All of us, whether we have realized it by now or not, are being traumatized by the COVID-19 pandemic.
Let’s begin with the darkening cloud apparent to many, the question I hear more than any other from my dismayed friends, “How can the richest, most technically advanced country in the world experience the worst effects of the pandemic?”
With four percent of the world’s population, the United States accounts for almost one quarter of all recorded infections and death. COVID-19 is an immediate personal trauma for those who are ill, or who have family members hospitalized or die of the disease. Those who recover from the more serious consequences of infection may suffer ill health for years to come. COVID-19 is an immediate personal trauma for our children and grandchildren who ask, why is this happening, why is my life changed?
The economic effects of the pandemic are broadly traumatic as well; we are experiencing the worst economic depression since the 1930s, with record unemployment, the destruction of countless small businesses, vanishing work opportunities for our young, and the dawning realization their lives will be forever changed. Social isolation, a consequence of efforts to control the pandemic, is in itself traumatic especially for the young. Social networks and relationships forged in our teenage and young adult lives remain amongst the most important throughout life. COVID-19 has shattered normal social life.
These combined traumas deliver a heavy psychological blow. A study released in mid-August by the Centers for Disease Control and Prevention found that anxiety and depression, substance abuse, and thoughts of suicide were on the rise because of the COVID-19 pandemic. Forty percent of more than five thousand U.S. adults participating in a late June survey said they had experienced one or more of those responses since April. Suicidal thoughts were notably higher among younger adults, aged 18 to 25, as well as Hispanics, Blacks, essential workers, and people who described themselves as unpaid caregivers for adults.
Trauma related to COVID-19 first affected health care workers who were on the frontlines of our society’s response to the pandemic. These medical professionals and staff confronted extreme emotional distress. They were forced to deal daily with a lack of necessary equipment to save the lives of an overwhelming number of patients and to protect themselves and their families for lack of adequate supplies of personal protective equipment, all the time listening to leaders who minimized the problems. A dedicated ICU nurse commits suicide. An overwhelmed ER doctor commits suicide. Not long ago, a friend, overstressed by day to day workplace confrontation with COVID-19, leapt to his death onto a New York City sidewalk.
Here I add another dimension to the traumas we all experience—what I will call moral trauma. I adapt the concept of moral trauma from the well studied military term moral injury that soldiers experience in wartime. The Wikipedia entry, citing several sources, defines moral injury and describes its causes and effects:
“The term moral injury… was first coined by psychiatrist Jonathan Shay and colleagues based upon numerous narratives presented by military/veteran patients given their perception of injustice as a result of leadership malpractice. Shay’s definition of moral injury had three components: “Moral injury is present when (i) there has been a betrayal of what is morally right, (ii) by someone who holds legitimate authority and (iii) in a high-stakes situation…”
The term “moral injury” was modified by Brett Litz and colleagues as “perpetrating, failing to prevent, or bearing witness to acts that transgress deeply held moral beliefs and expectations may be deleterious in the long term, emotionally, psychologically, behaviorally, spiritually, and socially”
Here I broaden the concepts underlying moral injury from the military to the civilian. I use the term moral trauma to distinguish the two. Until now moral injury has been used and studied almost exclusively in a military context. But isn’t moral trauma what we all experienced as we watched the video of the police officer staring definitely at onlookers as he squeezed the life from a handcuffed and helpless George Floyd? Isn’t moral trauma what we experience as we witness politicians lead our country into the worst avoidable public health disaster in our history?
Our moral fabric, however each of us may define this human quality, has been torn grievously on these two fronts—public health and civil rights—by failures of national political leaders. Six months and counting, our leaders continue to be overwhelmed and outmaneuvered by the COVID-19 virus, SARS-CoV-2. At the current rate, deaths in the United States from the pandemic will exceed within days, and in less than six months, more than three times the 58,000 Americans killed during eleven years of the Vietnam War. This is a shocking failure of our public health defenses.
Those of us in public health, and I suspect many others, understand that almost all the COVID-19 related death, economic havoc, and disruption of personal lives was avoidable. China’s experience with COVID-19 is a case in point. China has no medical tools to control COVID-19 that we lack. One can even argue that the US, a world leader in health research and cutting edge science, has the advantage.
The numbers tell us how badly we are failing to make the most of our advantage. China, the country first affected by COVID-19, has four times the population in the United States, yet on a typical day in August when more than fifty-five thousand new infections were tallied in the US, only 31 new infections were reported in China. Since the epidemic began more than twice as many Americas have died of COVID as have been infected in China. I cite these figures not to praise China but rather to express a collective sense of bewilderment as to what has gone wrong with our response to the pandemic.
