The pandemic is not the great equalizer: front-line labor and rationing in COVID-19 critical care

Abstract

BACKGROUND:

Framed as “the great-equalizer,” the COVID-19 pandemic has intensified pressure to adapt critical care labor and resulted in rationing by healthcare workers across the world.

OBJECTIVE:

To critically investigate how hospital intensive care units are critical sites of care labor and examine how rationing highlights key features of healthcare labor and its inequalities.

METHODS:

A practice-oriented ethnographic study was conducted in a United States academic ICU by a medical anthropologist and medical intensivists with global health expertise. The analysis drew on 57 in-depth interviews and 25 months of participant observation between 2020 and 2021.

RESULTS:

Embodied labor constitutes sites and practices of shortage or rationing along three domains: equipment and technology, labor, and emotions and energy. The resulting workers’ practices of adaptation and resilience point to a potentially more robust global health labor politics based on seeing rationing as work.

CONCLUSION:

Studies of pandemic rationing practices and critical care labor can disrupt too-simple comparative narratives of Global North/South divides. Further studies and efforts must address the toll of healthcare labor.

The first COVID-19 patient admitted to an intensive care unit (ICU) marked the start of seismic changes in critical care practice. A novel infectious agent coupled with strained hospital systems led social media and healthcare to frame COVID-19 as “the great equalizer,” attempting to convey a universal experience of healthcare systems under duress.¹ While rationing of health equipment and care occurred from the outset of the pandemic, pronounced disparities across lines of race, class, income, ability, and geography made the pandemic anything but equalizing.^2,3

“The great equalizer” discourse on rationing hides as much as it highlights. There are similarities between hospitals in lower-middle-income countries (LMICs) and pandemic hospitals in higher-income countries (HICs). However, divides between the presumed “Global North” of HICs and “Global South” of LMICs make generalizations simplistic, and restrict the generation of theory from non-European settings.^4,5 Such generalizations make it difficult to see how the “great equalizer” framing of COVID hinges on the materiality of what is rationed. A hazy North–South framing may miss a deeper understanding of labor practices at the heart of rationing across the globe. We thus focus on the specific objects of equivalence rather than a generic North-South framing.

Concerns about pandemic rationing in US healthcare settings must be situated in US healthcare literature. Some scholars address rationing via questions of universal health coverage.⁶ Others, such as Ubel and Goold, outline conditions for rationing focused on the doctor–patient connection and the physician’s actions as the grounds of ethical principles.⁷ Yet, the space of the ICU has not often been framed as a formative site of rationing. Instead, analyses of rationing focus on larger-scale regulatory and administrative infrastructures of “resource allocation.” Some scholars argue that rationing does indeed occur at the bedside in the ICU, but it remains “implicitly conducted and inadequately discussed” leading to a wide-scale silencing of rationing in critical care.⁷

ICU rationing in the Global North most clearly emerged during the HIV pandemic. It centered on the wide variation in mechanical ventilation use in acute Pneumocystis pneumonia-induced respiratory failure. One study concluded that 39% of all patients who died with HIV-related Pneumocystis pneumonia had ICU care withheld.”⁸ Another study found variations in ICU utilization linked to sociodemographic characteristics.⁹ Later, the influenza A virus subtype H1N1 highlighted the fact that in terms of knowledge about rationing amidst pandemics, “rigorous, relevant, timely, and ethical clinical and health services research is sorely lacking.”¹⁰

By contrast, the rationing of scarce ICU resources in the Global South has largely been explicit and visible. The basis of that visibility is healthcare labor. Scholars of critical care frequently point out the enormous burden of critical care in the Global South in terms of limited capacity, challenges to training, strained infrastructure, and lack of protocols adapted to local staffing.”^11–13 As Moosa & Luyckx argue, “An implicit global double standard has long upheld that rationing was unacceptable for HICs but was tolerable for LMICs.”¹⁴ Through the lens of a practice-oriented medical anthropology of healthcare labor, we address two questions: 1) How might rationing not only reflect inequalities, but also be as a site for their production and reproduction? 2) Might we see that COVID-19 is in fact a great unequalizer?

We identify sites and practices of shortage or rationing, and point to the ways embodied labor constitutes them may disrupt overly simplistic comparative narratives of the North/South divisions.

Study population, design, and methods

This ethnographic study was conducted in an academic, quaternary referral hospital in the Southeastern United States between July 2020 and December 2021 in a 24–28-bed medical intensive care unit (MICU). Our study team consisted of a medical anthropologist (male) and three practicing pulmonary and critical care physicians (two male, one female) with extensive clinical and research experience in global health and prior experience in qualitative and ethnographic research.

