Despite having been warned for decades, many countries were unprepared for the Covid-19 pandemic. Though some have managed to contain the virus, in most countries, the pandemic response has been poor at best; in some countries, it’s been disastrous. As of mid-March 2021, nearly 2.7 million deaths had been attributed to SARS-CoV-2, and many more aspects of the health and social impact are likely to come to light over the long term. Though there are no official global figures, among the casualties are likely to be tens of thousands of health care and other frontline workers; in late 2020, Amnesty International estimated that more than 7000 health care workers had died from Covid. Beyond risking their lives, such workers have had a challenging year, to put it mildly. Many continue to work in underresourced systems, with inadequate personal protective equipment (PPE), dealing with a situation that was both unprecedented and completely foreseeable.

While the heroics of health care workers have been celebrated and we’ve gained a renewed appreciation of the risks that many frontline workers face while providing fundamental services, less attention has been paid to those who have refused to work under such dangerous conditions and those who have pointed out that no health care workers needed to be placed at such high risk. Many have rightly argued that heroics were required only because of government neglect, underfunding, and lack of preparation for a pandemic that we knew was coming. Many workers are justifiably angry. Although there are no official figures, Covid-19 appears to have led to a substantial uptick in strike actions by health care workers.

In February 2020, facing an unknown “pneumonia,” experts in Hong Kong called for closing the borders in an effort to mitigate its spread until more could be ascertained about the nature of the virus (which would be labeled Covid-19 on February 11 and deemed a pandemic roughly a month later). The Hong Kong government failed to act, despite calls from experts and health care workers, with support from the general public. In late January, labor unions repeatedly called for dialogue with the government regarding border closure. When that effort failed, a vote was held on strike action, for which there was overwhelming support. From February 3 through 7, 2020, health care workers in Hong Kong went on strike, making a number of demands, including the closure of borders and a sufficient supply of PPE and facilities to manage the potential spread of the virus.

Such action has not been restricted to Hong Kong. Amid multiplying cases of Covid-19, health care workers in Zimbabwe went on strike in June 2020 because of a lack of PPE and low salaries. Indeed, strike action by health care workers has been a global phenomenon. In the United States, nurses have gone on strike, and in the United Kingdom pharmacists and nurses have threatened strike action. Doctors in South Korea launched a nationwide strike in August, and health care workers in Kenya, Spain, Bosnia, and Peru have all gone on strike at some point during the pandemic.

Health care workers even went on strike after the military coup in Myanmar in February 2021, with a spokesperson noting that they “simply [did] not want to work for the regime that staged the military coup.”1 Such action must be understood in the context of broader unrest. In Venezuela, for example, many health care workers have had no option to stop working during the pandemic. In what has been described as a crisis within a crisis, Covid-19 has exacerbated many of the problems of Venezuela’s ailing health care system. Though there has been unrest, the Venezuelan government has attempted to silence critics, deny PPE shortages, and blame health care workers. The government also denies that an estimated 200 health care workers have died, contending that there have been only 12 deaths attributable to Covid-19.2

Though these situations are distinct in multiple ways and health care workers have gone on strike (or protested) for myriad reasons, common demands underlying nearly all these actions relate to inadequate responses to Covid-19 and inadequate protections for frontline workers; every group taking action has explicitly demanded more PPE.

Experts in law, ethics, and medicine have long debated whether and when strike action by health care personnel can be justified. Although these debates have centered on the risks that strikes carry for patients, these actions also pose risks for health care workers — they may damage morale and team cohesion, for example, and in many countries strikes have been repressed violently. Other risks relate to public perceptions and to potentially broader harms for both society and the health care community as a whole.3 Perhaps most fundamentally, however, strikes raise questions about what health care workers owe society and what society owes them.

Past debates, however, have perhaps not had to consider such unprecedented circumstances: Should doctors in Myanmar, for example, have to continue to work under a military government during a pandemic? Although we can’t readily answer this question, there are some key considerations in assessing strikes during Covid-19. Perhaps the most obvious is that the pandemic has raised the stakes for such actions. On the one hand, it could be argued that health care workers are needed more than ever; on the other, it could also be argued that they should not be expected to work with inadequate PPE and other protections in place. Beyond these dilemmas, Covid-19 has not only highlighted our collective vulnerability, but also revealed the impact of decades of underfunding and neglect as well as a more recent disdain for science. In many ways, debates about the risks associated with strike action have led to a stalemate, as these dilemmas are only present because of deeper structural problems.

In an article published about 6 months before the first cases of Covid-19 were reported, entitled “Invest in public health now, or store up problems for the future,” Finch argues that the ongoing underfunding of public health in England was likely to have future implications, increasing the need for services and raising costs in the longer term.4 Underfunding was one of many problems faced by health care in the United Kingdom before the pandemic, with decades of austerity believed to have contributed to tens of thousands of preventable deaths.5

Covid-19 has led to some of the most profound changes to social life in living memory. It has also shed light on many challenges that might otherwise have been brushed aside: underfunding, neglect, and indifference to health and health care. It has left us with two related issues: What should be done to avert strike action? And more important, how can we address broader structural failings?

How we get to the root cause of these problems will vary from country to country, as will who should be accountable for them and what can be done to solve these problems. Contrasts can be drawn here among well-resourced countries, but even starker differences exist globally, especially given the likely future impact of Covid-19 in low- and middle-income countries. Yet some immediate steps could be taken everywhere in response to warnings about long-term effects on the mental health of health care workers: support should be provided, now and into the future.

Though it is tempting to say that we also need to pay health care workers more and improve their working conditions, and we do, such actions will have little long-term impact if health care systems remain neglected. It would be nice to say that it shouldn’t take a pandemic or a strike to force countries to confront these issues, but the past 12 months justify a certain skepticism. Even as Covid-19 continues to affect millions of people, we can only hope it prompts a reassessment not only of how health care workers are treated, but also of the value we place on health and health care.

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