In the summer of 2014, as I was preparing to fly to West Africa as an emergency responder to the largest Ebola outbreak in history, I sat in my room consumed with fear. I felt like a kid again, standing on the high dive for the very first time, about to plunge into the pool far below.

And while that fear dissipated somewhat over the coming weeks as I worked with Liberian and international colleagues to launch a new Ebola treatment center in Bong County, Liberia, it never went away entirely. My experiences in Liberia taught me that courage is not the absence of fear — it is doing what you know you must even when you are terrified.

Hundreds of thousands of health workers across the United States and the world are learning that same lesson, or will quite soon.

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Courage alone won’t be enough. You will also need to take care of yourselves — and each other — to make it through the Covid-19 pandemic. First and foremost, get enough rest. Second, remember to eat. Exhaustion and hunger magnify stress.

Taking care of yourself also means that you must first protect your own health when you are tending to your patients. This means taking those extra few minutes, no matter the urgency of the situation, to be certain that you put on your protective equipment correctly, and that your team members have done the same. Be even more careful when you remove the equipment so you don’t contaminate yourself or others in the process.

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You are a precious and limited resource, and you must act the part.

An unexpected lesson I learned from fighting Ebola was that as stressful as it was working in a treatment center in Liberia, coming home was far worse. In Liberia I had the camaraderie of my fellow health workers, all of us working together to defeat the virus. At work, you will be a hero. Perhaps Time magazine will someday recognize you, like it did the Ebola fighters, as its Person of the Year.

But when you come home, you will be a vector, a pariah. Your friends and family may shun you. You may even begin internalizing this sentiment, thinking of yourself as dirty or unclean, feeling guilty about exposing your loved ones to the possibility of being infected with the novel coronavirus. Never mind the data about asymptomatic transmission being rare — the amygdala doesn’t understand statistics.

If you’ve never had to provide health care in a resource-limited setting, you may find yourself learning what it means to ration care. You may be surprised to learn that rationing is rarely very rational. Your hospital or department of health or professional society may have developed guidelines, yet you will find them difficult to apply to the unique circumstances of the patient in front of you. It will always be harder to take someone off a ventilator than put someone on one, regardless of who needs it most.

And your decisions may be affected by your own implicit biases about who deserves care the most, rather than who needs it the most. This doesn’t mean you are a bad person or unprofessional: I have seen superb health workers in resources-constrained settings across the planet do the same — including myself. The only way you will be able to protect your patients from your own biases will be to recognize them in the moment.

If you are not a health worker, but happen to know one, you also have an important role to play by supporting them through this pandemic. A few years back, I gave a talk to a group of naval officers about my experiences fighting Ebola in West Africa. Afterwards, one of the participants came up to me and said, “Thank you for your service.” As a civilian, no one had ever said that to me before, and I was surprised by how deeply they affected me. If you’re unsure how best to support the health workers in your life, a simple thank you may go a long way.

Ebola health workers
Courtesy Adam Levine

Finally, we must all keep in mind that this too shall pass, though perhaps not as quickly as we might want it to. While I was working in Liberia, a truck pulled up one day with gravel to cover the floor of our treatment center. Underneath the front windshield someone placed a banner meant to read “No Condition is Permanent.”

As bad as it was, the Ebola epidemic in West Africa would have been far worse without the efforts of all the health workers on the ground. After two long years, it finally came to an end.

Covid-19 will, too.

Adam Levine, M.D., is an emergency physician, associate professor of emergency medicine, and director the Center for Human Rights and Humanitarian Studies and the Division of Global Emergency Medicine at Brown University in Providence, R.I.

  • Thank you for writing this. It must have been a highly distressing time. I feel for the medical staff in Italy – I don’t know how people keep going and believe that when this is all over, there may be ongoing emotional damage to contend with.
    Stay safe and thank you for your work.
    Regards
    Jenni

  • Thank you. I’m bookmarking this to share with my co-workers in a retail grocery store. As a former EMT the possibility of asymptomatic transmission has terrified myself and others. We love our older customers & I’m afraid to be near them because I know the risks and have a husband that’s health compromised & oblivious to what’s going on. I’m sewing masks for us so we can protect ourselves and others without taking from the medical community. With more cases my hospital is going to be overwhelmed as my store. I think of volunteering but who would be more at risk if I do?

    After over a month of dealing with panicked shoppers, fighting for toilet paper we have police in the store at opening to keep people from getting hurt. Sad in a small community but people look at empty selves, complain while bringing children into the store to buy supplies for making masks.