Investigators asked supervisors of various roles to send a scripted, institutional review board (IRB) approved email from the investigators to all of their employees. This email outlined the goals of the study and solicited voluntary participation in interviews. Written informed consent was obtained prior to each interview. Given that the three physician investigators had established professional relationships with many of the interviewees, all interviews were conducted by at least two study team members in either specific, private spaces or via video-teleconference using a pre-specified interview guide, which was pilot-tested prior to commencing interviews. Open-ended questions focused on adaptations at work and at home and changing forms of social communication amidst the uncertainties of COVID-19.

In addition, the recruitment email included a statement that members of the investigator team would be present in the ICU to periodically observe and collect anonymous, de-identified information about the routine daily course of COVID-19 care among providers and staff. It explained that observation would focus on inter- and intra-personal interactions between ICU staff, patients, and families, what workers are doing in the course of their normal workday, and would not include individual patient information, personally identifiable information about workers, or protected health information. This method is consonant with the American Anthropology Association Statement on Ethnography.¹⁵ The three intensivist’s fieldwork practice followed “observant participation,” involving a dual role of clinician and ethnographer.¹⁶ This “dual commitment” created opportunities to link respondents’ narratives to their own lived experiences in the ICU.¹⁶ The medical anthropologist, while not present in the ICU, provided an important counterbalancing perspective.

Demographic information was managed using REDCap® (Vanderbilt University, Nashville, TN, USA). All interviews were audio- and video-recorded and the audio files were transcribed for analysis. De-identified transcripts were analyzed using Dedoose® (SocioCultural Research Consultants, Los Angeles, CA, USA). Observation notes were taken during or immediately following observation sessions and also uploaded. First transcripts and observation notes were read several times by the study investigators and three trained student analysts guided by thematic analysis.¹⁷ An initial coding tree was developed based on the identification of common themes, and modifications were made by the investigators based on ongoing study findings during weekly coding team meetings. These meetings were also used to discuss coding memos, draw connections between various codes, establish themes, and identify representative quotes for each theme.

Ethics

This protocol for the study was approved by the IRB, Duke University Health System, Durham, NC, USA (Identification: Pro00105529).

RESULTS

Among our 57 interviewees, 33 (58%) identified as female; 44 (79%) identified as White or Caucasian, 6 (11%) as Black, 4 (7%) as LatinX, 4 (7%) as Asian and 2 (3.6%) as Middle Eastern or North African, with 3 interviewees identifying as multiple. Interviewees had a broad range of job roles: 22 (39%) were registered nurses or nurse assistants, 23 (40%) were physicians, 6 (10.5%) were respiratory therapists, and 6 (10.5%) were pharmacy, supply chain or environmental service staff, with a mean of 11 years (standard deviation: 9) in total in their current role. Many respondents had dedicated their lifetime work to our institution.

Rationing equipment and technology

As a practice, rationing unfolds in both the Global North and South as people retool their relations with technology, materials and supplies. It also impacts how knowledge is produced. Workers often forged rationing practices from news of shortages from other places. The anthropologist Charles Briggs has argued that biomedicine achieves its power often by fusing with culture industries such as the news media.¹⁸ We saw this fusion in play when a nurse remembered:

I know we would have CNN on in the breakroom, so I remember when there was the big shortage of ventilators and I think Tesla was talking about making them or what not.

Real or feared shortages were amplified by social media posts from caregivers in pandemic hotspots. Adapting critical care in the pandemic resulted in a cascade of innovative and often “out of the box” protocols. In a practice called “MacGyvering,” after the problem-solving TV character, plastic sheets and boxes using materials purchased from hardware stores were used to assist with COVID-19 airway management and resuscitation.^19,20 The previously underutilized intervention of proning during mechanical ventilation was rapidly disseminated to providers and even patients at home via social media.^21,22 The practice of awake self-proning (or “tummy time”) in non-intubated patients appeared in social media before medical journals had the chance to evaluate it.

These rationing practices were innovative, but also came with challenges. Workers reported stress related to innovating complex technologies such as mechanical ventilation and extracorporeal membrane oxygenation. A respiratory therapist suggested that even as they were “MacGyvering” respiratory support, there were little oversight on this seemingly desperate and overextended work:

We ended up doing things that, in our policy, we said we would never do…but that was the best we could come up with.... they have pretty much left us out there on a limb to figure it out on our own with no support whatsoever.

