2 vaccines, which were developed in less than a year, have high efficacy rates (> 90%) with only modest adverse effects.⁴ It is an unparalleled, really unimaginable, scientific feat. Americans’ characteristic gift for logistical efficiency and scientific innovation faces daunting administrative and technical barriers to achieve a similar viral victory, yet we may have faced even more formidable odds in World War II.

As of December 4, 2020, Johns Hopkins University reports that more than 275,000 Americans have died of coronavirus.⁵ The United States is on track to reach 200,000 cases a day with the signature holiday season of family festivities brutally morphed into gatherings of contagion.⁶ Hospitals across the country are running out of intensive care beds and nurses and doctors to staff them. Unlike the Spring surge in the Northeast, cases are rising in 49 states, and there is nowhere in the land from which respite and reinforcements can come.⁷

Thousands of health care professionals are exhausted, many with COVID-19 or recovering from it, morally distressed, and emotionally spent. Masks and social distancing are no longer public health essentials but elements of a culture war. Those same nurses, doctors, and public health officers still show up day after night for what is much closer to war than work. They struggle to prevent patients from going on ventilators they may never come off and use the few available therapies to keep as many patients alive as possible—whether those patients believe in COVID-19, wore a mask, no matter who they voted for—because that is what it means to practice health care according to a code of ethics.

In March 2020, I pledged to devote every editorial to COVID-19 for as long as the pandemic lasted, as one small candle for all those who have died of COVID-19, who are suffering as survivors of it, and who take risks and labor to deliver essential services from groceries to intensive care. Prudent public health officials wisely advise that the vaccine(s) are not a miracle cure to revive a depleted country, in part because it may undermine life-saving public health measures.⁸ And so the columns will continue in 2021 to illuminate the ethical issues of the pandemic as they affect all of us as federal health care professionals and Americans.

The Tale of Two Cities chapter that begins with the “best of times, and the worst of times” is entitled “Recalled to Life.” Let that be our hope and prayer for the coming year.

Some who read Federal Practitioner regularly may recall that since 2017, I have been dedicating the December and January editorials to a more substantive version of the popular best and worst awards that appear in the media this time of year. Everything from the most comfortable slippers to the weirdest lawsuits is scored annually. In an effort to elevate the ranking routine, this column has reviewed and evaluated ethical and unethical events and decisions in the 3 federal health care systems Federal Practitioner primarily serves. In previous years it was a challenge requiring research and deliberation to select the most inspiring and troubling occurrences in the world of federal health care. This year neither great effort or prolonged study was required as the choice was immediate and obvious—the year itself. A year in which our individual identities as health care professionals serving in the US Department of Defense, US Department of Veterans Affairs (VA), and US Public Health Service is subsumed in our realities as citizens of a nation in crisis.

The opening lines of A Tale of Two Cities have become such a literary platitude taken out of the context of the novel that the terror and fascination with which Dickens wrote these oft-quoted lines has been diluted and dulled.¹ In citing the entire paragraph as the epigraph, I hope to recapture the moral seriousness of its message, which is so relevant in 2020. While protesting the widespread injustice that fueled the progress of London’s industrial revolution, Dickens also feared such discontent would ignite a bloody uprising as it had done in Paris.¹ This passage is a classic example of the literary device of parallelism that so perfectly expressed Dickens’ reflections on the trajectory of the unprecedented historical impact of the French Revolution. A parallelism that also aptly captures the contemporary contrasts and comparisons of the best and worst of 2020.

It is estimated that at least 66% of those eligible to vote did so on November 3, 2020, the highest turnout in more than a century, demonstrating the strength of the United States as a representative democracy.² It is not about partisan politics, it is that more than 150 million citizens braved the winter, the virus, and potential intimidation to cast a ballot for their values.³ Still, America has never been more divided, and Dickens’ fear of political upheaval has never been more real in our country, or at least since the Civil War.

As I write this editorial, manufacturers for 2 vaccines have submitted phase 3 trial data to the US Food and Drug Administration for Emergency Use Authorizations and a third consortium may follow suit soon. Scientists report that the 2 vaccines, which were developed in less than a year, have high efficacy rates (> 90%) with only modest adverse effects.⁴ It is an unparalleled, really unimaginable, scientific feat. Americans’ characteristic gift for logistical efficiency and scientific innovation faces daunting administrative and technical barriers to achieve a similar viral victory, yet we may have faced even more formidable odds in World War II.

As of December 4, 2020, Johns Hopkins University reports that more than 275,000 Americans have died of coronavirus.⁵ The United States is on track to reach 200,000 cases a day with the signature holiday season of family festivities brutally morphed into gatherings of contagion.⁶ Hospitals across the country are running out of intensive care beds and nurses and doctors to staff them. Unlike the Spring surge in the Northeast, cases are rising in 49 states, and there is nowhere in the land from which respite and reinforcements can come.⁷

Thousands of health care professionals are exhausted, many with COVID-19 or recovering from it, morally distressed, and emotionally spent. Masks and social distancing are no longer public health essentials but elements of a culture war. Those same nurses, doctors, and public health officers still show up day after night for what is much closer to war than work. They struggle to prevent patients from going on ventilators they may never come off and use the few available therapies to keep as many patients alive as possible—whether those patients believe in COVID-19, wore a mask, no matter who they voted for—because that is what it means to practice health care according to a code of ethics.

In March 2020, I pledged to devote every editorial to COVID-19 for as long as the pandemic lasted, as one small candle for all those who have died of COVID-19, who are suffering as survivors of it, and who take risks and labor to deliver essential services from groceries to intensive care. Prudent public health officials wisely advise that the vaccine(s) are not a miracle cure to revive a depleted country, in part because it may undermine life-saving public health measures.⁸ And so the columns will continue in 2021 to illuminate the ethical issues of the pandemic as they affect all of us as federal health care professionals and Americans.

The Tale of Two Cities chapter that begins with the “best of times, and the worst of times” is entitled “Recalled to Life.” Let that be our hope and prayer for the coming year.

May 20 of this plague year, Reuters reported the death of a 32-year-old Florida nurse who had worked tirelessly to treat patients with COVID-19.¹ The presumption is that, like so many selfless health care providers (HCPs), this nurse was exposed to and then sadly succumbed to the virus. That presumption would be wrong: COVID-19 did not take his young life. The other pandemic—addiction— did. Bereaved friends and family reported that the nurse had been in recovery from opioid use disorder (OUD) before the onslaught of the public health crisis. The chronicle of his relapse is instructive for the devastating effect COVID-19 has had on persons struggling with addiction, even those like the nurse who was in sustained remission from OUD with a bright future.

Many of the themes are familiar to HCPs and have been the subject of prior columns in this COVID-19 series. The nurse experienced acute stress symptoms, such as nightmares from the repeated crises of sick and dying patients in the intensive care unit where he worked.² Like so many other HCPs, while he was desperately trying to save others, he also worried about having sufficient access to appropriate personal protective equipment (PPE).

Most relevant to this column, the caregiver was unable to access his primary source of support for his sobriety—attendance at 12-step meetings. Social distancing, which is one of the only proven means we have of reducing transmission of the virus, has had unintended consequences. Although many have found virtual connections rewarding, this nurse needed the curtailed face-to-face contact. The courage that had led him to volunteer for hazardous duty unwontedly resulted in his estrangement: Friends feared that he would expose them to the virus, and he worried that he would expose his family to danger. As in the 1918 flu pandemic, the humans we depend on for reality testing and companionship have been cruelly transformed into potential vectors of the virus.³

Isolation is the worst of all possible counselors as the great Spanish philosopher of alienation Miguel de Unamuno has argued. The deceptive promise of a rapid deliverance from anxiety and pain that substances of abuse proffer apparently led the nurse back to opioids. The virtue of being clean permitted the dirty drug to take advantage of the nurses’ reduced physiologic tolerance to opioids. It is suspected but not confirmed that he fatally overdosed alone in his car.

This Florida nurse is an especially tragic example of a terrible phenomenon being repeated all over the country. And the epidemic of substance use disorders (SUDs) related to COVID-19 is not confined to the US; there are similar reports from other afflicted nations, making addiction truly the other pandemic.⁴ The Centers for Disease Control and Prevention reported that 13.3% of American adults have started or increased their substance use as a means of managing the negative emotions associated with the pandemic.⁵ Also from March to May 2020, researchers in Baltimore found a 17.6% increase in suspected overdoses in counties advising social distancing and/or mandating stay at home orders.⁵

These data reinforce a well-known maxim in the addiction community that “addiction is a disease of isolation.”^6-8 The burden of the lockdown falls harder on many of the patients we treat in the federal health care system whose other mental and physical health conditions, including chronic pain, depression, and posttraumatic stress disorder already placed them at elevated risk of SUDs.⁹ Director of the National Institute of Drug Abuse Nora Volkow, MD, recently traced the well-known arc from isolation to increased use of drugs and alcohol.¹⁰ Isolation is stressful and amplifies negative thoughts, dysphoria, and fearful emotions, which are recognized triggers for the use of substances of abuse. The usually available means of coping with craving, and in many cases withdrawal, such as prescribed medications, visits to therapists, participation in support groups are either not available or much more difficult to access.¹⁰ Nor are those without a current or even historical SUD immune to the psychosocial pressures of the pandemic: Isolation also constitutes a risk for the development of de novo addiction particularly among already marginalized groups, such as the elderly and disabled.

The federal government has initiated several important measures to reduce the adverse impact of isolation on persons with SUDs. The Drug Enforcement Administration is exempting qualified practitioners of medication-assisted treatment from the in-person evaluation that is usually required for the prescription of controlled substances, including buprenorphine. This exemption applies to both established patient prescriptions for buprenorphine and new buprenorphine patient prescriptions.¹¹ These and other administrative contingencies at the federal government level can assist persons with OUD to continue to receive medicationassisted treatment.

1020_editorial_table.png

As individual clinicians in federal practice, we alone cannot engineer such major policy accommodations in response to COVID-19, yet we can still make a difference in the lives of our patients. We can focus a few minutes of our telehealth interactions on checking in with patients who have a history or a current SUD. We can remember to use evidence-based screens for these patients and those with other risk factors to detect drug or alcohol use before it becomes a disorder. And we can identify and refer not only patients but also our beleaguered colleagues who feel alone at sea—to the many lifelines our agencies have cast into what other commentators have referred to as a Perfect Storm of COVID-19 and the opioid crisis (Table).¹²

May 20 of this plague year, Reuters reported the death of a 32-year-old Florida nurse who had worked tirelessly to treat patients with COVID-19.¹ The presumption is that, like so many selfless health care providers (HCPs), this nurse was exposed to and then sadly succumbed to the virus. That presumption would be wrong: COVID-19 did not take his young life. The other pandemic—addiction— did. Bereaved friends and family reported that the nurse had been in recovery from opioid use disorder (OUD) before the onslaught of the public health crisis. The chronicle of his relapse is instructive for the devastating effect COVID-19 has had on persons struggling with addiction, even those like the nurse who was in sustained remission from OUD with a bright future.