Our moral trauma is witnessing death, contagion, and economic destruction around us, knowing full well it is unnecessary. Our country has been deeply morally traumatized—in my view, by the President through his denials, incompetence, and finger-pointing, and by his administration, his enablers in Congress, and compliant state governors.
By contrast, our military leaders have long understood their responsibility to support troops they place in harm’s way. On occasion, bad commanders issue orders that are repugnant even to seasoned hard-nosed veterans. The vast majority of soldiers despise killing other human beings. Medical professionals in the military recognize moral injury from treating veterans unable to quiet memories of witnessing, perpetrating, or failing to prevent violent deaths of enemy soldiers or civilians. This is beyond post-traumatic stress disorder. Emotional, physical, and spiritual harm persists in these men and women because those actions violated some deeply held moral beliefs or expectations of justice.
The traumas we face now in civil life can and should be illuminated by our military’s rigorous analyses. As injuries and death inflicted by COVID-19 become more pronounced, more immediate in our lives, and those of family and friends, we suffer increasing moral trauma. For our mental health, we need to take time to reflect on our troubling thoughts and experiences, understand and analyze them, then take action to restore what is being damaged most: our self-respect.
Our mental states suffer when the pain we experience is beyond our ability to control. We lose hope. We become overwhelmed. Family and friends find feelings and distressing events too painful to talk about. We find the feelings and distressing events too painful to talk about. We may retreat into our dark thoughts, feeling alone. But none of us should feel isolated or alone.
Psychiatrists and psychologists often are trained to guide patients through four stages of awareness to understand, modify, and resolve disturbing behaviors or thoughts. The first is identifying the characteristics of these behaviors or thoughts; “See it.” The second step is crucially important: picking precise words or phrases to describe the problem; or, “Name it.” The name of our collective experience is moral trauma.
Words or phrases become tools to help a patient or a society examine the problem they need to solve. In other words, “Analyze it.” The fourth step is to take stock of the analysis and then, take action. If you do not take action, a well-trained therapist will counsel, nothing will change. That is why the fourth step is, simply and emphatically: “Change it.”
The COVID-19 pandemic has caused me to relive two personal traumas long past. The first was with HIV/AIDS. I was among a small group of virus experts pressing urgently to map HIV’s distinct and deadly molecular biology in the early 1980s. I knew and tried to comfort dear friends, people I knew who struggled horribly then died from AIDS. We in medical science had no treatments for them. It was agonizing, deeply disturbing. At the time our national leaders refused to acknowledge the magnitude of the problem and to devote the public health and research funds needed to confront it. Those at the front lines of the fight against HIV/AIDS experienced what I now recognize as moral trauma.
It took action, immediate action by a few, to change the nation’s indifference to AIDS. A campaign that summer led by Republican Senator Ted Stevens and Democratic Senator Ted Kennedy, actor Elizabeth Taylor, me, and others convinced a bipartisan coalition in Congress at the eleventh hour stand up to an indifferent Reagan White House and fund $320 million in 1986. That action resulted in discoveries by the early ‘90s that ended the AIDS death sentence, helping people infected to live nearly normal lives on a regimen of antiviral medications. We saw how our actions changed government policy.
My other experience, shared with millions of others, was with the Vietnam War. Many felt the war was unnecessary and unjust. We were witness to hundreds of thousands of Vietnamese and tens of thousands of Americans dying for what appeared to be no valid reason. With the publication of the Pentagon Papers, we learned that our government under three presidents, Republican and Democratic, had been deceptive in describing the reasons for the war, the progress on the ground, the casualties inflicted on both sides, and the prospects for success. This while we mourned the deaths of many high school and college friends who had volunteered or been drafted into the war effort. Massive countrywide protests changed our national policy as much as defeat on the battlefield. We had no name for our collective trauma but we do now.
The most important response we need to take as individuals and as a nation to heal is to recognize these deepening anxieties, restore our self-respect, and then do our utmost to help ourselves and others recover from these unprecedented and accumulating moral trauma of our time. We need collective action to return our government to a disciplined plan based on science to control the pandemic. We know with certainty it can be done with the tools at hand. No new miracle drug or vaccine is needed, only resolve, that of our government to do what is right, and, if not, by we the people to make sure they do!