There were also concerns about the most basic technology of COVID care: the N95 mask. Amid the threat of N95 shortages, our institution introduced peroxide re-sterilization of N95 masks.²³ However, despite FDA (Food and Drug Administration) emergency use approval, nurses highlighted fears and uncertainties of wearing re-sterilized masks. For them, to practice re-used masking was potentially dangerous, even as it was possibly protective. Another nurse explained:

It was worrisome, because they’re using this sterilization process that really wasn’t, at least, known to us…. on the labeling itself, it says these are not to be reused…So, for us to then be faced with this sterilization process or decontamination process, is it going to be safe for us in five, ten, fifteen years from now…. ’Well crap, is this going to kill me in 15 years?’ You just kind of go down that rabbit hole.

A labor dilemma emerged in this juxtaposition of trying to do one’s jobs safely, while also rationing supplies and equipment in the interest of others and the future unknowns. Personal protective equipment acted as a protector of one’s labor, but rationing it threatened workers’ sense of safety and security. Rationing’s materiality was a threat felt in terms of both the work of care and what workers believed their institution could and would do to protect that work.

Rationing labor

Over the course of our study, the rationing of labor and labor’s compensation were key features of pandemic responses. Some respondents in nursing and respiratory therapy drew attention to their exhaustion and how their labor was not fairly compensated. As one nurse reflected:

I’ll be the first person to say, nurses [here] should be more supported. We deserve to know what upper management’s plan is for the retention of our employees. [The institution] should be aware that when employee satisfaction goes down, quality also goes down. I joined this organization to provide high quality patient centered care and it’s difficult to do when we don’t feel appreciated by our employer…There’s not many people on this earth that can do the job that we do. We are not replaceable.

Administrators and response leaders perceived labor rationing as a result of longer-term national patterns in health systems administration. One administrator explained,

I think you have a couple of things that are happening all at one time and you had that famous Swiss cheese effect…Everybody was behind in their hiring and that was pre-COVID. So, they were playing catchup [and] we’ve changed our nurse-to-patient ratios, and our nursing hours per patient day, because of COVID.

The experience of labor rationing changed over time, as a trainee who spent several of the pandemic’s early months in the ICU reflected:

Maybe the first time I ever felt that vulnerable…as we transitioned to June and July, it felt like a lot of the rest of the world tried to go back to normal…. but there was this stark reality when I came to work that this wasn’t over …and then we would go to work and still be deep in the thick of it, gowned up for hours, masks fogging up, trying to do all this COVID stuff and it felt like the rest of the world kind of moved on.

These framing of rationing reveal how ICU labor often went unnoticed by the authorities supervising that labor. Furthermore, as the trainee noted, “the rest of the world kind of moved on.” As critical care pandemic labor continued, the world left them to navigate their practice of labor rationing on their own. The structured rationing of labor was embodied, experienced, and deeply felt.

Rationing emotions and energy

Our respondents also pointed to practices of conservation, strategic allocation, and depletion in emotional terms. For healthcare workers, one’s body and mind is subject to emotional and physical self-rationing even as one selectively allocates resources to care for patients. Even before the surge of Delta variant COVID-19, exhaustion from this practice was a common refrain among ICU workers. One respiratory therapist described it as reckoning with the reality of providing care during a workforce shortage:

You get to that exhaustion point where you’re so frustrated and baffled that you’re like, oh my God, I can’t… and you get a little bit weak and tired and worn down and frustrated. If you had this interview with me last night at five o’clock, you’d have seen a lunatic. My mind was mush.

A physician described the intricate connections between rationing practices in the ICU and personal exhaustion:

I recall a day last week where I had on my N95 mask and my face shield for too long. I put it on about eight and I took it off somewhere two or three in the afternoon, and that was the day I felt really tired and really tired of the mask… I just wanted to push through and see everybody and just have it on that one instance. I think the exhaustion is real…We’d like to think about something else and move beyond this, as a community and as a, well country, for sure.

Mental and emotional energy stores were depleted due to limited opportunities for the usual practices of self-care and recharge. As a nurse reflected, this deepened the sense of exhaustion and emotional distress:

Before all this, I did a lot of yoga classes, I did a lot of spin classes and stuff like that. I’d take my dogs hiking, but now, trying to find new ways to recharge has been really difficult.

There were somatic signs of exhaustion as well. Rationing and the perceived inequities of the system became evident in the very bodies of workers. A nurse noted:

We’re picking up these crazy patients while getting the same no reward, no incentive pay, no hazard pay and people are actually at home getting paid differential night shift, and weekends. We’re all sweating and literally with marks on our face and people are kind of just chilling.

