“Have you EVER received, or are currently certified to receive in the future any of the following benefits?” United States Citizenship and Immigration Services (USCIS) now poses this question to all immigrants seeking legal permanent residence in the United States. These benefits include the Supplemental Nutrition Assistance Program, Medicaid, Public Housing, and cash assistance for income maintenance. If an immigrant answers yes to having received any of these health and social services, they risk being deemed a “public charge” and being barred from ever gaining legal permanent residence.

Under this brand new USCIS Public Charge Rule, since February 2020 immigrants to the United States must prove “self-sufficiency” when filing for permanent residency – also known as “green cards” – or even for temporary visas. Although the federal government has the legal mandate to regulate immigration, restricting access to health care, food, and other essential benefits on the basis of immigration status during a global pandemic is a dangerous and even lethal gamble to make.

“The U.S. government is forcing undocumented immigrants to choose between their health and a future path to U.S. citizenship, and many will choose the latter.”

This rule instills fear and confusion within the immigrant community, including amongst undocumented people and the large number of “mixed-status” households. Medical experts have already sounded the alarm on the “chilling effect” this rule has had on many immigrants, who are fearful of accessing benefits that may risk them being considered a “public charge” – such as Women, Infants, and Children (WIC) nutrition programs and Medicaid coverage during pregnancy. It is also likely to dissuade undocumented immigrants from obtaining potentially lifesaving testing and treatment for COVID-19. While the rule does not apply to refugees, asylum seekers, and applicants for other forms of humanitarian relief, this unpredictable policy environment creates fear and uncertainty in many immigrants across the board, not knowing what may come next.

I grew up in a predominantly immigrant community in the suburbs of Boston. My grade school classmates hailed from Brazil, El Salvador, Haiti, Morocco, and other parts of the world. My neighbors were from the Philippines, and the corner store was owned by a man who was deeply proud of his Italian heritage, as demonstrated by the countless Italian flags in his establishment. Many people in our community were either undocumented, on their path to U.S. citizenship (i.e. legal permanent residents) or newly minted U.S. citizens.

But the fear of deportation was ever-looming, and I witnessed many friends and family members forego medical care and refuse to enroll in public benefits for fear that their immigration status would be recorded, and that they would be deported as a result. The former federal agency that was charged with administering immigration and naturalization laws, the Immigration and Naturalization Service, was just as much a source of fear and anxiety for undocumented immigrants in the 1990s as Immigration and Customs Enforcement (ICE) is today. Today, however, the changes to the Public Charge Rule make those fears a reality.

“I witnessed many friends and family members forego medical care and refuse to enroll in public benefits for fear that their immigration status would be recorded, and that they would be deported as a result.”

I investigated the health impacts of this issue even before the COVID-19 pandemic heightened concerns. In September 2018, I traveled to Houston, Texas with Physicians for Human Rights and interviewed physicians to assess how recent immigration policies like family separation, increased Customs and Border Protection enforcement activities, and prolonged ICE detention affected the immigrant community in Houston. I spoke to one physician – a pediatrician who runs a free mobile clinic for low-income children in the area – about her experiences. She told me that the children she sees will often come to her asking about symptoms of various ailments that their parents are experiencing. When she asks why the parents do not seek medical care, the children reply that they are afraid of being deported and separated from their U.S. citizen children.

Policies that separate children from their parents, dissuade undocumented immigrants from enrolling in essential public benefits – including those NOT considered under the new rule – and allow community sweeps to deport individuals who may have lived in the United States for decades are meant to intimidate and create anxiety and confusion within immigrant communities like the one I grew up in. This is always wrong. But during a global pandemic, where undocumented immigrants are terrified to seek much-needed medical care, these policies may be deadly.

Although USCIS publicly stated that the Public Charge Rule does not restrict access to testing for or treatment of COVID-19, many immigrants already have and will undoubtedly continue to avoid hospitals and community clinics. They have heard the intended message loud and clear—you’re not safe here. The U.S. government is forcing undocumented immigrants to choose between their health and a future path to U.S. citizenship, and many will choose the latter. Three states have already asked the Supreme Court to suspend this rule and the U.S. government must heed this call. Only then will undocumented immigrants and others within the immigrant community feel comfortable seeking medical care and other essential benefits. The U.S. government must act now to save lives.  

COVID -19 has kept many other outrages out of sight – and, for some governments, probably the hope that those outrages might be forgotten entirely.

The Syrian government is one that might have been banking on some amnesia as far as chemical weapons use is concerned. It will be disappointed, likely infuriated, that the Organisation for the Prohibition of Chemical Weapons (OPCW), an intergovernmental organization that oversees the implementation of the Chemical Weapons Convention (CWC), this month affirmed the longstanding and extensive documentation of the Syrian government’s repeated, abhorrent, and illegal use of chemical weapons.