Many of the themes are familiar to HCPs and have been the subject of prior columns in this COVID-19 series. The nurse experienced acute stress symptoms, such as nightmares from the repeated crises of sick and dying patients in the intensive care unit where he worked.² Like so many other HCPs, while he was desperately trying to save others, he also worried about having sufficient access to appropriate personal protective equipment (PPE).

Most relevant to this column, the caregiver was unable to access his primary source of support for his sobriety—attendance at 12-step meetings. Social distancing, which is one of the only proven means we have of reducing transmission of the virus, has had unintended consequences. Although many have found virtual connections rewarding, this nurse needed the curtailed face-to-face contact. The courage that had led him to volunteer for hazardous duty unwontedly resulted in his estrangement: Friends feared that he would expose them to the virus, and he worried that he would expose his family to danger. As in the 1918 flu pandemic, the humans we depend on for reality testing and companionship have been cruelly transformed into potential vectors of the virus.³

Isolation is the worst of all possible counselors as the great Spanish philosopher of alienation Miguel de Unamuno has argued. The deceptive promise of a rapid deliverance from anxiety and pain that substances of abuse proffer apparently led the nurse back to opioids. The virtue of being clean permitted the dirty drug to take advantage of the nurses’ reduced physiologic tolerance to opioids. It is suspected but not confirmed that he fatally overdosed alone in his car.

This Florida nurse is an especially tragic example of a terrible phenomenon being repeated all over the country. And the epidemic of substance use disorders (SUDs) related to COVID-19 is not confined to the US; there are similar reports from other afflicted nations, making addiction truly the other pandemic.⁴ The Centers for Disease Control and Prevention reported that 13.3% of American adults have started or increased their substance use as a means of managing the negative emotions associated with the pandemic.⁵ Also from March to May 2020, researchers in Baltimore found a 17.6% increase in suspected overdoses in counties advising social distancing and/or mandating stay at home orders.⁵

These data reinforce a well-known maxim in the addiction community that “addiction is a disease of isolation.”^6-8 The burden of the lockdown falls harder on many of the patients we treat in the federal health care system whose other mental and physical health conditions, including chronic pain, depression, and posttraumatic stress disorder already placed them at elevated risk of SUDs.⁹ Director of the National Institute of Drug Abuse Nora Volkow, MD, recently traced the well-known arc from isolation to increased use of drugs and alcohol.¹⁰ Isolation is stressful and amplifies negative thoughts, dysphoria, and fearful emotions, which are recognized triggers for the use of substances of abuse. The usually available means of coping with craving, and in many cases withdrawal, such as prescribed medications, visits to therapists, participation in support groups are either not available or much more difficult to access.¹⁰ Nor are those without a current or even historical SUD immune to the psychosocial pressures of the pandemic: Isolation also constitutes a risk for the development of de novo addiction particularly among already marginalized groups, such as the elderly and disabled.

The federal government has initiated several important measures to reduce the adverse impact of isolation on persons with SUDs. The Drug Enforcement Administration is exempting qualified practitioners of medication-assisted treatment from the in-person evaluation that is usually required for the prescription of controlled substances, including buprenorphine. This exemption applies to both established patient prescriptions for buprenorphine and new buprenorphine patient prescriptions.¹¹ These and other administrative contingencies at the federal government level can assist persons with OUD to continue to receive medicationassisted treatment.

1020_editorial_table.png

As individual clinicians in federal practice, we alone cannot engineer such major policy accommodations in response to COVID-19, yet we can still make a difference in the lives of our patients. We can focus a few minutes of our telehealth interactions on checking in with patients who have a history or a current SUD. We can remember to use evidence-based screens for these patients and those with other risk factors to detect drug or alcohol use before it becomes a disorder. And we can identify and refer not only patients but also our beleaguered colleagues who feel alone at sea—to the many lifelines our agencies have cast into what other commentators have referred to as a Perfect Storm of COVID-19 and the opioid crisis (Table).¹²

May 20 of this plague year, Reuters reported the death of a 32-year-old Florida nurse who had worked tirelessly to treat patients with COVID-19.¹ The presumption is that, like so many selfless health care providers (HCPs), this nurse was exposed to and then sadly succumbed to the virus. That presumption would be wrong: COVID-19 did not take his young life. The other pandemic—addiction— did. Bereaved friends and family reported that the nurse had been in recovery from opioid use disorder (OUD) before the onslaught of the public health crisis. The chronicle of his relapse is instructive for the devastating effect COVID-19 has had on persons struggling with addiction, even those like the nurse who was in sustained remission from OUD with a bright future.

Many of the themes are familiar to HCPs and have been the subject of prior columns in this COVID-19 series. The nurse experienced acute stress symptoms, such as nightmares from the repeated crises of sick and dying patients in the intensive care unit where he worked.² Like so many other HCPs, while he was desperately trying to save others, he also worried about having sufficient access to appropriate personal protective equipment (PPE).

Most relevant to this column, the caregiver was unable to access his primary source of support for his sobriety—attendance at 12-step meetings. Social distancing, which is one of the only proven means we have of reducing transmission of the virus, has had unintended consequences. Although many have found virtual connections rewarding, this nurse needed the curtailed face-to-face contact. The courage that had led him to volunteer for hazardous duty unwontedly resulted in his estrangement: Friends feared that he would expose them to the virus, and he worried that he would expose his family to danger. As in the 1918 flu pandemic, the humans we depend on for reality testing and companionship have been cruelly transformed into potential vectors of the virus.³

Isolation is the worst of all possible counselors as the great Spanish philosopher of alienation Miguel de Unamuno has argued. The deceptive promise of a rapid deliverance from anxiety and pain that substances of abuse proffer apparently led the nurse back to opioids. The virtue of being clean permitted the dirty drug to take advantage of the nurses’ reduced physiologic tolerance to opioids. It is suspected but not confirmed that he fatally overdosed alone in his car.

This Florida nurse is an especially tragic example of a terrible phenomenon being repeated all over the country. And the epidemic of substance use disorders (SUDs) related to COVID-19 is not confined to the US; there are similar reports from other afflicted nations, making addiction truly the other pandemic.⁴ The Centers for Disease Control and Prevention reported that 13.3% of American adults have started or increased their substance use as a means of managing the negative emotions associated with the pandemic.⁵ Also from March to May 2020, researchers in Baltimore found a 17.6% increase in suspected overdoses in counties advising social distancing and/or mandating stay at home orders.⁵

These data reinforce a well-known maxim in the addiction community that “addiction is a disease of isolation.”^6-8 The burden of the lockdown falls harder on many of the patients we treat in the federal health care system whose other mental and physical health conditions, including chronic pain, depression, and posttraumatic stress disorder already placed them at elevated risk of SUDs.⁹ Director of the National Institute of Drug Abuse Nora Volkow, MD, recently traced the well-known arc from isolation to increased use of drugs and alcohol.¹⁰ Isolation is stressful and amplifies negative thoughts, dysphoria, and fearful emotions, which are recognized triggers for the use of substances of abuse. The usually available means of coping with craving, and in many cases withdrawal, such as prescribed medications, visits to therapists, participation in support groups are either not available or much more difficult to access.¹⁰ Nor are those without a current or even historical SUD immune to the psychosocial pressures of the pandemic: Isolation also constitutes a risk for the development of de novo addiction particularly among already marginalized groups, such as the elderly and disabled.

The federal government has initiated several important measures to reduce the adverse impact of isolation on persons with SUDs. The Drug Enforcement Administration is exempting qualified practitioners of medication-assisted treatment from the in-person evaluation that is usually required for the prescription of controlled substances, including buprenorphine. This exemption applies to both established patient prescriptions for buprenorphine and new buprenorphine patient prescriptions.¹¹ These and other administrative contingencies at the federal government level can assist persons with OUD to continue to receive medicationassisted treatment.

1020_editorial_table.png

As individual clinicians in federal practice, we alone cannot engineer such major policy accommodations in response to COVID-19, yet we can still make a difference in the lives of our patients. We can focus a few minutes of our telehealth interactions on checking in with patients who have a history or a current SUD. We can remember to use evidence-based screens for these patients and those with other risk factors to detect drug or alcohol use before it becomes a disorder. And we can identify and refer not only patients but also our beleaguered colleagues who feel alone at sea—to the many lifelines our agencies have cast into what other commentators have referred to as a Perfect Storm of COVID-19 and the opioid crisis (Table).¹²

A torrent of blame has deluged the administration’s management of the pandemic. There is though one part of the government that deserves the praise of the nation for its response to this public health crisis—the federal health care system. In this column, we discuss the ways in which the Veterans Health Administration (VHA), the Department of Defense (DoD), and the US Public Health Service (PHS) Commissioned Corps especially have bravely and generously responded to the medical emergency of COVID-19 in the US.

Four missions drive the US Department of Veterans Affairs (VA). Though the fourth of these missions usually is in the background, it has risen to the forefront during the pandemic. To put the fourth mission in its proper perspective, we first should review the other 3 charges given to the largest integrated health care system in the country.

The first mission is to provide the highest quality care possible for the more than 9 million veterans enrolled in that system at each of the 1,255 VHA locations. The second mission is to ensure that the Veterans Benefits Administration delivers the full range of benefits that veterans earned through their service. These including funding for education, loans for homes, and many other types of support that assist service men and women to be successful in their transition from military to civilian life. The third mission is to honor the commitment of those who fought for their country unto death. The National Cemeteries Administration oversees 142 national cemeteries where veterans are buried with dignity and remembered with gratitude for their uniformed service. The purpose of these 3 internally focused missions is to provide a safety net for eligible veterans from the day they separate from the military until the hour they pass from this earth.

