Using Medical Students

The 1918 pandemic began after the United States became involved in World War I. Nine thousand nurses were sent overseas, and thousands were deployed to military bases. ^{Reference Keeling25} As a result, there was a widespread health-care personnel shortage, making the fight against the 1918 influenza more difficult. The need for health-care personnel led to the use of medical students. In a firsthand account, Dr. Isaac Starr, who was beginning his third year at University of Pennsylvania School of Medicine, recalled how third- and fourth-year medical students were called into action in September of 1918, after only receiving 1 lecture on influenza. ^{Reference Starr26} Students assembled beds from storage and prepared makeshift hospitals. Fourth-year students became the interns, while third-year students acted as nurses. With only 2 trained nurses on each shift, retired physicians, priests, clergymen, and nuns assisted. ^{Reference Johnson and Mueller27}

Like the 1918 influenza, the health-care personnel shortage during the COVID-19 pandemic led to the recruitment of medical students. In short-staffed areas, local medical schools instituted their own policies to increase personnel on the frontlines. For example, fourth-year medical students from New York University, Oregon Health and Sciences University, University of Massachusetts, Tufts University, Boston University, and New York Medical College graduated early to help with hospital staffing. ^{28–Reference O’Byrne, Gavin and McNicholas32}

Despite historical recruitment of medical students as health-care personnel during shortages, there is much disagreement regarding the clinical roles of medical students and the extent of their participation across varying institutions in routine medical care. ^{Reference Miller, Pierson and Doernberg33} In an effort to advocate for students, the American Association of Medical Colleges established interim recommendations in March 2020 that stated “medical students are students, not employees” and “unless there is a critical health-care workforce (HCW) need locally, we strongly suggest that medical students not be involved in any direct patient care activities”. ^{Reference Whelan, Prescott and Young34} As seen from past pandemics and epidemics, however, using the aid of medical students can significantly ameliorate the heavy burden on health-care personnel.

Expanding the Scope of Practice

While the 1918 pandemic mitigated health-care personnel shortage by expanding the role of medical students, the 2009 pandemic extended the scope of practice of active health-care personnel. ^{Reference Courtney, Morhard and Bouri35} In November 2009, the Maryland governor issued an order allowing emergency medical technicians (EMT)-Paramedics and Cardiac Rescue Technicians to vaccinate patients. ^{Reference Courtney, Morhard and Bouri35}

During the COVID-19 pandemic, response to the health-care personnel shortage was seen at both the federal and local institutional levels. Early in the pandemic, the US Department of Health and Human Services eased restrictions to allow licensed health-care providers to practice in another state in which they did not have a license. ^{Reference Hentze36} This early action facilitated an influx of physicians, nurses, and other health-care personnel to New York and New Jersey to assist within various departments in hospitals. ^{Reference Azar37} In addition, during the COVID-19 pandemic, New York State allowed EMTs, licensed practical nurses, pharmacists, podiatrists, midwives, dentists, and dental hygienists to administer vaccinations against COVID-19. ³⁸ These changes in regulations call attention to ways that health-care workers expanded scope of practice can be used to supplement the shortage in specific care areas in future pandemics.

To further accommodate for the overflow of patients in hospitals and the shortage of health-care staff, the federal government deployed the hospital ship, United States Naval Ship (USNS) Comfort, and converted the Javits Center, a large convention center in New York City, into a makeshift hospital with military health-care personnel. ^{Reference Lalani, Lee and Laing39} In mid-July 2020, several states including Arizona, Texas, California, and Florida experienced persistent surges in cases and hospitals were overwhelmed and understaffed at many health-care facilities. ^{Reference Bellware, Hawkins and Knowles40} As the cases in New York leveled off, some hospitals in New York sent health-care personnel to severely affected states such as Utah in August 2020. ^{Reference Goff41} Throughout the pandemic, the military also sent resources to many states that needed support and resources. ^{Reference Bowman42}

Previous public health emergencies caused shortages in health-care personnel that were similar to those seen during the COVID-19 pandemic. In planning for future public health emergencies, health-care systems may consider mirroring the mitigation strategies seen throughout history by using medical students, easing state licenses, expanding the scope of already practicing health-care personnel, using military assets, and shifting health-care providers from 1 region to another.

General Public

The daily lives of the general population were severely altered by the pandemic of COVID-19. The rates of depression, suicide, anxiety, and other psychological comorbidities significantly increased during this period. ^{Reference Czeisler, Lane and Petrosky43} During the COVID-19 outbreak, many people were forced to work from home, while millions lost their jobs and continue to be laid off. During the pandemic, the US unemployment reached a peak rate of 14.8% in April 2020, gradually decreasing to 6.7% by December 2020. With schools closed, families had to simultaneously provide childcare while working. ^{Reference Falk, Carter and Nicchitta46} In the last 2 wk of March 2020, there was a 60% increase in calls to the New York City branch of the National Alliance on Mental Illness, a nonprofit organization that provides support to those affected by mental illness. Other hotlines, including the Federal Disaster Distress Helpline saw unprecedented surges in calls, far exceeding any recent natural disasters. ^{Reference Russell and Smith Hopkins47}

The profound impact of public health emergencies on the mental health of the public was noted during the 1918 and 1957 influenza pandemics. According to a Norwegian mental health researcher, Norwegian survivors of the 1918 influenza pandemic reported depression, distractibility, and difficulty coping at work. ^{Reference Mamelund48}

As localized outbreaks of the 1957 pandemic occurred in the United Kingdom, fear was so widespread throughout the population that the Minister of Health was asked to make a statement in an effort to allay fears. He declined twice, as he believed the pandemic was not actually spreading in the United Kingdom. ^{Reference Jackson24} This highlights a disconnect between the emotions and mental health of the population and the perception of infectivity and the impact that has by governing bodies.