The OPCW’s newly established Investigation and Identification Team (IIT) concluded in a report issued on April 8 that there are “reasonable grounds” to believe that Syrian air force planes and helicopters were responsible for dropping aerial bombs of the highly toxic nerve agent sarin and a cylinder of chlorine on three separate occasions on the village of al-Latamneh. The IIT estimates more than 100 women, men, and children were injured in these attacks, of whom three died.

One chemical attack that the IIT investigated on al-Latamneh Surgical Hospital was previously documented by Physicians for Human Rights (PHR). Based on an analysis of open-source data, PHR researchers concluded that on March 25, 2017: “a barrel bomb containing a toxic substance believed to be chlorine was dropped on al-Latamneh Surgical Hospital. A doctor was killed, and the hospital temporarily suspended its operations. Due to the weapon used in the attack, PHR believes that Syrian government forces were responsible for the incident.” The OPCW has confirmed this conclusion following its highly detailed analysis in the new report.

Chemical weapons use is illegal under an international treaty signed or ratified by 193 nations, including Syria. It is disgraceful that Syria, which is a signatory to the Chemical Weapons Convention forbidding such use, continues to use sarin and chlorine with impunity. Syria provided no help to the IIT and has dismissed its conclusions as “misleading”; it accused the OPCW report of containing “falsified and fabricated conclusions aimed at falsifying truths and accusing the Syrian government,” without elaborating. But the IIT report, based on multiple sources of information, interviews, physical tests on samples, flight records, and the like, is suitably forensic and provides powerful evidence of the Syrian government’s illegal use of chemical weapons. 

The IIT’s remit is to identify those who use chemical weapons. This it has done, although the names of individual actors in government and the Syrian air force involved in these illegal attacks have been redacted in the published report. However, they are clearly now known. Syria cannot be allowed to get away with flouting the CWC. If no action is taken to hold the perpetrators of chemical weapons use accountable, of what value is the Chemical Weapons Convention?

The Executive Council of the OPCW must now decide what action it should follow. So, too, must the United Nations’ Secretary-General, Antonio Guterres. The potential duration of the trauma of dealing with COVID-19 remains an open question. But in the meantime, the international community must decide what it does to punish those Syrian officials who have repeatedly and flagrantly flouted the rules on chemical weapons use.

As the COVID-19 pandemic overwhelms medical institutions, reports have been growing about health care workers (HCWs) around the world who have been subjected to retaliation for speaking out about Personal Protective Equipment (PPE) shortages, dangerous hospital conditions, inconsistent guidance, and even for bringing their own PPE to work. While legal and regulatory conditions vary by state and country, the following document outlines procedures U.S. health workers seeking to express safety concerns might follow.

HCWs have raised concerns in a variety of ways, including with fellow colleagues, to hospital management, to government officials, to the press, and to the general public. The retaliatory measures taken against them have included formal warnings, reassignment, suspension, or even termination. This has occurred despite that fact that many HCWs have been acting from a sense of professional, moral, and ethical duty to protect themselves and others and/or to report what they consider to be gaps in safety that could impact their own health as well as the health of their colleagues, patients, and communities.

Although numerous U.S. associations of health professionals have issued statements calling on employers to refrain from such retaliation, the actual protections and recourses for HCWs are not always evident, often varying from state to state and even from one institution to another.

Yet, as a health care professional, you do have a range of supports and protections, as well as the ability to defend yourself and make changes at your institution. Physicians for Human Rights (PHR) has compiled a few suggestions below on what should be considered.

The text is also available in PDF format here.

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Ensure Patient Confidentiality

Importantly, you are always bound by patient privacy laws and broader ethical obligations regarding how you treat all patients. In speaking publicly on matters of concern, you must practice great caution and avoid violations of a patient’s right to privacy. Disclosing information that might lead to the identification of a patient should be done only with the explicit consent of that individual. As long as you do not reveal individual patient data or specific information which might lead to the identification of a patient, these privacy rules do not prevent you from speaking about general workplace safety concerns.

Review Your Employee Handbook

As applicable, check the employee handbookof your institutionfor sections about public speaking and internal processes for grievances. Make sure that it is the latest version, as health systems and institutions often assert the right to change the content of these at will and without notifying employees. Nevertheless, this review will likely be useful to inform your understanding of internal processes. Also, check your letter of employment or contract to see whether there is a non-disparagement clause. If so, you may need to consult with a lawyer before speaking out. 