    The lack of coming sense is going to make this much worse than the flu. People are driving crazy causing accidents, getting into fights, & shooting in stores – are we going to add those injuries & deaths to the total for Covid 19?? They should be.

  • What a fantastic article. I’ve been experiencing such anxiety and fear being a front line worker during covid19. This article gives me hope and reassurance that I need to work through this. Thank you for sharing your experience during the Ebola outbreak.

  • Wonderful piece. We are very lucky to have you here in Rhode Island. One of the things UEMF excelled at was bringing together an extraordinary group of docs who care about one another. Great work, stay safe.

  • I want Dr. Levine to give this speech every year before Flu season. We are now comparing “battling” COVID-19 (with a current and falling mortality and morbidity rate getting damn close to seasonal flu) to fighting EBOLA? Really? If so, Dr. Fauci has led the most inadequate public response in the History of man.

    Ebola has a case fatality rate around of 50% up to 90%.

    The current COVID 19 mortality rate in NY is 0.5%

    The mortality rate for flu in elderly Italians is 9.5%. COVID 19 is currently at 8.9%.

    This COVID 19 response is unbelievable dumb.

    China averages 88,100 seasonal flu deaths and currently at 3,225 COVID-19 deaths.

    South Korea has 2,900 seasonal flu deaths and currently has 104 COVID-19 deaths.

    The state of Ohio estimated they had 100K of COVID cases 10 days ago and still zero deaths in Ohio.

    Florida, Arizona and Illinois held primaries voted last Tuesday.

    Stop the madness.

    We should be more worried about the 2 million Americans that lost their job this week.

    • As it happens, I agree with most of your points, and yet the message of my op-ed remains true. Like Ebola in West Africa, but unlike seasonal influenza, the current global COVID-19 epidemic is accompanied by an epidemic of fear. This epidemic of fear is as real as one caused by the virus, and health workers will need to manage and navigate both simultaneously. I too worry about the millions of Americans losing their jobs, and worry even more about them losing their housing and health insurance as a result. This is why I called for a more nuanced approach to the response this morning (https://vimeo.com/399127884), one which responds as robustly as possible to the epidemic while minimizing the harms that the response will certainly cause.

  • Sigh. You do realize that many of our health workers have already had to do without personal Protective gear because of the shortage? Imaging people doing chest X-rays in Covid-19 cases in San Diego for example. They are being told the standards are Being relaxed. Very ironic. They would love to take care of themselves I’m the way you describe. And this is in the US. Being reported from ER doctors as well.

  • Never mind the data about asymptomatic transmission being rare
    Could you please link to this data?

    • That source says the opposite — people with no or mild symptoms are highly contagious:

      These are the first detailed analyses of the extent of viral shedding at different stages of the disease, says Osterholm. The data confirm what many scientists have suspected: that some infected people “can be highly contagious when they have mild or no symptoms”, he says. But he stresses that the scale of the problem is still unclear.

    • While several studies have shown evidence of asymptomatic infection in a significant portion of patients testing positive for COVID-19, only a few case reports to date have been published regarding asymptomatic transmission (i.e. someone who is truly asymptomatic infecting another individual). The term “viral shedding,” which is used frequently in the literature, has been misinterpreted by the lay press. Viral shedding, which absolutely happens in patients before and after they have symptoms, means that viral particles can be detected on the surface of their mucous membranes by a nasal or throat swab. Since the disease is not airborne, in order to transfer those particles to someone else, the person would have to sneeze or cough them out. If they did that, then by definition they are not asymptomatic. Could a person with viral shedding who is asymptomatic still transfer the infection to someone else through very intimate contact? Perhaps – we don’t have data to say one way or another. But it’s unlikely to occur during routine interaction, even within a household.

    • Thank you for the explanation, though I don’t fully understand the distinction between study findings (the Munich paper went into some detail about individuals) and case reports. There are folks on the internet suggesting that the virus gets aerosolized through normal breathing. Then there is the Biogen conference which was supposedly asymptomatic. You could probably write another blog article just on this theme.

  • Thank you Dr. Levine. We are proud to be your colleagues in the trenches, fighting alongside you.

  • Thoughtful and intelligent – your words ‘the Amygdala doesn’t know statistics’ sheds light on the reality faced by healthcare workers daily. Thank you for your service and all all those involved in serving the ill during this time of uncertainty.

  • This is the very first time in all these years that I’ve left a comment however I need to express how appreciated and meaningful your message is to me this morning. Thank you.
    K

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