The fourth mission is different. This mission looks outside the military family to the civilian world. Its goal is to bolster the ability of the nation as a whole to handle wars, terrorism, national emergencies, and natural disasters. It does this through emergency response plans that preserve the integrity of the 3 other missions to veterans while enhancing the capacity of local and state governments to manage the threat of these public health, safety, or security crises.¹

At the same time the VA was aggressively mounting a defense against the threat COVID-19 posed to the other missions, it also launched the fourth mission. In announcing these actions in April 2020, VA Secretary Robert Wilke succinctly summarized the need to balance the fourth mission with the other 3. “VA is committed to helping the nation in this effort to combat COVID-19. Helping veterans is our first mission, but in many locations across the country we’re helping states and local communities. VA is in this fight not only for the millions of veterans we serve each day; we’re in the fight for the people of the United States.”²

During the 2009 H1N1 pandemic I saw firsthand how VA disaster preparedness and emergency training were far superior to many academic and community health care systems. Given VA’s detailed and drilled crisis response plans, its specialized expertise in public health disasters, and its immense resources, it is no wonder that as the virus stretched civilian health care systems, some states turned to the VA for help. At my Albuquerque, New Mexico, VA medical center, 5 medical surgical beds and 3 intensive care beds were opened to the Indian Health Service overwhelmed with cases of COVID-19 in the hard-hit Navajo Nation. In New Jersey where Federal Practitioner is published, the fourth mission reached out to the state-run veterans homes as 90 VA nurses and gerontologists were deployed to 2 of its veterans facilities where close to 150 veterans have died.³ State veterans homes in Massachusetts, Pennsylvania, Alabama, and many other states have received supplies, including direly needed testing and personal protective equipment, staff, technology, and training.⁴

In July, VA published an impressive summary of fourth mission activities, which I encourage you to read. When you are look at this site, remember with a moment of silent appreciation all the altruistic and courageous VA clinical and administrative staff who volunteered for these assignments many of which put them directly in harm’s way.⁵

The VA is not alone in answering the call of COVID-19. In March, despite the grave risk to their health, their life, and their families, the USNS Comfort was deployed to New York City to help with its COVID-19 response while the USNS Mercy assisted in the efforts in Los Angeles. More recently, the military deployed > 700 Military Health System medical and support professionals to support COVID-19 operations in both Texas and California. Brooke Army Medical Center in San Antonio has taken on a handful of civilian patients with COVID-19 and increase its level I trauma cases as local hospitals have strained under the caseload.⁶

For the PHS Commissioned Corps its first mission is to serve as “America’s health responders.”⁷ This pandemic has intensified the extant health inequities in our country and compounded them with racial injustice and economic disparity. Thus, it is important to recognize that the very purpose of the PHS is to “fight disease, conduct research, and care for patients in underserved communities across the nation.”⁸ More than 3,900 PHS officers have been deployed nationally and internationally in COVID-19 clinical strike teams. Early in the pandemic the clinical response teams were deployed to a long-term care facility in Kirkland, Washington; convention center-based hospitals in New York City, Detroit, Michigan, and Washington DC, and Navajo Nation facilities. PHS officers also are providing clinical guidance at Bureau of Prison facilities for infection control and personal protective equipment training.

We know that there are many more examples of heroic service by federal health care professionals and staff than we could locate or celebrate in this brief column. Readers of this journal are well aware of the near constant criticism of the VA and calls for privatization,⁹ the inadequate funding of the PHS,¹⁰ and the recent downsizing of DoD health care¹¹ that threatens to undermine its core functions. The pandemic has powerfully demonstrated that degrading the ability of federal health care to agilely and masterfully mobilize in the event of a public health disaster endangers not just veterans and the military but the health and well-being of a nation, particularly its most vulnerable citizens.

A torrent of blame has deluged the administration’s management of the pandemic. There is though one part of the government that deserves the praise of the nation for its response to this public health crisis—the federal health care system. In this column, we discuss the ways in which the Veterans Health Administration (VHA), the Department of Defense (DoD), and the US Public Health Service (PHS) Commissioned Corps especially have bravely and generously responded to the medical emergency of COVID-19 in the US.

Four missions drive the US Department of Veterans Affairs (VA). Though the fourth of these missions usually is in the background, it has risen to the forefront during the pandemic. To put the fourth mission in its proper perspective, we first should review the other 3 charges given to the largest integrated health care system in the country.

The first mission is to provide the highest quality care possible for the more than 9 million veterans enrolled in that system at each of the 1,255 VHA locations. The second mission is to ensure that the Veterans Benefits Administration delivers the full range of benefits that veterans earned through their service. These including funding for education, loans for homes, and many other types of support that assist service men and women to be successful in their transition from military to civilian life. The third mission is to honor the commitment of those who fought for their country unto death. The National Cemeteries Administration oversees 142 national cemeteries where veterans are buried with dignity and remembered with gratitude for their uniformed service. The purpose of these 3 internally focused missions is to provide a safety net for eligible veterans from the day they separate from the military until the hour they pass from this earth.

The fourth mission is different. This mission looks outside the military family to the civilian world. Its goal is to bolster the ability of the nation as a whole to handle wars, terrorism, national emergencies, and natural disasters. It does this through emergency response plans that preserve the integrity of the 3 other missions to veterans while enhancing the capacity of local and state governments to manage the threat of these public health, safety, or security crises.¹

At the same time the VA was aggressively mounting a defense against the threat COVID-19 posed to the other missions, it also launched the fourth mission. In announcing these actions in April 2020, VA Secretary Robert Wilke succinctly summarized the need to balance the fourth mission with the other 3. “VA is committed to helping the nation in this effort to combat COVID-19. Helping veterans is our first mission, but in many locations across the country we’re helping states and local communities. VA is in this fight not only for the millions of veterans we serve each day; we’re in the fight for the people of the United States.”²

During the 2009 H1N1 pandemic I saw firsthand how VA disaster preparedness and emergency training were far superior to many academic and community health care systems. Given VA’s detailed and drilled crisis response plans, its specialized expertise in public health disasters, and its immense resources, it is no wonder that as the virus stretched civilian health care systems, some states turned to the VA for help. At my Albuquerque, New Mexico, VA medical center, 5 medical surgical beds and 3 intensive care beds were opened to the Indian Health Service overwhelmed with cases of COVID-19 in the hard-hit Navajo Nation. In New Jersey where Federal Practitioner is published, the fourth mission reached out to the state-run veterans homes as 90 VA nurses and gerontologists were deployed to 2 of its veterans facilities where close to 150 veterans have died.³ State veterans homes in Massachusetts, Pennsylvania, Alabama, and many other states have received supplies, including direly needed testing and personal protective equipment, staff, technology, and training.⁴

In July, VA published an impressive summary of fourth mission activities, which I encourage you to read. When you are look at this site, remember with a moment of silent appreciation all the altruistic and courageous VA clinical and administrative staff who volunteered for these assignments many of which put them directly in harm’s way.⁵

The VA is not alone in answering the call of COVID-19. In March, despite the grave risk to their health, their life, and their families, the USNS Comfort was deployed to New York City to help with its COVID-19 response while the USNS Mercy assisted in the efforts in Los Angeles. More recently, the military deployed > 700 Military Health System medical and support professionals to support COVID-19 operations in both Texas and California. Brooke Army Medical Center in San Antonio has taken on a handful of civilian patients with COVID-19 and increase its level I trauma cases as local hospitals have strained under the caseload.⁶

For the PHS Commissioned Corps its first mission is to serve as “America’s health responders.”⁷ This pandemic has intensified the extant health inequities in our country and compounded them with racial injustice and economic disparity. Thus, it is important to recognize that the very purpose of the PHS is to “fight disease, conduct research, and care for patients in underserved communities across the nation.”⁸ More than 3,900 PHS officers have been deployed nationally and internationally in COVID-19 clinical strike teams. Early in the pandemic the clinical response teams were deployed to a long-term care facility in Kirkland, Washington; convention center-based hospitals in New York City, Detroit, Michigan, and Washington DC, and Navajo Nation facilities. PHS officers also are providing clinical guidance at Bureau of Prison facilities for infection control and personal protective equipment training.

We know that there are many more examples of heroic service by federal health care professionals and staff than we could locate or celebrate in this brief column. Readers of this journal are well aware of the near constant criticism of the VA and calls for privatization,⁹ the inadequate funding of the PHS,¹⁰ and the recent downsizing of DoD health care¹¹ that threatens to undermine its core functions. The pandemic has powerfully demonstrated that degrading the ability of federal health care to agilely and masterfully mobilize in the event of a public health disaster endangers not just veterans and the military but the health and well-being of a nation, particularly its most vulnerable citizens.

A torrent of blame has deluged the administration’s management of the pandemic. There is though one part of the government that deserves the praise of the nation for its response to this public health crisis—the federal health care system. In this column, we discuss the ways in which the Veterans Health Administration (VHA), the Department of Defense (DoD), and the US Public Health Service (PHS) Commissioned Corps especially have bravely and generously responded to the medical emergency of COVID-19 in the US.

Four missions drive the US Department of Veterans Affairs (VA). Though the fourth of these missions usually is in the background, it has risen to the forefront during the pandemic. To put the fourth mission in its proper perspective, we first should review the other 3 charges given to the largest integrated health care system in the country.

The first mission is to provide the highest quality care possible for the more than 9 million veterans enrolled in that system at each of the 1,255 VHA locations. The second mission is to ensure that the Veterans Benefits Administration delivers the full range of benefits that veterans earned through their service. These including funding for education, loans for homes, and many other types of support that assist service men and women to be successful in their transition from military to civilian life. The third mission is to honor the commitment of those who fought for their country unto death. The National Cemeteries Administration oversees 142 national cemeteries where veterans are buried with dignity and remembered with gratitude for their uniformed service. The purpose of these 3 internally focused missions is to provide a safety net for eligible veterans from the day they separate from the military until the hour they pass from this earth.

The fourth mission is different. This mission looks outside the military family to the civilian world. Its goal is to bolster the ability of the nation as a whole to handle wars, terrorism, national emergencies, and natural disasters. It does this through emergency response plans that preserve the integrity of the 3 other missions to veterans while enhancing the capacity of local and state governments to manage the threat of these public health, safety, or security crises.¹

At the same time the VA was aggressively mounting a defense against the threat COVID-19 posed to the other missions, it also launched the fourth mission. In announcing these actions in April 2020, VA Secretary Robert Wilke succinctly summarized the need to balance the fourth mission with the other 3. “VA is committed to helping the nation in this effort to combat COVID-19. Helping veterans is our first mission, but in many locations across the country we’re helping states and local communities. VA is in this fight not only for the millions of veterans we serve each day; we’re in the fight for the people of the United States.”²

During the 2009 H1N1 pandemic I saw firsthand how VA disaster preparedness and emergency training were far superior to many academic and community health care systems. Given VA’s detailed and drilled crisis response plans, its specialized expertise in public health disasters, and its immense resources, it is no wonder that as the virus stretched civilian health care systems, some states turned to the VA for help. At my Albuquerque, New Mexico, VA medical center, 5 medical surgical beds and 3 intensive care beds were opened to the Indian Health Service overwhelmed with cases of COVID-19 in the hard-hit Navajo Nation. In New Jersey where Federal Practitioner is published, the fourth mission reached out to the state-run veterans homes as 90 VA nurses and gerontologists were deployed to 2 of its veterans facilities where close to 150 veterans have died.³ State veterans homes in Massachusetts, Pennsylvania, Alabama, and many other states have received supplies, including direly needed testing and personal protective equipment, staff, technology, and training.⁴

In July, VA published an impressive summary of fourth mission activities, which I encourage you to read. When you are look at this site, remember with a moment of silent appreciation all the altruistic and courageous VA clinical and administrative staff who volunteered for these assignments many of which put them directly in harm’s way.⁵

The VA is not alone in answering the call of COVID-19. In March, despite the grave risk to their health, their life, and their families, the USNS Comfort was deployed to New York City to help with its COVID-19 response while the USNS Mercy assisted in the efforts in Los Angeles. More recently, the military deployed > 700 Military Health System medical and support professionals to support COVID-19 operations in both Texas and California. Brooke Army Medical Center in San Antonio has taken on a handful of civilian patients with COVID-19 and increase its level I trauma cases as local hospitals have strained under the caseload.⁶

For the PHS Commissioned Corps its first mission is to serve as “America’s health responders.”⁷ This pandemic has intensified the extant health inequities in our country and compounded them with racial injustice and economic disparity. Thus, it is important to recognize that the very purpose of the PHS is to “fight disease, conduct research, and care for patients in underserved communities across the nation.”⁸ More than 3,900 PHS officers have been deployed nationally and internationally in COVID-19 clinical strike teams. Early in the pandemic the clinical response teams were deployed to a long-term care facility in Kirkland, Washington; convention center-based hospitals in New York City, Detroit, Michigan, and Washington DC, and Navajo Nation facilities. PHS officers also are providing clinical guidance at Bureau of Prison facilities for infection control and personal protective equipment training.