The physical, bodily aspects of this work brought on further emotional and ethical questions. For one trainee physician, to be in personal protective equipment and to sweat marked the practice of rationing care:

I think going into the patient’s room and dressing up was a whole process and so it got me to reflect a little bit before I went into a [non-intubated] patient’s room about what exactly my agenda for the encounter is going to be…it felt somewhat like an artificially coded interaction because of the PPE…. You came out drenched in sweat and as a learner; it was another kind of nuance that we had to incorporate in our training.

Dealing with the broader ethical and moral dilemmas of pandemic critical care labor took an enormous toll on emotions and energy of staff. The staff struggled to make crucial judgments at significant ethical crossroads due to a lack of or insufficient objective information. Moments such as patient coding, were major ethical turning points, as a nurse put it:

I think initially…there had been a discussion about do we code these patients? Anybody who has COVID? Is this going to be something that we even think about and we consider? And I think there was a big divide with you either said absolutely, yes, we code all our patients, this is what we do, this is why we’re here and other people said, no, you just gotta let them go. It’s not worth the risk. I mean bluntly. So, I think that was kind of the struggle.

The dilemma around how to handle a patient code situation was more than an ethical question, it was a question felt in the body. The nurse continued:

I think we exhaust all of our options in a code and that’s the other tricky thing…you’ve been in that room for three hours already, you’re sweating, you’re exhausted, you’re tired, your face hurts…you’ve just gotta go fast and take care of that patient…Our job as a nurse is to take care of that patient to our fullest extent and do the best we can, but at what point do we feel like we’re crossing that line?

Such questions of “Do we keep going?” and “Do we keep pushing” highlight the uncertain limits of rationed labor in the ICU. Our interlocutors struggled with the ways in which they found themselves rationing their own energy and emotions to prevent or curtail exhaustion, sadness, and frustration. This practice, or perhaps embodiment, of self-rationing raises questions around the limits of rationing. To what extent can we ration any one item, hour of work, or emotion? Who determines those extents where rationing and shortages may be ubiquitous? And what is lost in the practice of rationing?

DISCUSSION

In sum, our findings show that rationing is borne out through both the materialities and practices of critical care labor. Specifically, we found that this occurred in three major domains: equipment and technology, labor, and emotions and energy. These point to a potentially more robust global health labor politics based on assessing rationing as work, centering a respondent-driven perspective in two ways. First, it centers materiality: the qualities of material goods, from gowns to masks, that come to be meaningful as they are used. Second, it foregrounds the local specificities of medical care work. Thus our study adds to ethnographic research on social inequalities of healthcare by focusing on rationing in practice.^24–29

Our findings also fill a research void that has formed from overly simplistic global comparisons of rationing. At first glance, pandemic-related healthcare rationing in the Global North may seem exceptional compared to its everyday occurrence in the Global South. However, we discovered that it occurs in settings thought to be immune from resource scarcity, and thus complicates the politics of comparison in global health. Our ethnography did not concentrate on “global” critical care settings, where “global” incorrectly means “non-US.” Yet, we see at our own research site the ubiquitous physical and emotional toll of rationing labor. Consequently, understanding adjustments in labor practices is crucial for understanding the local specificities of critical care resource constraints.

Our research prompts several recommendations for policy makers and institutional leaders. First, they must ask: Who must bear the costs of rationing? What are its experiential differences? What are the multiple possible forms of work at play in rationing? Here the task is to delineate rationing’s specific labor practices: how it works, to what ends, at what costs, and for whose benefit. The endpoint of this process must the reaffirmation of care commitments and the strengthening of healthcare infrastructures. Second, we recommend frank discussions about rationing with workers, but to proceed with caution. There is a risk that leaders may interpret rationing to be a site of workers’ strength, courage, flexibility, and empathy with vulnerability. Given the widespread corporatization of “resilience,” we are cautious about celebrating flexibility. Uncritically ignoring the enduring toll of healthcare labor will likely lead to more, rather than less uncertainty; and less, rather than more, resilience across both the Global North and South. As we encounter the next wave of this pandemic and prepare for other pandemics, attention to the emotional, embodied, and localized qualities and consequences of care labor practices – including rationing – must be prioritized.

Funding Statement

This study was supported by the National Science Foundation, Cultural Anthropology Program, Award #2032735 for “RAPID: Healthcare Workforce Resilience in the Time of Covid-19”.