Beware of Information Security

Under all circumstances, be careful about the manner in which you communicate, including with a union representative, colleagues, government regulator, journalist, or even a lawyer, unless it is your own lawyer, in which case, the conversation is privileged. To be safe, assume that any communications from work devices (e.g., emails, texts, calls) or on work premises can be monitored and stored. Be careful about using Gmail or other private email services from a work computer (which could still be monitored, whether or not that is allowable). If you intend to submit a tip anonymously, consider using an online service or smartphone app (or a public phone) for more secure communications. Conversations with an attorney should be confidential and protected by attorney-client privilege, but it is still inadvisable to have such conversations from a work device or account.

Know How to Document Your Concerns

For almost all rights and remedies discussed below, it helps to have some written documentation to support your concerns or claims. This can take the form of contemporaneous notes, calendar entries, diaries, written statements, audio or video recordings, photos, emails, or other documents. Ideally, this documentation should be contemporaneous (dated) and have some useful level of detail. Again, be especially careful not to implicate patient data or privacy, even inadvertently. Some hospitals may have policies or contractual provisions about bringing files from work to home. Most hospital computer systems are likely to maintain an archive of messages (e.g., forwarded emails) or log unusual activity, such as the copying of large amounts of files to an external device. Most hospitals are likely to view hospital documents and files as company property. Review your contract to see if there is an applicable confidentiality clause. Be aware that accessing an employer’s files which you do not have the right to access or misappropriating them can result in firing, litigation, or, in extreme situations, criminal charges for violations of the Computer Fraud and Abuse Act.

Understand the Reasonable Allowance for Self-Correction

In deciding on your first steps when you observe lapses in safety, it is generally advisable to first research and seek remedies using your institution’s internal channels. HCWs who identify errors or misjudgments should work to see such mistakes corrected by internal processes rather than through public reporting, if at all possible. If institutions and individuals are responsive and willing to correct such failures on a permanent basis when they are identified, public disclosure may not serve a useful purpose and may ultimately even cause more harm than good. However, when such efforts do not lead to necessary changes, depending upon your situation, you may choose to exercise some of the options below to protect yourself, your patients, your colleagues, and the general community.

Act Swiftly

If you are fired or retaliated against, consult an attorney or check the relevant deadline(s) (known as a “statutes of limitation”) as quickly as possible. In several jurisdictions, the time limit for filing a retaliation claim under the workplace safety and health laws is only thirty (30) days.

Understand OSHA Workplace Protections

Workplace protections for speaking out about safety concerns have traditionally been within the jurisdiction of OSHA, the Occupational Safety and Health Administration, as well as under various state equivalent organizations. Under Section 11(c) of the Occupational Safety and Health Act, private sector workers – including in the health care sector – are protected from retaliation if they raise health- and safety-related concerns about their workplace. Unfortunately, by all reports, OSHA (or the Department of Labor leadership) has to date either been unwilling or unable to address many of the complaints that have stemmed from the COVID-19 pandemic. Nor, to date, has OSHA issued a further emergency temporary standard to definitively protect health care workers in the current context. In reporting to OSHA, it is best at this time to:

• Submit an anonymous complaint to OSHA. While this will not aid you directly, it will be entered into a national database and may inform future research and legislation. Thousands of complaints to OSHA have been filed by HCWs since March 2020.

• Know your rights under the Occupational Safety and Health Act. This is a federal law that protects workers from retaliation for complaining to their employer, OSHA, or other government agencies about unsafe conditions in the workplace. If you have reported unsafe or unhealthy working conditions, and your employer has retaliated against you for it, you can file an OSHA whistleblower complaint online.

• Know Your Rights in Your State. Your state may have its own occupational and health requirements. Here is a list state-based OSHA safety plans.  

Be Aware of Key Legislation

• The National Labor Relations Act (NRLA). Under Section 7 of the NLRA, a nonsupervisory employee (even in a nonunionized environment) has the right to engage in concerted activity to effect change to improve working conditions. As quoted from the National Labor Relations Board (NLRB):
   

“You have the right to act with co-workers to address work-related issues in many ways. Examples include: talking with one or more co-workers about your wages and benefits or other working conditions, circulating a petition asking for better hours, participating in a concerted refusal to work in unsafe conditions, openly talking about your pay and benefits, and joining with co-workers to talk directly to your employer, to a government agency, or to the media about problems in your workplace. Your employer cannot discharge, discipline, or threaten you for, or coercively question you about, this “protected concerted” activity. A single employee may also engage in protected concerted activity if he or she is acting on the authority of other employees, bringing group complaints to the employer’s attention, trying to induce group action, or seeking to prepare for group action. However, you can lose protection by saying or doing something egregiously offensive or knowingly and maliciously false, or by publicly disparaging your employer’s products or services without relating your complaints to any labor controversy.”