We know that there are many more examples of heroic service by federal health care professionals and staff than we could locate or celebrate in this brief column. Readers of this journal are well aware of the near constant criticism of the VA and calls for privatization,⁹ the inadequate funding of the PHS,¹⁰ and the recent downsizing of DoD health care¹¹ that threatens to undermine its core functions. The pandemic has powerfully demonstrated that degrading the ability of federal health care to agilely and masterfully mobilize in the event of a public health disaster endangers not just veterans and the military but the health and well-being of a nation, particularly its most vulnerable citizens.

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

fdp03707300_image.png

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

fdp03707300_image.png

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

The editorials I have written so far in this series on COVID-19 have been on weighty topics as befits the serious situation of the pandemic, which as of June 30, 2020 had taken more than 500,000 lives across the globe and caused anguish and sorrow such as the world has not known since the 1918 influenza pandemic.²

The human spirit can bear only so much distress and tragedy before it is bowed and unable to stand. Stand though we must; not just against the inanimate invasion of viruses from the outside, but also our own endemic national tensions and conflicts. A periodic lifting of our burdens and a recharging of our psychological and spiritual energies are crucial to the resilience and flexibility that are necessary to walk the long difficult road ahead of us as a nation and as public servants in health care. This column takes a lighter look at COVID-19 and considers the restorative role companion animals, especially, for me, my beloved canines, have played in caring for and about us humans during the pandemic.

You will likely read this editorial during the official dog days of summer, which run from July 22 to August 22. We all may imagine a big dog laying on a porch in the American South while his owners drink lemonade and quietly rock in chairs watching the long lazy days pass in a simpler time.

fdp03707300_image.png

However pleasant this bucolic picture, it has little to do with the origin of the expression, which dates back to ancient Greece. The dog refers not to our literal furry friends but, according to National Geographic (and who should know better), to the position of the “dog star” in a constellation in the night sky.³ Unfortunately, we cannot completely get away from the sobering theme of the pandemic: The rise of the star to prominence during the peak of the Mediterranean summer’s heat was a period associated with disaster and illness.

Real dogs, cats, and assorted other so-called pandemic pets, though, have been another type of star in this difficult period. Early in the shelter-in-place, pet adoptions from city and county animal shelters and rescue organizations skyrocketed.⁴ Although animal welfare experts have legitimate concerns that some of these adoptees will be surrendered if there is ever a return to normal. For now many people feel it is the perfect time to adopt, precisely because they now have space to bring a new member into the family. Before adopting, as a recent National Public Radio report emphasized, individuals should consider whether they truly have the resources both material and emotional to care for a pet.⁵ For those who take stock honestly and believe they have the room in their heart and budget, rescuing a companion is good psychological news, arguably even more for the human than for the animal.

Sheltering-in-place has reduced the transmission of the virus, which scientists estimate has saved thousands of lives.⁶ But it also has triggered a second health crisis, this time of mental health with an unprecedented increase in rates of depression, anxiety, suicide attempts, and substance use that is expected to worsen over the coming months and years.⁷ Companion animals certainly cannot solve this complex and mammoth public health problem; however, they can contribute in simple and small yet very significant ways to the mental health of individuals.⁸

Caring for a pet who shows unconditional love and loyalty to you can reduce isolation; foster hope; provide meaning, comfort, and cheer to you when you are down or afraid; and offer a routine and reason to get out of bed every day and take a walk outside. Research shows that those positive effects can decrease the risk of the very mental health conditions that are now plaguing us in such alarming numbers.^9,10

“How many more lives are we willing to sacrifice in the name of containing the virus?” Elinore McCance-Katz, MD, PhD, the nation’s top mental health official ominously asked about the potential effects of another shutdown during a cabinet meeting.¹¹ For some of us, a companion animal who does not require physical distancing (at least when you are healthy) may permit us to prevent the spread of the virus while protecting our mental health.

Nor is emotional support the only clinical way in which animals are helping pandemic- beleaguered humans. There is a low risk we can infect household pets, and dogs are not likely to transmit the virus. In fact, they even can be trained to serve as highly efficient virus testers who don’t need scarce reagents or carry high price tags—just a pat on the head and an occasional treat.¹² Medscape reported that clinical trials starting in the United Kingdom are set to evaluate the accuracy of these “bio-detection” dogs. The story quotes a leading British public health official as saying, “Properly trained sniffer dogs could revolutionise our approach to this whole pandemic, screening 250 people an hour for the virus.”¹³

Canines are not only healers who can ease our troubles through the pandemic but also peacemakers. As injustice and violence rock the country, we would do well to imitate their attitudes of nonjudgmental acceptance. “Dogs are our link to paradise. They do not know evil or jealousy or discontent,” wrote novelist Milan Kundera. “To sit with a dog on a hillside on a glorious afternoon is to be back in Eden, where doing nothing was not boring—it was peace.”¹⁴ Those indeed would be dog days as when better nature we sometimes share with animals prevailed.

For health care professionals, especially those in the epicenters of the pandemic, among the most distressing aspects of this first wave of COVID-19 has been the absence of any drug to treat the virus. The practitioners on the frontlines have confronted repeated surges of critically ill and dying patients without any effective treatment to offer, resulting in feelings of hopelessness, guilt, moral distress, depression, and in some tragic cases, suicide.²

On May 12th, the Centers of Disease Control and Prevention (CDC) released additional guidance on the antiviral medications that are the subject of this essay. The CDC may have updated its treatment guidelines in part to try and bring a measure of clinical reasoning and scientific order into the impassioned and politicized chaos that surrounded hydrocloroquine and remdesivir in the media.³

In this fourth installment of my series on pandemic ethics, we examine the desperate race for hope in the form of drug treatments for COVID-19. The race has been run faster than any in history thanks to biotechnology, genetic engineering, and artificial intelligence, although many experts believe it will still be a marathon rather than a sprint to a vaccine.⁴

The first editorial in this series provided a primer of the key differences between public health ethics and clinical ethics. Another crucial distinction is the far more pervasive and powerful influence of nonmedical factors in decision making, including political agendas, economic motives, journalistic hyperbole, and cultural biases and orientations. These competing interests make it even more challenging for scientists of integrity and health care institutions that are trying to uphold core values to make principled judgments about what is best for critically ill patients and the demoralized staff caring for them. In the remainder of this column, I will trace the dynamics of these forces as they impact the use of 2 drugs in federal practice: hydroxychloroquine and remdesivir.

The trajectory of hydroxychloroquine has been a political and medical roller-coaster since the pandemic hit, as is evident in its US Department of Veterans Affairs (VA) ride. Various media outlets have reported that beginning about March 26, 2020, VA placed orders for up to $400,000 of the antimalarial drug hydroxychloroquine to be given to veterans hospitalized with COVID-19.⁵ The same day the VA Office of Inspector General (OIG) issued a report critical of VA pandemic readiness and its availability of hydroxychloroquine.⁶

The VA strongly refuted the report, objecting to the premise of the OIG investigation, which was to determine whether VA facilities had on hand a 14-day supply of chloroquine or hydroxychloroquine. “This is both inaccurate and irresponsible.” Noting that the drugs were still under investigation, the VA insisted that “No conclusions have been made on their effectiveness. To insist that a 14 days’ supply of these drugs is appropriate or not appropriate displays this dangerous lack of expertise on COVID-19 and Pandemic response.”⁶

In April, National Institutes of Health-sponsored researchers released data that hydroxychloroquine actually increased mortality among VA patients with COVID-19,⁷ leading veterans’ groups and the Senate minority leader to demand that VA cease to use hydroxychloroquine for COVID-19.⁸ As recently as May 15, the Associated Press reported that top VA officials have defended their use of the medication and stated they will not stop administering the medication for this indication.⁹ And VA is not alone, many other health care institutions are still prescribing hydroxychloroquine even amid scientific controversy about its putative benefits. In response to the growing awareness of the potential harms of the drug, the World Health Organization on May 25 announced it was halting all hydroxychloroquine trials.¹⁰ Why then do some physicians and health care providers continue to prescribe it? Because when nothing else stands between the patient and certain death even if there are known risks and uncertain benefits, some in health care feel morally obliged to use their best clinical judgment to help a patient.

Remdesivir’s fortunes both scientific and monetary also rose and fell on the tide of mixed results from studies. Military Times reported on March 10, 2020, that the US Army Medical Research and Development Command had made an agreement with Gilead Sciences, the manufacturer of remdesivir, to provide the medication to COVID-19-positive service members.¹¹ The antiviral had failed against Ebola and hepatitis but showed some efficacy for Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). On April 15, the Secretary of the Army announced that 2 COVID-19-positive soldiers had recovered after being given remdesivir.¹² In late April, the National Institute of Allergy and Infectious Diseases reported that in the scientific gold standard randomized placebo-controlled trial, remdesivir did speed the recovery of patients with advanced COVID-19. With the publication of the study in the prestigious New England Journal of Medicine on May 22, 2020, clearly the Army had bet on the right horse.¹³

This column has not been about quack cures and patent medicines that greed and ignorance breed in almost every American public health crisis—although these are by no means absent in this pandemic. This is about the serious endeavor of the top scientists and physicians in the country and, indeed, the world to discover a new medication or to repurpose an older pharmaceutical that is effective in the battle against COVID-19. The pressure on scientists and physicians to find a magic bullet in the battle against such an implacable enemy is unprecedented and unimaginable and can easily lead to sloppy science and ethical erosion.

In a utopia, pharmaceutical and vaccine research would be a matter of the discoveries of basic science trialed in the proof of concept of clinical care on a methodical, deliberate, and exacting timetable that balanced burdens and benefits.

In our current dystopia, science and medicine are only one of the many considerations affecting drug and vaccine development. As scientists and health care practitioners, we all experience a therapeutic imperative that we must heed with both caution and courage. Without caution we risk causing more harm than the disease we are fighting. Without courage we lose hope, the most potent antidote of all.

For health care professionals, especially those in the epicenters of the pandemic, among the most distressing aspects of this first wave of COVID-19 has been the absence of any drug to treat the virus. The practitioners on the frontlines have confronted repeated surges of critically ill and dying patients without any effective treatment to offer, resulting in feelings of hopelessness, guilt, moral distress, depression, and in some tragic cases, suicide.²

On May 12th, the Centers of Disease Control and Prevention (CDC) released additional guidance on the antiviral medications that are the subject of this essay. The CDC may have updated its treatment guidelines in part to try and bring a measure of clinical reasoning and scientific order into the impassioned and politicized chaos that surrounded hydrocloroquine and remdesivir in the media.³

In this fourth installment of my series on pandemic ethics, we examine the desperate race for hope in the form of drug treatments for COVID-19. The race has been run faster than any in history thanks to biotechnology, genetic engineering, and artificial intelligence, although many experts believe it will still be a marathon rather than a sprint to a vaccine.⁴

The first editorial in this series provided a primer of the key differences between public health ethics and clinical ethics. Another crucial distinction is the far more pervasive and powerful influence of nonmedical factors in decision making, including political agendas, economic motives, journalistic hyperbole, and cultural biases and orientations. These competing interests make it even more challenging for scientists of integrity and health care institutions that are trying to uphold core values to make principled judgments about what is best for critically ill patients and the demoralized staff caring for them. In the remainder of this column, I will trace the dynamics of these forces as they impact the use of 2 drugs in federal practice: hydroxychloroquine and remdesivir.