Similarly, the MERS epidemic in 2015 sparked fear and anxiety in many people due to the uncertainty of treatment options and the absence of a vaccine. In a study of Korean citizens, it was found that the epidemic led to fears of daily activities, such as using public transportation and running errands. Of the 1000 Koreans surveyed who had participated in a 2-wk isolation, 80.2% reported fear of being infected and 46% reported emotional distress. ^{Reference Jeong, Yim and Song49} These data show that isolation during an epidemic can have significant effects on emotional well-being.

Health-care systems have attempted to improve mental health in their own population by creating system wide changes to increase resources available to their own communities. During the 2009 pandemic, the National Biodefense Science Board (NBSB) identified major factors impacting the public’s mental health. They found that the population was most concerned about limited availability of vaccines and health care, conflicting news reports, increased US unemployment, and access to childcare. It also identified vulnerable populations including children, the elderly, the poor, and people with prior/current mental health and addictive disorders. To address these concerns across a wide population, the NBSB recommended the incorporation of mental health staff at clinics and vaccination centers to educate patients and to identify those experiencing significant distress. ^{Reference Pfefferbaum, Schonfeld and Flynn50}

Health-Care Personnel

During the COVID-19 pandemic, first responders and health-care personnel have faced the physical, mental, and emotional toll of treating a large number of critically ill persons, many of whom died in a short period of time. They witnessed the use of refrigerated trucks to store the bodies of those who had perished. ^{Reference Rose51} At a time when the COVID-19 virus was not fully understood, health-care personnel were at the frontlines, without sufficient PPE. Individuals sacrificed going home to their families and slept in cars, garages, and hotels for weeks to months to protect their loved ones. The mental health impact of COVID-19 was seen in New York City in August 2020, with the suicides of 1 emergency physician, 2 paramedics, and 1 EMT. ^{Reference Maguire, O’Neill and Gerard52,53}

The adverse effects on mental health are not novel to the COVID-19 pandemic. High levels of comorbidities including posttraumatic stress disorder (PTSD), anxiety, and burnout were seen in those involved in direct patient care both during and after the SARS epidemic in 2003. ^{Reference Jun, Tucker and Melnyk54,Reference Chong, Wang and Hsieh55} There was a 28% increase in mental health comorbidities among physicians who provided care to patients with SARS compared with those who did not. ^{Reference Grace, Hershenfield and Robertson56} During the 2014 Ebola epidemic, 1 in 4 health-care professionals involved in direct patient care experienced adverse mental health outcomes, including obsessive compulsions, depression, paranoid ideation, and interpersonal sensitivity. ^{Reference Jun, Tucker and Melnyk54}

In addition to the hierarchical changes to improve mental health in the general population, similar changes are occurring to help health-care personnel. In memory of the emergency physician, Dr. Lorna Breen, lost to suicide in April 2020, the Dr. Lorna Breen Health Care Provider Protection Act (Bill S.4349) was introduced to the US Senate on July 29, 2020, with the goal of establishing training programs to encourage health-care personnel to seek help and support and to increase awareness of physician mental health and burnout. ^53,57

As of May 2020, the American Medical Association (AMA) released a set of 17 steps for an organization to take before, during, and after a crisis to reduce the psychosocial trauma of a crisis. ^{Reference Ripp, Peccoralo and Charney58} The AMA recommends a systemic approach rather than an individual approach to mental health, emphasizing movement toward a focus on mental health on a larger, systemic scale. In accordance with such principles, health-care institutions across the United States began to increasingly focus on the mental health of health-care personnel. For example, in New York City, the Mount Sinai Health System organized a crisis support task force in March 2020 called the Center for Stress, Resilience, and Personal Growth, with the goal of promoting mental well-being of its staff. ^{Reference Ripp, Peccoralo and Charney58} The task force focused on enhancing communication and developing strong psychosocial and mental health support systems. It offered services such as virtual psychologist-facilitated support groups; system-wide peer support hotline; psychiatry services; free apps for meditation, yoga, music therapy; and social networking groups. ^{Reference Ripp, Peccoralo and Charney58} Similarly, Cody Regional Health of Wyoming established a designated “wellness area” featuring a meditation room, exercise room, and licensed therapists to support its health-care workers. ⁵⁹ In hopes of combatting the rising suicide rates, Atrium Health of North Carolina joined other hospitals, such as Cleveland Clinic, in establishing a Code Lavender program to provide rapid responses to emergent mental health needs. Code Lavender started to incorporate multiple therapeutic methods including music therapy, acupressure, and Reiki, as well as a wide range of staff from board certified chaplains to community volunteers. ⁵⁹

Evidence of mental health effects from past public health emergencies emphasizes the need to prevent, prepare, and address the impact of a crisis like COVID-19 at an institutional and individual level. While assuring individual access to mental health resources, an institutional approach is important, as traumatized health-care personnel may not recognize a decline in their mental health or know how to reach out for help. Creating a systemic culture of prioritizing mental health in the workplace brings awareness to these issues. Additionally, the feeling that 1 is valued by their supervisor has been found to reduce employee anxiety. ^{Reference Fleisher, Sweeney and Clapp60} This underscores the significant role that the health-care system plays in the mental health of health-care personnel. Systemic approaches toward mental health can provide data on how many workers are using provided resources and highlight the impact of the current pandemic on mental health with real time data. With an increased awareness of mental health in today’s society, there is the opportunity to be proactive and acknowledge the psychological impacts of the pandemic to help lessen the mental health burden.