If you believe that these rights have been violated, you may file a complaint with the NLRB. Complaints under the National Labor Relations Act should be made with the NLRB.

• The Labor Management Relations Act of 1947. Under Section 502 of the Labor Management Relations Act (the Taft-Hartley Act), workers may refuse to work under “unusually dangerous conditions.” You may need to consult with an attorney to assess how this will likely be defined in your situation.

Other Things You Can Do

Contact Your Union Representative (Ifyou are a union member)

You might find that there are ongoing actions on behalf of bargaining units that are attempting to address your complaints and may be helpful to you personally. If not, you will still be alerting the union to what you have observed.

Consider Contacting an Attorney

Consider contacting an attorney whospecializes in employment law. In addition to situations mentioned above, an attorney may be able to advise you on the individual characteristics of your situation. Additionally, some firms have been taking cases on a pro bono (free) or contingency basis (you usually only pay if you win) and may be able to help in various ways, ranging from writing a letter to hospital CEOs or managers to entering into settlement negotiations, advising you in detail about your personal circumstances and protections, or initiating a full-blown lawsuit for wrongful termination in violation of public policy. Your local legal aid society or bar pro bono center may be able to provide further assistance and direction.

Talk to Your Colleagues

There can be strength in numbers. If possible, and the problem is widespread, consider taking action as a group. If other HCWs in your institution share the same concerns, submit an internal letter with multiple signatures or ask for a group meeting with administrators.

Raise Concerns to Your Health System’s Ethics Committee

Many of these safety issues fall within the boundary of professional ethics when actions are taken to protect the health of your patients and the public. A committee decision supporting your and your colleagues’ concerns and demands may hold sway with administrators. Under certain circumstances, you may be able to approach the committee and have your identity be protected if you fear retaliation.

Consider Speaking to Your Institution’s Ombudsperson

You may be able to submit anonymous complaints if your institution has an ombudsperson. As more people from the institution use this option, the likelihood of a response increases.

Organize

Consider partnering with other local groups, including HCWs from the same area or health systems experiencing similar situations. Work with experienced community organizers to launch a letter-writing campaign to those who may be able to improve the safety situation, targeting local representatives (i.e., mayor, state legislator, congressperson, or governor).

Approach Your Member Organization or Society

Many of these organizations have already issued statements supporting HCWs and their backing, national voice, and advocacy prowess may be important and useful. These can be shared with colleagues and also with managers at your institution to explain and justify your actions. Some have created databases for complaints. Contacting them will add weight to the concerns that you are raising.

Speak to the Media

You can contact reputable and trusted journalists to offer anonymous tips and provide background information. You may ask to speak “off the record” (meaning that the information you disclose cannot be reported), or “on background” (meaning that the information you disclose can be reported, but only around parameters you define, such as “according to one source in the hospital…” rather than “according to Dr. Smith in the hospital”), but make sure to mutually agree to those parameters before you speak to the reporter. You may also speak “on the record” (both the information you disclose and your name can be reported) with a reporter or publicly, but that obviously carries a greater degree of risk. Keep in mind that employers have varying policies related to speaking to the media. Before approaching or speaking to a reporter, read their past coverage to better understand their tone and reporting style. Most news outlets offer secure and confidential methods to share information (e.g. through secure messaging apps like Signal and Proton Mail). Here are a few links for well-known news organizations where you can provide news tips:      

Washington Post

ProPublica

New York Times

Boston Globe

Los Angeles Times

San Francisco Chronicle

Miami Herald

Atlanta Journal-Constitution

Philadelphia Inquirer

Chicago Tribune

CBS News

File an Official Whistleblower Complaint

Whistleblowers are individuals who decide to expose illegal or unethical activities within their institution (private or public), often where finances are at issue. Note that OSHA has its own, multiple whistleblower statutes. Whistleblowers often have special protections, but the process may at the same time carry significant risks for the whistleblower. As such, this may be a last-resort action. National Nurses United has compiled a state-by-state list of whistleblower protection laws for health care workers. There are a number of attorneys who specialize in this litigation who can advise you. Additionally, there are independent organizations who may support you if this is the path you wish to take, including:

The Government Accountability Project

The National Whistleblower Center

Whistleblower Aid

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NOTE: This document neither offers nor constitutes legal advice or legal work product and it should not be relied upon as such. Your circumstances, risks, and applicable laws may vary. When in doubt, consult an attorney who can provide you legal advice.

Originally published in Just Security on April 17, 2020

On March 20, the Trump administration closed United States land borders to all but essential travel through joint agreements with Canada and Mexico.