The trajectory of hydroxychloroquine has been a political and medical roller-coaster since the pandemic hit, as is evident in its US Department of Veterans Affairs (VA) ride. Various media outlets have reported that beginning about March 26, 2020, VA placed orders for up to $400,000 of the antimalarial drug hydroxychloroquine to be given to veterans hospitalized with COVID-19.⁵ The same day the VA Office of Inspector General (OIG) issued a report critical of VA pandemic readiness and its availability of hydroxychloroquine.⁶

The VA strongly refuted the report, objecting to the premise of the OIG investigation, which was to determine whether VA facilities had on hand a 14-day supply of chloroquine or hydroxychloroquine. “This is both inaccurate and irresponsible.” Noting that the drugs were still under investigation, the VA insisted that “No conclusions have been made on their effectiveness. To insist that a 14 days’ supply of these drugs is appropriate or not appropriate displays this dangerous lack of expertise on COVID-19 and Pandemic response.”⁶

In April, National Institutes of Health-sponsored researchers released data that hydroxychloroquine actually increased mortality among VA patients with COVID-19,⁷ leading veterans’ groups and the Senate minority leader to demand that VA cease to use hydroxychloroquine for COVID-19.⁸ As recently as May 15, the Associated Press reported that top VA officials have defended their use of the medication and stated they will not stop administering the medication for this indication.⁹ And VA is not alone, many other health care institutions are still prescribing hydroxychloroquine even amid scientific controversy about its putative benefits. In response to the growing awareness of the potential harms of the drug, the World Health Organization on May 25 announced it was halting all hydroxychloroquine trials.¹⁰ Why then do some physicians and health care providers continue to prescribe it? Because when nothing else stands between the patient and certain death even if there are known risks and uncertain benefits, some in health care feel morally obliged to use their best clinical judgment to help a patient.

Remdesivir’s fortunes both scientific and monetary also rose and fell on the tide of mixed results from studies. Military Times reported on March 10, 2020, that the US Army Medical Research and Development Command had made an agreement with Gilead Sciences, the manufacturer of remdesivir, to provide the medication to COVID-19-positive service members.¹¹ The antiviral had failed against Ebola and hepatitis but showed some efficacy for Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). On April 15, the Secretary of the Army announced that 2 COVID-19-positive soldiers had recovered after being given remdesivir.¹² In late April, the National Institute of Allergy and Infectious Diseases reported that in the scientific gold standard randomized placebo-controlled trial, remdesivir did speed the recovery of patients with advanced COVID-19. With the publication of the study in the prestigious New England Journal of Medicine on May 22, 2020, clearly the Army had bet on the right horse.¹³

This column has not been about quack cures and patent medicines that greed and ignorance breed in almost every American public health crisis—although these are by no means absent in this pandemic. This is about the serious endeavor of the top scientists and physicians in the country and, indeed, the world to discover a new medication or to repurpose an older pharmaceutical that is effective in the battle against COVID-19. The pressure on scientists and physicians to find a magic bullet in the battle against such an implacable enemy is unprecedented and unimaginable and can easily lead to sloppy science and ethical erosion.

In a utopia, pharmaceutical and vaccine research would be a matter of the discoveries of basic science trialed in the proof of concept of clinical care on a methodical, deliberate, and exacting timetable that balanced burdens and benefits.

In our current dystopia, science and medicine are only one of the many considerations affecting drug and vaccine development. As scientists and health care practitioners, we all experience a therapeutic imperative that we must heed with both caution and courage. Without caution we risk causing more harm than the disease we are fighting. Without courage we lose hope, the most potent antidote of all.

For health care professionals, especially those in the epicenters of the pandemic, among the most distressing aspects of this first wave of COVID-19 has been the absence of any drug to treat the virus. The practitioners on the frontlines have confronted repeated surges of critically ill and dying patients without any effective treatment to offer, resulting in feelings of hopelessness, guilt, moral distress, depression, and in some tragic cases, suicide.²

On May 12th, the Centers of Disease Control and Prevention (CDC) released additional guidance on the antiviral medications that are the subject of this essay. The CDC may have updated its treatment guidelines in part to try and bring a measure of clinical reasoning and scientific order into the impassioned and politicized chaos that surrounded hydrocloroquine and remdesivir in the media.³

In this fourth installment of my series on pandemic ethics, we examine the desperate race for hope in the form of drug treatments for COVID-19. The race has been run faster than any in history thanks to biotechnology, genetic engineering, and artificial intelligence, although many experts believe it will still be a marathon rather than a sprint to a vaccine.⁴

The first editorial in this series provided a primer of the key differences between public health ethics and clinical ethics. Another crucial distinction is the far more pervasive and powerful influence of nonmedical factors in decision making, including political agendas, economic motives, journalistic hyperbole, and cultural biases and orientations. These competing interests make it even more challenging for scientists of integrity and health care institutions that are trying to uphold core values to make principled judgments about what is best for critically ill patients and the demoralized staff caring for them. In the remainder of this column, I will trace the dynamics of these forces as they impact the use of 2 drugs in federal practice: hydroxychloroquine and remdesivir.

The trajectory of hydroxychloroquine has been a political and medical roller-coaster since the pandemic hit, as is evident in its US Department of Veterans Affairs (VA) ride. Various media outlets have reported that beginning about March 26, 2020, VA placed orders for up to $400,000 of the antimalarial drug hydroxychloroquine to be given to veterans hospitalized with COVID-19.⁵ The same day the VA Office of Inspector General (OIG) issued a report critical of VA pandemic readiness and its availability of hydroxychloroquine.⁶

The VA strongly refuted the report, objecting to the premise of the OIG investigation, which was to determine whether VA facilities had on hand a 14-day supply of chloroquine or hydroxychloroquine. “This is both inaccurate and irresponsible.” Noting that the drugs were still under investigation, the VA insisted that “No conclusions have been made on their effectiveness. To insist that a 14 days’ supply of these drugs is appropriate or not appropriate displays this dangerous lack of expertise on COVID-19 and Pandemic response.”⁶

In April, National Institutes of Health-sponsored researchers released data that hydroxychloroquine actually increased mortality among VA patients with COVID-19,⁷ leading veterans’ groups and the Senate minority leader to demand that VA cease to use hydroxychloroquine for COVID-19.⁸ As recently as May 15, the Associated Press reported that top VA officials have defended their use of the medication and stated they will not stop administering the medication for this indication.⁹ And VA is not alone, many other health care institutions are still prescribing hydroxychloroquine even amid scientific controversy about its putative benefits. In response to the growing awareness of the potential harms of the drug, the World Health Organization on May 25 announced it was halting all hydroxychloroquine trials.¹⁰ Why then do some physicians and health care providers continue to prescribe it? Because when nothing else stands between the patient and certain death even if there are known risks and uncertain benefits, some in health care feel morally obliged to use their best clinical judgment to help a patient.

Remdesivir’s fortunes both scientific and monetary also rose and fell on the tide of mixed results from studies. Military Times reported on March 10, 2020, that the US Army Medical Research and Development Command had made an agreement with Gilead Sciences, the manufacturer of remdesivir, to provide the medication to COVID-19-positive service members.¹¹ The antiviral had failed against Ebola and hepatitis but showed some efficacy for Middle East respiratory syndrome (MERS) and severe acute respiratory syndrome (SARS). On April 15, the Secretary of the Army announced that 2 COVID-19-positive soldiers had recovered after being given remdesivir.¹² In late April, the National Institute of Allergy and Infectious Diseases reported that in the scientific gold standard randomized placebo-controlled trial, remdesivir did speed the recovery of patients with advanced COVID-19. With the publication of the study in the prestigious New England Journal of Medicine on May 22, 2020, clearly the Army had bet on the right horse.¹³

This column has not been about quack cures and patent medicines that greed and ignorance breed in almost every American public health crisis—although these are by no means absent in this pandemic. This is about the serious endeavor of the top scientists and physicians in the country and, indeed, the world to discover a new medication or to repurpose an older pharmaceutical that is effective in the battle against COVID-19. The pressure on scientists and physicians to find a magic bullet in the battle against such an implacable enemy is unprecedented and unimaginable and can easily lead to sloppy science and ethical erosion.

In a utopia, pharmaceutical and vaccine research would be a matter of the discoveries of basic science trialed in the proof of concept of clinical care on a methodical, deliberate, and exacting timetable that balanced burdens and benefits.

In our current dystopia, science and medicine are only one of the many considerations affecting drug and vaccine development. As scientists and health care practitioners, we all experience a therapeutic imperative that we must heed with both caution and courage. Without caution we risk causing more harm than the disease we are fighting. Without courage we lose hope, the most potent antidote of all.

As of April 9, 2020, the Centers for Disease Control and Prevention (CDC) reported that 9,282 health care providers in the US had contracted COVID-19, and 27 had died of the virus.² Medscape reports the toll as much higher. Thousands more nurses, doctors, epidemiologists, social workers, physician assistants, dentists, pharmacists, and other health care workers from Italy, China, and dozens of other countries have died fighting this plague.³

The truth is no one knows how many health care workers are actually sick or even have died. State and federal governments have not been routinely and specifically tracking that data, making these already grim statistics likely a gross underestimation.⁴ While not all of these health care providers were exposed to COVID-19 in the line of duty, many were, and many more will be as the pandemic subsides in one epicenter only to erupt in another, and smolders for months until a vaccine quenches it.

Each of those lost lives of promise had a story of hard work and sacrifice to become a health care professional, of friends and family who loved and cared for them when ill, who need and grieve for them, now gone far too soon. Nor should we forget to mourn all of the administrative professionals, the line and support staff of health care facilities, who also perished fighting the pestilence. It is fitting then, that this second editorial in my pledge to write each month about COVID-19 until the pandemic ends, be about the duty to care and its limits.

The duty to care is among the most fundamental and ancient ethical obligations of health care providers. It is included even in modern codes of ethics like that of the American Medical Association and American Nurses Association. The obligation to not abandon patients is even more compelling for the Military Health System, Veterans Health Administration (VHA), and the US Public Health Service whose health care mission also is a public trust. The duty is rooted in the fiduciary nature of the health professions in which the interests of the patient should take priority over other considerations, including a risk to their own health and life. Prioritization though has exceptions. Physician and attorney David Orentlicher points out the unconditional obligation that bound physicians in the 14th century Black Death, or the 1918 Spanish influenza, now admits exceptions and qualifications.⁵

The exception that has become the object of greatest concern to health care workers is personal protective equipment (PPE). In modern public health ethics, health care systems and state and federal governments have a corresponding ethical obligation of reciprocity toward their employees whose work places them at elevated risk of harm—in this case, COVID-19 exposure. The principle of reciprocity encompasses the measures and materials that health care institutions need to provide to health care workers to reasonably minimize the risk of viral transmission. The reasonableness standard does not demand that there be zero risk. It does require that health care workers have adequate and appropriate PPE so that in fulfilling their duty to care they are not exposed to a disproportionate risk.

This last assertion has been the subject of controversy in the media and consternation on the part of health care professionals for several disconcerting reasons. First and foremost, a cascade failure on the part of government and industry has resulted in PPE being the scarcest health care resource in this pandemic.⁶ The shortage is as serious as that of the life-saving ventilators that are rightly at the center of most crisis standards resource allocation plans.⁷ Second, the guidance from the CDC and other authoritative sources continues to change. This is, in part, to adjust to the even more rapid pace of knowledge about the virus and its behavior and to adapt to the reality of insufficient PPE.⁸

Understandably, health care providers, especially those on the frontlines, may lose trust in the scientific experts and the leadership of their institutions, compounding the climate of moral distress in a public health crisis. Health care workers in the community, and even in federal service, have launched socially distanced protests and taken to social media to voice their concern and rally assistance.^9,10 In response, VHA Executive-in-Charge Richard Stone, MD, admitted that VHA does have a shortage of PPE in a Washington Post interview.¹¹ He outlined how the organization plans to address staff concerns. The article also reported only a 4% absentee rate of VHA staff as opposed to the 40% that plans predicted was possible. This demonstrates once more the dedication of VHA health care professionals and workers to fulfill their duty to care for veterans even amid fears about inadequate PPE.

In the epigraph, Albert Camus captures the uncertainty and fear that as humans all health care providers experience as they face the unpredictable but very real threat of COVID-19.¹ Camus expresses even more strongly the devotion to duty of health care providers to care for vulnerable ill patients in need despite the inherent threat in a highly transmissible and potentially deadly infection that is inextricably linked to that caring. Orentlicher wisely opines that the integrity of the health professions and their respected role in society benefit from a strong duty to care.⁵ The best way to promote that duty is to do all in our power to protect those who willingly brave the pestilence to treat, and hope and pray someday to cure COVID-19.

As of April 9, 2020, the Centers for Disease Control and Prevention (CDC) reported that 9,282 health care providers in the US had contracted COVID-19, and 27 had died of the virus.² Medscape reports the toll as much higher. Thousands more nurses, doctors, epidemiologists, social workers, physician assistants, dentists, pharmacists, and other health care workers from Italy, China, and dozens of other countries have died fighting this plague.³

The truth is no one knows how many health care workers are actually sick or even have died. State and federal governments have not been routinely and specifically tracking that data, making these already grim statistics likely a gross underestimation.⁴ While not all of these health care providers were exposed to COVID-19 in the line of duty, many were, and many more will be as the pandemic subsides in one epicenter only to erupt in another, and smolders for months until a vaccine quenches it.

Each of those lost lives of promise had a story of hard work and sacrifice to become a health care professional, of friends and family who loved and cared for them when ill, who need and grieve for them, now gone far too soon. Nor should we forget to mourn all of the administrative professionals, the line and support staff of health care facilities, who also perished fighting the pestilence. It is fitting then, that this second editorial in my pledge to write each month about COVID-19 until the pandemic ends, be about the duty to care and its limits.

The duty to care is among the most fundamental and ancient ethical obligations of health care providers. It is included even in modern codes of ethics like that of the American Medical Association and American Nurses Association. The obligation to not abandon patients is even more compelling for the Military Health System, Veterans Health Administration (VHA), and the US Public Health Service whose health care mission also is a public trust. The duty is rooted in the fiduciary nature of the health professions in which the interests of the patient should take priority over other considerations, including a risk to their own health and life. Prioritization though has exceptions. Physician and attorney David Orentlicher points out the unconditional obligation that bound physicians in the 14th century Black Death, or the 1918 Spanish influenza, now admits exceptions and qualifications.⁵

The exception that has become the object of greatest concern to health care workers is personal protective equipment (PPE). In modern public health ethics, health care systems and state and federal governments have a corresponding ethical obligation of reciprocity toward their employees whose work places them at elevated risk of harm—in this case, COVID-19 exposure. The principle of reciprocity encompasses the measures and materials that health care institutions need to provide to health care workers to reasonably minimize the risk of viral transmission. The reasonableness standard does not demand that there be zero risk. It does require that health care workers have adequate and appropriate PPE so that in fulfilling their duty to care they are not exposed to a disproportionate risk.

This last assertion has been the subject of controversy in the media and consternation on the part of health care professionals for several disconcerting reasons. First and foremost, a cascade failure on the part of government and industry has resulted in PPE being the scarcest health care resource in this pandemic.⁶ The shortage is as serious as that of the life-saving ventilators that are rightly at the center of most crisis standards resource allocation plans.⁷ Second, the guidance from the CDC and other authoritative sources continues to change. This is, in part, to adjust to the even more rapid pace of knowledge about the virus and its behavior and to adapt to the reality of insufficient PPE.⁸

Understandably, health care providers, especially those on the frontlines, may lose trust in the scientific experts and the leadership of their institutions, compounding the climate of moral distress in a public health crisis. Health care workers in the community, and even in federal service, have launched socially distanced protests and taken to social media to voice their concern and rally assistance.^9,10 In response, VHA Executive-in-Charge Richard Stone, MD, admitted that VHA does have a shortage of PPE in a Washington Post interview.¹¹ He outlined how the organization plans to address staff concerns. The article also reported only a 4% absentee rate of VHA staff as opposed to the 40% that plans predicted was possible. This demonstrates once more the dedication of VHA health care professionals and workers to fulfill their duty to care for veterans even amid fears about inadequate PPE.

In the epigraph, Albert Camus captures the uncertainty and fear that as humans all health care providers experience as they face the unpredictable but very real threat of COVID-19.¹ Camus expresses even more strongly the devotion to duty of health care providers to care for vulnerable ill patients in need despite the inherent threat in a highly transmissible and potentially deadly infection that is inextricably linked to that caring. Orentlicher wisely opines that the integrity of the health professions and their respected role in society benefit from a strong duty to care.⁵ The best way to promote that duty is to do all in our power to protect those who willingly brave the pestilence to treat, and hope and pray someday to cure COVID-19.

As of April 9, 2020, the Centers for Disease Control and Prevention (CDC) reported that 9,282 health care providers in the US had contracted COVID-19, and 27 had died of the virus.² Medscape reports the toll as much higher. Thousands more nurses, doctors, epidemiologists, social workers, physician assistants, dentists, pharmacists, and other health care workers from Italy, China, and dozens of other countries have died fighting this plague.³

The truth is no one knows how many health care workers are actually sick or even have died. State and federal governments have not been routinely and specifically tracking that data, making these already grim statistics likely a gross underestimation.⁴ While not all of these health care providers were exposed to COVID-19 in the line of duty, many were, and many more will be as the pandemic subsides in one epicenter only to erupt in another, and smolders for months until a vaccine quenches it.

Each of those lost lives of promise had a story of hard work and sacrifice to become a health care professional, of friends and family who loved and cared for them when ill, who need and grieve for them, now gone far too soon. Nor should we forget to mourn all of the administrative professionals, the line and support staff of health care facilities, who also perished fighting the pestilence. It is fitting then, that this second editorial in my pledge to write each month about COVID-19 until the pandemic ends, be about the duty to care and its limits.

The duty to care is among the most fundamental and ancient ethical obligations of health care providers. It is included even in modern codes of ethics like that of the American Medical Association and American Nurses Association. The obligation to not abandon patients is even more compelling for the Military Health System, Veterans Health Administration (VHA), and the US Public Health Service whose health care mission also is a public trust. The duty is rooted in the fiduciary nature of the health professions in which the interests of the patient should take priority over other considerations, including a risk to their own health and life. Prioritization though has exceptions. Physician and attorney David Orentlicher points out the unconditional obligation that bound physicians in the 14th century Black Death, or the 1918 Spanish influenza, now admits exceptions and qualifications.⁵

The exception that has become the object of greatest concern to health care workers is personal protective equipment (PPE). In modern public health ethics, health care systems and state and federal governments have a corresponding ethical obligation of reciprocity toward their employees whose work places them at elevated risk of harm—in this case, COVID-19 exposure. The principle of reciprocity encompasses the measures and materials that health care institutions need to provide to health care workers to reasonably minimize the risk of viral transmission. The reasonableness standard does not demand that there be zero risk. It does require that health care workers have adequate and appropriate PPE so that in fulfilling their duty to care they are not exposed to a disproportionate risk.

This last assertion has been the subject of controversy in the media and consternation on the part of health care professionals for several disconcerting reasons. First and foremost, a cascade failure on the part of government and industry has resulted in PPE being the scarcest health care resource in this pandemic.⁶ The shortage is as serious as that of the life-saving ventilators that are rightly at the center of most crisis standards resource allocation plans.⁷ Second, the guidance from the CDC and other authoritative sources continues to change. This is, in part, to adjust to the even more rapid pace of knowledge about the virus and its behavior and to adapt to the reality of insufficient PPE.⁸

Understandably, health care providers, especially those on the frontlines, may lose trust in the scientific experts and the leadership of their institutions, compounding the climate of moral distress in a public health crisis. Health care workers in the community, and even in federal service, have launched socially distanced protests and taken to social media to voice their concern and rally assistance.^9,10 In response, VHA Executive-in-Charge Richard Stone, MD, admitted that VHA does have a shortage of PPE in a Washington Post interview.¹¹ He outlined how the organization plans to address staff concerns. The article also reported only a 4% absentee rate of VHA staff as opposed to the 40% that plans predicted was possible. This demonstrates once more the dedication of VHA health care professionals and workers to fulfill their duty to care for veterans even amid fears about inadequate PPE.

In the epigraph, Albert Camus captures the uncertainty and fear that as humans all health care providers experience as they face the unpredictable but very real threat of COVID-19.¹ Camus expresses even more strongly the devotion to duty of health care providers to care for vulnerable ill patients in need despite the inherent threat in a highly transmissible and potentially deadly infection that is inextricably linked to that caring. Orentlicher wisely opines that the integrity of the health professions and their respected role in society benefit from a strong duty to care.⁵ The best way to promote that duty is to do all in our power to protect those who willingly brave the pestilence to treat, and hope and pray someday to cure COVID-19.

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

I am writing this editorial on a beautiful day in the high desert of the Southwest: a bright blue clear sky such as you see only in the mountain air, a sun warm and comforting, and birds singing as if they had not a care in the world. Spring has come early as if to dramatize the cognitive dissonance between this idyllic scene and a seemingly invincible winter of disease and death that has gripped the globe.