The new COVID-19 border restrictions included exemptions for truck drivers, temporary workers, students, and others, with one glaring omission: asylum seekers and unaccompanied children seeking U.S. protection.

People fleeing persecution are protected under U.S. and international law, and the United Nations Refugee Agency (UNHCR) has confirmed that countries must not deny entry to asylum seekers solely because of the COVID-19 pandemic.

Nonetheless, the Centers for Disease Control and Prevention (CDC), relying on logistical claims by the Department of Homeland Security (DHS) and Customs and Border Protection (CBP), issued an order on March 20 purporting to allow the U.S. government to immediately turn back asylum seekers and unaccompanied children at the border. Some 10,000 migrants have been sent back to Mexico since then, joining the tens of thousands the administration has already returned to dangerous border towns through the “Remain in Mexico” program.

Last month, Physicians for Human Rights (PHR) released a joint statement with other human rights organizations calling for the border to be reopened to asylum seekers in accordance with U.S. legal obligations. In the statement, we outlined a path for safe asylum processing at the border.

This latest attack on the right to seek asylum is immigration policy masquerading as public health policy. We at PHR believe it is imperative that the public understands how little a basis the CDC order has in science. To help facilitate this, we asked six infectious disease epidemiology experts to respond to the CDC’s public health justifications for closing the border to asylum seekers.

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There is No Logic to a Categorical Ban

The abrupt change in U.S. policy is premised on the notion that asylum seekers, as a group, pose a greater public health threat than the students, temporary workers, and others who are still permitted to cross the border.

The public health experts PHR consulted agreed that there is no public health rationale for a ban on asylum seekers as a group.

“By refusing to let asylum seekers enter the U.S. – thereby condemning them to live in dangerous and unsanitary conditions in Mexico, where social distancing measures may be impossible to implement – the Trump administration… is actively undermining public health.”

Sanjana Ravi

“The virus is a non-discriminating agent,” said Dr. Ronald Waldman, physician and professor of global health at George Washington University and president of Doctors of the World – USA. “There is no reason why asylum seekers would be more likely to be at risk of contracting or transmitting the virus than any other group of people.”

Professor Lawrence Gostin, director of the O’Neill Institute for National and Global Health Law at Georgetown University, agreed: “It makes no sense. In public health, any time there is a categorical classification—any time there is a category about who you apply your measure to or who you don’t—is highly suspect. The courts suspect it. Public health people suspect it. There is no scientific evidence for it. And it’s discriminatory.”

For Dr. Monik Jiménez, Assistant Professor at Harvard Medical School and Harvard T.H. Chan School of Public Health, it’s clear the classifications are based on political motivations. “They’re not based on sound epidemiological evidence of groups that may be at higher or lower risk,” she told us.

Laurie Garrett, Pulitzer-prize winning journalist and pandemic expert, said of asylum seekers, “There is no particular reason to single them out. And there is no particular reason to believe that closing the border has any effect whatsoever on the spread of disease. The disease is already here.”

The U.S. is currently reporting the highest COVID-19 infection rate in the Americas, with community transmission already occurring in all 50 states, noted Sanjana Ravi, senior analyst at the Johns Hopkins Center for Health Security and senior research associate at the Johns Hopkins Bloomberg School of Public Health. “By refusing to let asylum seekers enter the U.S. – thereby condemning them to live in dangerous and unsanitary conditions in Mexico, where social distancing measures may be impossible to implement – the Trump administration… is actively undermining public health.”

Dr. Gregg Gonsalves, Assistant Professor in Epidemiology of Microbial Diseases at Yale School of Medicine and co-director of the Yale Global Health Justice Partnership, said that if the U.S. government were really worried that an individual asylum seeker was carrying COVID-19, the government could simply test them, as it could with a member of any other group. There was no logical consistency, he said, to excluding an asylum seeker but not a truck driver, since both could be asymptomatic carriers.

“If somebody is at risk of persecution and/or death,” he said, “and you’re worried about the potential for them to transmit coronavirus, test them for the virus rather than leaving them to die a more certain death from the political conditions at home.”

Risks vs. Benefits

Even if the U.S. government acknowledged that asylum seekers pose no greater risk than groups whose travel it considers essential, it might justify its decision to bar asylum seekers based on a weighing of risks and benefits. Its argument might be that groups like truck drivers and temporary agricultural workers provide an essential benefit while asylum seekers do not.

But, Gonsalves questioned the very notion of letting a cost-benefit analysis dictate asylum policy. “The idea that we are going to start to open the doors based on how economically useful somebody is to us in the context of them requesting asylum, it just doesn’t seem morally right and doesn’t really seem to make sense from an epidemiological perspective.”