For now, my editorials will focus on the most threatening infectious disease outbreak since, perhaps, 1918. I have been teaching public health and pandemic ethics to health care professionals and trainees for more than a decade. I always tell the medical students, “it is not if but when” the next viral wave overwhelms society. It is human nature to disbelieve this inevitability and to ignore, dismiss, or even attack the infectious disease experts and science journalists who, like Cassandra, warn us of the return of the plague.¹

In the early 2000s, virologists were concerned that Avian influenza with a mortality rate of > 60% would mutate into a virus capable of jumping the species barrier with sustained human transmission; however, that threat has not materialized (yet).² Instead, in 2009 the H1N1 influenza pandemic struck viciously. The always capricious genetic mutations of viral combinations outwitted vaccine manufacturers, offering little protection, resulting in an estimated 12,469 deaths, tragically many of them children, young, and middle-aged people.³ In between, there were periodic eruptions of the deadly Ebola virus in Africa. In 2014, 11 Americans who had either served as health care workers or traveled in the region were treated in the US.⁴

This much abridged survey of recent pandemics reminds us of how wrong were those who returning victorious from World War II with newly developed antibiotics and at the zenith of American military medicine argued that we would also beat infectious disease.⁵ As my Army pediatrician father would tell me, “the bugs will always be smarter than the drugs.” For now, COVID-19 is outwitting those in science and medicine who are engaged in a desperate race to discover a vaccine or a drug to “stop the virus in its tracks” as the media is so fond of saying.⁶ Irresponsible news outlets are giving a panicked citizenry false hope. Experts recently testified before the US House of Representatives that according to the most optimistic estimates, a vaccine is a year away.⁷ Yet information is a double-edged sword, as the Internet also is able to communicate accurate lifesaving information from the Centers of Disease Control and Prevention and state health departments with unprecedented speed and reach.

The best chance for civilization to “flatten the curve” of the pandemic is, as it has been so many times before, through precautionary measures and preventive public health efforts. There is a reason that in 2007, readers of the prestigious British Journal of Medicine ranked public health interventions as the most important advances in medical history.⁸

The initial installment of this pandemic series will offer a primer in public health ethics. Just as almost everything else in daily life has rapidly and radically changed, from cancelled church services to school closures, so too public health ethics is significantly different in many important aspects from the clinical health ethics we are accustomed to in our practice.

The first difference is focus. In clinical health ethics the focus of the individual health care practitioner is the individual patient, but public health ethics focuses on “what we as a society do to keep people healthy.”⁹ In a pandemic when decisions must be made (to paraphrase Mr. Spock) “for the good of the many” this creates an intrinsic ethical tension for the health care practitioner whose ethos is to advocate for his or her patient.

The second difference is that in order to accomplish these communitarian aims, the law and political and cultural factors have much more influence in medical decision making than within the ideal dyad of a health care practitioner and the patient engaged in shared decision making about the patient’s health. This is nowhere more evident than in the President’s recent declaration of a public health emergency. “The Federal Government, along with State and Local governments, has taken preventive and proactive measures to slow the spread of the virus and treat those affected. . .”¹⁰ Federal and state governments can exercise wide-ranging powers that can restrict individual liberties in ways that would never be legal or ethically justifiable in the course of routine clinical care.

The third difference relates to the ethical principles that guide public health care decision making in comparison with those of clinical ethics. The primacy of autonomy in modern American medical ethics must for the health of the public sometimes yield to the overarching goal of preventing serious harm to the public and mitigating the transmission of the infection. Values such as nonmaleficence and justice become even more important than individual self-determination especially as the pandemic worsens and the demand for scarce ventilators and other life-saving resources outstrips the supply.¹¹

The fourth difference is that in nonemergent care, whether in the clinic or the hospital, the health care provider bears the primary responsibility for making decisions. Practitioners bring their knowledge and experience and patients their values and preferences to arrive at a mutually acceptable treatment plan. In stark contrast the profound and tragic life and death decisions made in a pandemic should not be left to the individual clinician who to the degree possible should remain faithful to the individual patient’s interests to preserve his or her professional integrity. Instead, decisions should be in the hands of highly trained and respected committees with diverse membership and expertise in accordance with evidence-based scientific protocols that are in response to changing pandemic conditions and the best available evidence. This process ensures that the values of consistency, transparency, and fairness which take center place in a public health emergency are the moral basis of decisions rather than ad hoc decisions that risk bias and inequity especially regarding vulnerable populations.¹¹

There is one characteristic of medical decision making that does not change whether in a routine checkup or resource allocation in an intensive care unit in a pandemic: the need to respect individual human dignity and to show compassion for the suffering of those who will not survive. In the Star Trek episode “Wrath of Khan,” Spock sacrificed himself to save his ship, his comrades, and his friends who mourned his death and honored his life.

The impeachment trial has concluded. By the time you read this editorial, Super Tuesday will be over. Then there will be the political party conventions, and finally the general election. Politics is everywhere and will be for the rest of 2020. As a preventive ethics measure, the legal arms of almost every federal agency will be sending cautionary e-mails to employees to remind us that any political activity undertaken must comply with the Hatch Act. Many of you who have worked in federal health care for some years may have heard a fellow employee say, “be careful you don’t violate the Hatch Act.”

Most readers probably had not heard of the statute before entering federal service. And you may have had an experience similar to mine in my early federal career when through osmosis I absorbed my peers fear and trembling when the Hatch Act was mentioned. This was the situation even though you were not at all sure you understood what the lawyers were warning you not to do. In my decades in federal service, I have heard that the Hatch Act dictates everything from you cannot vote to you can run for political office.

All this makes the timing right to review a piece of legislation that governs the political actions of every federal health and administrative professional. The Hatch Act sets apart federal employees from many, if not most, of our civilian counterparts, who, depending on your perspective, have more freedom to express their political views or are not held to such a high standard of ethical conduct.

In legalese, the Hatch Act is Political Activity Authorized; Prohibitions, 5 USC §7323 (1939). The title of this editorial, “To Prevent Pernicious Political Activities” is the formal title of the Hatch Act enacted at a time when government legislation was written in more ornamental rhetoric than the staid language of the current bureaucratic style. The alliterative title phrase of the act is an apt, if dated, encapsulation of the legislative intention of the act, which in modern parlance:

The law’s purpose is to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced based on merit and not based on political affiliation. ²

For all its poetic turn of phrase, the title is historically accurate. The Hatch Act was passed in response to rampant partisan activity in public office. It was a key part of an effort to professionalize civil service, and as an essential aspect of that process, to protect federal employees from widespread political influence. The ethical principle behind the legislation is the one that still stands as the ideal for federal practitioners: to serve the people and act for the good of the public and republic.

The Hatch Act was intended to prevent unscrupulous politicians from intimidating federal employees and usurping the machinery of major government agencies to achieve their political ambitions. Imagine if your supervisor was running for office or supporting a particular candidate and ordered you to put a campaign sign in your yard, attend a political rally, and wear a campaign button on your lapel or you would be fired. All that and far worse happened in the good old USA before the Hatch Act.³

The Office of Special Counsel (OSC) is the authoritative guardian of the Hatch Act providing opinions on whether an activity is permitted under the act; investigating compliance with the provisions of the act; taking disciplinary action against the employee for serious violations; and prosecuting those violations before the Merit Systems Protection Board. Now I understand why the incantation “Hatch Act” casts a chill on our civil service souls. While there have been recent allegations against a high-profile political appointee, federal practitioners are not immune to prosecution.⁴ In 2017, Federal Times reported that the OSC sought disciplinary action against a VA physician for 15 violations of the Hatch Act after he ran for a state Senate seat in 2014.⁵

Fortunately, the OSC has produced a handy list of “Though Shalt Nots” and “You Cans” as a guide to the Hatch Act.⁶ Only the highpoints are mentioned here:

• Thou shalt not be a candidate for nomination or election to a partisan public office;
• Thou shalt not use a position of official public authority to influence or interfere with the result of an election;
• Thou shalt not solicit or host, accept, or receive a donation or contribution to a partisan political party, candidate, or group; and
• Thou shalt not engage in political activity on behalf of a partisan political party, candidate, or group while on duty, in a federal space, wearing a federal uniform, or driving a federal vehicle.

Covered under these daunting prohibitions is ordinary American politicking like hosting fundraisers or inviting your coworkers to a political rally, distributing campaign materials, and wearing a T-shirt with your favorite candidates smiling face at work. The new hotbed of concern for the Hatch Act is, you guessed it, social media—you cannot use your blog, Facebook, Instagram, or e-mail account to comment pro or con for a partisan candidate, party, office, or group.⁶

You may be asking at this point whether you can even watch the political debates? Yes, that is allowed under the Hatch Act along with running for nonpartisan election and participating in nonpartisan campaigns; voting, and registering others to vote; you can contribute money to political campaigns, parties, or partisan groups; attend political rallies, meetings and fundraisers; and even join a political party. Of course these activities must be on your own time and dime, not that of your federal employer. All of these “You Cans” enable a federal employee to engage in the bare minimum of democracy: voting in elections, but opponents argue they bar the civil servant from fully participating in the complex richness of the American political process.⁷

Nonetheless, since its inception the Hatch Act has been a matter of fierce debate among federal employees and other advocates of civil liberties. Those who feel it should be relaxed contend that the modern merit-based system of government service has rendered the provisions of the Hatch Act unnecessary, even obsolete. In addition, unlike in 1939, critics of the act claim there are now formidable whistleblower protections for employees who experience political coercion. Over the years there have been several efforts to weaken the conflict of interest safeguards that the act contains, leading many commentators to think that some of the amendments and reforms have blurred the tight boundaries between the professional and the political. Others such as the government unions and the American Civil Liberties Union (ACLU) believe that the tight line drawn between public and private binds the liberty of civil servants.⁸ Those who defend the Hatch Act believe that the wall it erects between professional and personal in the realm of political activities for federal employees must remain high and strong to protect the integrity of the administrative branch and the public trust.⁹

So, as political advertisements dominate television programming and the texts never stop asking for campaign donations, you can cast your own vote for or against the Hatch Act. As for me and my house, we will follow President Jefferson in preferring to be the property of the people rather than be indebted to the powerful. You need never encounter a true conflict of interest if you have no false conflict of obligation: history teaches us that serving 2 masters usually turns out badly for the slave. Many of you will completely disagree with my stance, holding that your constitutional rights as a citizen are being curtailed, if not outright denied, simply because you choose to serve your country. Our ability to freely hold and express our differences of opinions about the Hatch Act and so much else is what keeps democracy alive.

The impeachment trial has concluded. By the time you read this editorial, Super Tuesday will be over. Then there will be the political party conventions, and finally the general election. Politics is everywhere and will be for the rest of 2020. As a preventive ethics measure, the legal arms of almost every federal agency will be sending cautionary e-mails to employees to remind us that any political activity undertaken must comply with the Hatch Act. Many of you who have worked in federal health care for some years may have heard a fellow employee say, “be careful you don’t violate the Hatch Act.”

Most readers probably had not heard of the statute before entering federal service. And you may have had an experience similar to mine in my early federal career when through osmosis I absorbed my peers fear and trembling when the Hatch Act was mentioned. This was the situation even though you were not at all sure you understood what the lawyers were warning you not to do. In my decades in federal service, I have heard that the Hatch Act dictates everything from you cannot vote to you can run for political office.

All this makes the timing right to review a piece of legislation that governs the political actions of every federal health and administrative professional. The Hatch Act sets apart federal employees from many, if not most, of our civilian counterparts, who, depending on your perspective, have more freedom to express their political views or are not held to such a high standard of ethical conduct.

In legalese, the Hatch Act is Political Activity Authorized; Prohibitions, 5 USC §7323 (1939). The title of this editorial, “To Prevent Pernicious Political Activities” is the formal title of the Hatch Act enacted at a time when government legislation was written in more ornamental rhetoric than the staid language of the current bureaucratic style. The alliterative title phrase of the act is an apt, if dated, encapsulation of the legislative intention of the act, which in modern parlance:

The law’s purpose is to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced based on merit and not based on political affiliation. ²

For all its poetic turn of phrase, the title is historically accurate. The Hatch Act was passed in response to rampant partisan activity in public office. It was a key part of an effort to professionalize civil service, and as an essential aspect of that process, to protect federal employees from widespread political influence. The ethical principle behind the legislation is the one that still stands as the ideal for federal practitioners: to serve the people and act for the good of the public and republic.

The Hatch Act was intended to prevent unscrupulous politicians from intimidating federal employees and usurping the machinery of major government agencies to achieve their political ambitions. Imagine if your supervisor was running for office or supporting a particular candidate and ordered you to put a campaign sign in your yard, attend a political rally, and wear a campaign button on your lapel or you would be fired. All that and far worse happened in the good old USA before the Hatch Act.³

The Office of Special Counsel (OSC) is the authoritative guardian of the Hatch Act providing opinions on whether an activity is permitted under the act; investigating compliance with the provisions of the act; taking disciplinary action against the employee for serious violations; and prosecuting those violations before the Merit Systems Protection Board. Now I understand why the incantation “Hatch Act” casts a chill on our civil service souls. While there have been recent allegations against a high-profile political appointee, federal practitioners are not immune to prosecution.⁴ In 2017, Federal Times reported that the OSC sought disciplinary action against a VA physician for 15 violations of the Hatch Act after he ran for a state Senate seat in 2014.⁵

Fortunately, the OSC has produced a handy list of “Though Shalt Nots” and “You Cans” as a guide to the Hatch Act.⁶ Only the highpoints are mentioned here:

• Thou shalt not be a candidate for nomination or election to a partisan public office;
• Thou shalt not use a position of official public authority to influence or interfere with the result of an election;
• Thou shalt not solicit or host, accept, or receive a donation or contribution to a partisan political party, candidate, or group; and
• Thou shalt not engage in political activity on behalf of a partisan political party, candidate, or group while on duty, in a federal space, wearing a federal uniform, or driving a federal vehicle.

Covered under these daunting prohibitions is ordinary American politicking like hosting fundraisers or inviting your coworkers to a political rally, distributing campaign materials, and wearing a T-shirt with your favorite candidates smiling face at work. The new hotbed of concern for the Hatch Act is, you guessed it, social media—you cannot use your blog, Facebook, Instagram, or e-mail account to comment pro or con for a partisan candidate, party, office, or group.⁶

You may be asking at this point whether you can even watch the political debates? Yes, that is allowed under the Hatch Act along with running for nonpartisan election and participating in nonpartisan campaigns; voting, and registering others to vote; you can contribute money to political campaigns, parties, or partisan groups; attend political rallies, meetings and fundraisers; and even join a political party. Of course these activities must be on your own time and dime, not that of your federal employer. All of these “You Cans” enable a federal employee to engage in the bare minimum of democracy: voting in elections, but opponents argue they bar the civil servant from fully participating in the complex richness of the American political process.⁷

Nonetheless, since its inception the Hatch Act has been a matter of fierce debate among federal employees and other advocates of civil liberties. Those who feel it should be relaxed contend that the modern merit-based system of government service has rendered the provisions of the Hatch Act unnecessary, even obsolete. In addition, unlike in 1939, critics of the act claim there are now formidable whistleblower protections for employees who experience political coercion. Over the years there have been several efforts to weaken the conflict of interest safeguards that the act contains, leading many commentators to think that some of the amendments and reforms have blurred the tight boundaries between the professional and the political. Others such as the government unions and the American Civil Liberties Union (ACLU) believe that the tight line drawn between public and private binds the liberty of civil servants.⁸ Those who defend the Hatch Act believe that the wall it erects between professional and personal in the realm of political activities for federal employees must remain high and strong to protect the integrity of the administrative branch and the public trust.⁹

So, as political advertisements dominate television programming and the texts never stop asking for campaign donations, you can cast your own vote for or against the Hatch Act. As for me and my house, we will follow President Jefferson in preferring to be the property of the people rather than be indebted to the powerful. You need never encounter a true conflict of interest if you have no false conflict of obligation: history teaches us that serving 2 masters usually turns out badly for the slave. Many of you will completely disagree with my stance, holding that your constitutional rights as a citizen are being curtailed, if not outright denied, simply because you choose to serve your country. Our ability to freely hold and express our differences of opinions about the Hatch Act and so much else is what keeps democracy alive.

The impeachment trial has concluded. By the time you read this editorial, Super Tuesday will be over. Then there will be the political party conventions, and finally the general election. Politics is everywhere and will be for the rest of 2020. As a preventive ethics measure, the legal arms of almost every federal agency will be sending cautionary e-mails to employees to remind us that any political activity undertaken must comply with the Hatch Act. Many of you who have worked in federal health care for some years may have heard a fellow employee say, “be careful you don’t violate the Hatch Act.”

Most readers probably had not heard of the statute before entering federal service. And you may have had an experience similar to mine in my early federal career when through osmosis I absorbed my peers fear and trembling when the Hatch Act was mentioned. This was the situation even though you were not at all sure you understood what the lawyers were warning you not to do. In my decades in federal service, I have heard that the Hatch Act dictates everything from you cannot vote to you can run for political office.

All this makes the timing right to review a piece of legislation that governs the political actions of every federal health and administrative professional. The Hatch Act sets apart federal employees from many, if not most, of our civilian counterparts, who, depending on your perspective, have more freedom to express their political views or are not held to such a high standard of ethical conduct.

In legalese, the Hatch Act is Political Activity Authorized; Prohibitions, 5 USC §7323 (1939). The title of this editorial, “To Prevent Pernicious Political Activities” is the formal title of the Hatch Act enacted at a time when government legislation was written in more ornamental rhetoric than the staid language of the current bureaucratic style. The alliterative title phrase of the act is an apt, if dated, encapsulation of the legislative intention of the act, which in modern parlance:

The law’s purpose is to ensure that federal programs are administered in a nonpartisan fashion, to protect federal employees from political coercion in the workplace, and to ensure that federal employees are advanced based on merit and not based on political affiliation. ²

For all its poetic turn of phrase, the title is historically accurate. The Hatch Act was passed in response to rampant partisan activity in public office. It was a key part of an effort to professionalize civil service, and as an essential aspect of that process, to protect federal employees from widespread political influence. The ethical principle behind the legislation is the one that still stands as the ideal for federal practitioners: to serve the people and act for the good of the public and republic.

The Hatch Act was intended to prevent unscrupulous politicians from intimidating federal employees and usurping the machinery of major government agencies to achieve their political ambitions. Imagine if your supervisor was running for office or supporting a particular candidate and ordered you to put a campaign sign in your yard, attend a political rally, and wear a campaign button on your lapel or you would be fired. All that and far worse happened in the good old USA before the Hatch Act.³

The Office of Special Counsel (OSC) is the authoritative guardian of the Hatch Act providing opinions on whether an activity is permitted under the act; investigating compliance with the provisions of the act; taking disciplinary action against the employee for serious violations; and prosecuting those violations before the Merit Systems Protection Board. Now I understand why the incantation “Hatch Act” casts a chill on our civil service souls. While there have been recent allegations against a high-profile political appointee, federal practitioners are not immune to prosecution.⁴ In 2017, Federal Times reported that the OSC sought disciplinary action against a VA physician for 15 violations of the Hatch Act after he ran for a state Senate seat in 2014.⁵

Fortunately, the OSC has produced a handy list of “Though Shalt Nots” and “You Cans” as a guide to the Hatch Act.⁶ Only the highpoints are mentioned here:

• Thou shalt not be a candidate for nomination or election to a partisan public office;
• Thou shalt not use a position of official public authority to influence or interfere with the result of an election;
• Thou shalt not solicit or host, accept, or receive a donation or contribution to a partisan political party, candidate, or group; and
• Thou shalt not engage in political activity on behalf of a partisan political party, candidate, or group while on duty, in a federal space, wearing a federal uniform, or driving a federal vehicle.

Covered under these daunting prohibitions is ordinary American politicking like hosting fundraisers or inviting your coworkers to a political rally, distributing campaign materials, and wearing a T-shirt with your favorite candidates smiling face at work. The new hotbed of concern for the Hatch Act is, you guessed it, social media—you cannot use your blog, Facebook, Instagram, or e-mail account to comment pro or con for a partisan candidate, party, office, or group.⁶

You may be asking at this point whether you can even watch the political debates? Yes, that is allowed under the Hatch Act along with running for nonpartisan election and participating in nonpartisan campaigns; voting, and registering others to vote; you can contribute money to political campaigns, parties, or partisan groups; attend political rallies, meetings and fundraisers; and even join a political party. Of course these activities must be on your own time and dime, not that of your federal employer. All of these “You Cans” enable a federal employee to engage in the bare minimum of democracy: voting in elections, but opponents argue they bar the civil servant from fully participating in the complex richness of the American political process.⁷

Nonetheless, since its inception the Hatch Act has been a matter of fierce debate among federal employees and other advocates of civil liberties. Those who feel it should be relaxed contend that the modern merit-based system of government service has rendered the provisions of the Hatch Act unnecessary, even obsolete. In addition, unlike in 1939, critics of the act claim there are now formidable whistleblower protections for employees who experience political coercion. Over the years there have been several efforts to weaken the conflict of interest safeguards that the act contains, leading many commentators to think that some of the amendments and reforms have blurred the tight boundaries between the professional and the political. Others such as the government unions and the American Civil Liberties Union (ACLU) believe that the tight line drawn between public and private binds the liberty of civil servants.⁸ Those who defend the Hatch Act believe that the wall it erects between professional and personal in the realm of political activities for federal employees must remain high and strong to protect the integrity of the administrative branch and the public trust.⁹

So, as political advertisements dominate television programming and the texts never stop asking for campaign donations, you can cast your own vote for or against the Hatch Act. As for me and my house, we will follow President Jefferson in preferring to be the property of the people rather than be indebted to the powerful. You need never encounter a true conflict of interest if you have no false conflict of obligation: history teaches us that serving 2 masters usually turns out badly for the slave. Many of you will completely disagree with my stance, holding that your constitutional rights as a citizen are being curtailed, if not outright denied, simply because you choose to serve your country. Our ability to freely hold and express our differences of opinions about the Hatch Act and so much else is what keeps democracy alive.