Ravi focused on the fact that the U.S. is prohibited from turning away asylum seekers under international law. “Neglecting to uphold this obligation not only reinforces the misconception that refugees and asylum seekers are vectors of disease,” she said, “but also makes it exceedingly difficult for asylum seekers to access shelter, healthcare, and other needed social services. And ultimately, a State’s failure to dismantle barriers to accessing these services – particularly among vulnerable populations like asylum seekers – is what amplifies the risk of disease transmission.”

Waldman also framed this as a question of fundamental rights and characterized the ability to seek asylum as itself an essential benefit for the U.S. “It allows us to exercise our most deeply held values during a time when they could be challenged.”

Gostin agreed. “I would argue that asylum seekers provide at least the same level of ‘benefit.’ It is a different kind of benefit, one that is moral, ethical and in compliance with human rights and the international rule of law.”

Jiménez disputed the premise that asylum seekers are not capable of offering the material benefits that agricultural workers and truck drivers bring: “Asylum seekers are not coming here to be put in detention facilities. They are coming here because they need safety. And they want to work. That need to work is a very universal and fundamental desire for most people who are coming to the U.S. So, I think the way that we process asylum seekers and cage them keeps them from becoming important contributors to our society in all aspects.”

She emphasized that such cost-benefit analysis “really is motivated by political interest and not what we need scientifically.”

Garrett cautioned against such reasoning, too. “I think you end up buying into the whole question of weighing the value of one human being against another.”

Safer Quarantine Options Are Available

The CDC order describes ports of entry and Border Patrol stations as, by definition, “congregate settings” that are not designed for social distancing and therefore cannot safely accommodate asylum seekers.

It states: “many aliens covered by this order may lack homes or other places in the United States where they can self-isolate.” In actuality, an October 2019 study of 607 asylum seekers waiting in Mexico found that almost 92 percent had family or close friends in the United States.

The border closure is therefore premised on the false assumption that asylum seekers must be detained in congregate settings, when in fact the vast majority could be screened for symptoms like everyone else, referred to health services for additional testing if necessary, and then released to family or friends in the U.S. with whom they could safely quarantine.

“If the State is so concerned about congregate settings,” Gonsalves said, “they should maybe clear the federal jails and prisons and ICE detention centers.” He cited the dozens of cases around the country in which CBP, Immigration and Customs Enforcement (ICE), and the Bureau of Prisons are fighting release orders by arguing that facilities are equipped to handle social distancing. The federal government, he said, cannot “have it both ways.” Either federal detention centers are equipped to handle social distancing, or they are not.

From a public health standpoint, Garrett said, allowing asylum seekers to quarantine with family in the U.S. would be far better than detention. “If the asylum seekers… have access to a lower density co-housing situation in a home or an apartment, then the latter is clearly preferable form a purely health point of view.”

Gostin agreed. “After all, it would just be following the advice that CDC is giving everybody.”

Options for Asylum Seekers with Family or Friends in the U.S.

There would still be logistical questions as to how asylum seekers could safely travel from the border to their final destination, though.

“In terms of transport,” Gostin said, “it’s always a problem, but we have experience with it. We had to do it with the evacuees from Wuhan. We had to do it with the evacuees from the cruise ships. And so, you need to make safe provision for them to be moved.” The question, he said, was less about logistics than political will. “They just have to think it’s politically important and morally important and provide the capacity and planning.”

Waldman noted that asylum seekers would have access to the same public and private transit options as everyone else in the state. “I think it has been made clear that states can establish their own rules and regulations,” he said, “and it means that anybody who is in a state becomes subject to those.” If buses were still operating in the state, for example, asylum seekers could take them like anyone else, sitting at appropriate distances from other passengers.

Garrett emphasized that on buses, people should be seated two rows apart, very sparsely, which would require a third or a quarter as many passengers as usual. The driver should be behind plexiglass, and everyone should be issued masks, gloves, and hand sanitizer. Individual transport would be ideal to people’s destination cities.

Gonsalves said that something similar could be achieved in any U.S. government transport of asylum seekers: Passengers could sit in the back of the van, with a plexiglass barrier separating them from the driver, as is already the case in police cars.

Jiménez proposed that the government leverage community strengths and facilitate a “safe distancing pickup process by family members themselves.”

“Let’s call it what it is,” she said. “This is a racist policy against the Latinx community. There is incredible strength within the Latinx community that is underappreciated by the white majority. And so leveraging that community strength, those culturally relevant and healthy family bonds, could facilitate methods to decrease government burden with respect to having to provide transportation for everyone.”

The government’s job, she said, would be to ensure there was “culturally appropriate, relevant messaging to inform people if they wanted to do self-quarantine in their homes.”

This would be possible with “very deliberate collaboration between the healthcare system, the public health system, law enforcement, and community advocates.”

Options for Asylum Seekers without U.S.-Based Family or Friends

For asylum seekers who did not have family or friends with whom to stay, Waldman stated that accommodating them in shelters or vacant hotels, where they could have their own rooms, would be a viable option. “If people are screened on admission and determined to be not infected, then I don’t see the problem,” he said, “as long as they comply with the rules or regulations in the jurisdiction where they end up.”

Cities across the country—Chicago, Durham, Greensboro, Los Angeles, Minneapolis, Oakland, and others— are doing exactly this to allow homeless people to quarantine safely: transporting them by buses, vans, or other means to now-empty motels, hotels, and YMCAs.

The large network of religious and other community organizations already working in many U.S. towns along the border to help asylum seekers, such as Annunciation House in El Paso, can also help with immediate transportation, housing, and medical needs.

Jiménez said that all of these options “are absolutely great solutions that are there and are being under-utilized in addition to school dormitories,” which some students are pushing their universities to open to homeless people or individuals released from carceral settings.

Gonsalves noted that Yale had opened up its dormitories to first responders and that New York City had numerous vacant hotel rooms. “It’s not like we are wanting for empty hotel rooms or other kinds of settings,” he said. “There are plenty of places to put people right now.”

“I think it’s disgusting,” Jiménez said, “that we have so many empty spaces and so many people who need to be in those spaces, and we’re not connecting them.”

She also emphasized that any housing situation for asylum seekers needs to take into account their high level of trauma. “I think it is really important that we provide safe spaces to not further retraumatize individuals.”

Local Hospital Capacity Should Not be an Impediment

Another premise of the CDC order is that the possible entry of asylum seekers with COVID-19 would overwhelm already strained local hospital systems at the border.

Waldman disputed this assertion. “It’s not a viable statement right now because I don’t think that there is a problem with health system capacity on the border yet. I’m not saying it couldn’t happen later on. But for now, there isn’t.” And again, he said, the same would be true for the other groups that are still allowed to enter. “I understand their reasoning, but I don’t think it’s tenable. The imperatives for allowing asylum seeking to continue outweigh the concerns.”

Gostin noted that hospitals in some parts of the country are “overrun and overwhelmed.” But he said that if people are sick and need help, they do have the right to health.

According to Ravi, hospital systems at the southern border are indeed generally “overburdened and underfunded,” but “ignoring the rights of asylum seekers will not solve this problem, especially in the context of a pandemic caused by a virus that does not respect national borders.” She said the solution would be for U.S. government to increase federal funding for local and regional hospitals “by increasing Medicare and Medicaid reimbursements for healthcare facilities serving these communities, and/or by appropriating supplemental funds through the Hospital Preparedness Program.”

Garrett said, “In theory, humanity cares about these people, and they are already at the border. They’re just on one side of it. So local hospitals in theory are already overwhelmed if they have COIVD-19. They’re just on the Mexican side of the border rather than the American side.”

“There are ways to work around that,” Jiménez said, again emphasizing that messaging was key. Hospital emergency rooms did not have to be the first destination for all sick asylum seekers who were sheltering in place in the U.S. Community health workers are more likely to be trusted and, if reimbursed appropriately, could do virtual check-ins. They could share correct health information to help people understand whether they needed to be triaged by primary care or urgent care facilities rather than emergency rooms, and therefore minimize unnecessary use of the medical system.

Jiménez referred to the “healthy immigrant effect,” citing statistics that immigrants generally tend to be healthier than the average person who is in the US and may be at lower risk of complications. “On average, you’re not getting super sick people who are coming. You have to be well enough to make that journey.”

Gonsalves noted that if a large group of people with COVID-19 symptoms sought to cross the border, “The CDC can ban people with communicable diseases from coming into the country.” However, application of the policy would have to be consistent. “If they say people who come with fever are going to be turned away or thrown into quarantine, it has to be for everyone coming in.” There is “no logical consistency or rationale for applying it to one group of people and not the other.”

Crowded Border Encampments Are Another Reason to Allow in Asylum Seekers

The CDC order states, “Medical experts believe that community transmission and spread of COVID-19 at asylum camps and shelters along the U.S. border is inevitable, once community transmission begins in Mexico.”

“It is true,” Garrett said, “that refugee camps, whether they’re in Syria or Lebanon or in Bangladesh or Mexico, are dangerous settings for transmission of all sorts of diseases.”

“That doesn’t mean that the answer is therefore you have to stay there, and we’re going to wall you off to protect the rest of humanity that is more fortunate,” she said. “The answer is that those settings should become as quickly as possible conduits to getting people to safer places to live.”

Gostin, too, acknowledged that asylum seekers in crowded camps in Mexico are at high risk of contracting the virus. “But why would you keep them at high risk?” he asked. “Wouldn’t you want to mitigate their risk and then when they come, to do comprehensive testing and medical assessment? And if it turns out that your testing and medical assessment does confirm that they are high risk, then the guidance is for them to shelter in place.”

The problem, he said, was that “The Trump administration is conflating its immigration policy with its public health policy, and it shouldn’t do that.”

Jiménez said that the government was using this justification to keep out asylum seekers when it could also apply to other groups coming from equally dense settings, like urban areas. “If we are going to put those same sorts of qualifications,” she said, “then it needs to be across the board, and not applied to one specific group, because otherwise, it’s racist.”

Gonsalves stressed that people are going to cross the border illegally anyway. “A managed process is much better than a process of denial in both senses of the term: denying asylum seekers but also denying the fact that you are creating the wave of infection that you are so worried about by the way you are applying your policies.” A lot of border states, he observed, were late adopters of social distancing measures. The internal spread of COVID was always the greatest risk, so denying entry to asylum seekers now is “incoherent.”

Global Context

Reportedly, as of April 1, Mexico, which has a much smaller asylum agency than the U.S., was determined to continue accepting asylum seekers, although doing so inconsistently. European countries like Norway and Sweden also continue to recognize the right to seek asylum at their borders.

“Several countries have modeled excellent approaches toward processing asylum seekers amid the ongoing pandemic that effectively address public health concerns around COVID-19 without compromising human rights considerations,” Ravi said. “Portugal, for example, has temporarily granted all asylum-seekers full citizenship until the end of June, thereby ensuring that they have access to healthcare.”

Yet even Canada has recently closed its border to asylum seekers, demonstrating the currency of mistaken assumptions about border closure. Asylum seekers who were previously able to request asylum at informal border crossings will now be sent back to the United States, where they may face deportation to their home countries, in violation of the principle of non-refoulement, which prohibits the return of people to dangerous settings.

Gonsalves responded to Canada’s decision by noting that the time for travel bans to prevent spread of COVID-19 had long passed. “Local spread is by far the most powerful epidemiological factor in the perpetuation of the epidemic,” he said. “We know epidemics are excuses for xenophobia, for sort of hyper ethnonationalism, and sometimes epidemics are excuses for bad policymaking.”

Gostin agreed. “Governments and people behave quite differently in crisis than they would otherwise, but you can’t let a crisis fundamentally erode our commitment to democratic freedoms, the rule of law, and human rights.”

Like many others in the world, Iraqis are facing unprecedented quarantine measures to control the spread of the coronavirus. In a country still recovering from decades of war, sanctions, and extremism, experts fear that Iraq would be unable to adequately respond if there is a widespread outbreak of COVID-19. Moreover, Iraqis who have been stricken with the novel coronavirus are also facing deep discrimination within their neighborhoods and communities. This current of stigmatization is driving those infected, particularly women, to deny that they have the virus and avoid potentially life-saving medical interventions.

In Iraq, people suspected of having contracted COVID-19 are quarantined for 24-48 hours in a medical facility to await test results; there is no policy for in-home quarantines. If the result is positive, the infected person is quarantined for 14 days at a hospital focused on treating COVID-19 patients. However, many Iraqis are hiding their symptoms and refusing to be tested.  According to Dr. Ali al-Bayati, a practicing psychiatrist and commissioner at the Iraqi High Commission of Human Rights, this is happening, in part, because “those infected are becoming (social) outcasts. The public is panicking, and due to lack of general health awareness, people do not understand the pandemic” or how to respond to it. 

This current of stigmatization is driving those infected, particularly women, to deny that they have the virus and avoid potentially life-saving medical interventions.

The resistance has grown so intense that, increasingly, the Iraqi government is sending armed security forces with medical professionals to apprehend people infected with coronavirus and hospitalize them. These measures appear to criminalize the infected person and their family – and echo darker days in Iraq, when security forces would seize suspects from their neighborhood streets to imprison them. Dr. Saif Erzooqi, an internal medicine doctor in Baghdad, noted, “many patients refuse to be quarantined; for them it is considered an accusation.”

In fact, this intense opposition to medical evaluation and government intervention might help explain why Iraq has reported exponentially fewer cases than neighboring Iran, one of the countries hardest hit by COVID-19. As of April 22, 2020, Iraq’s Ministry of Health reported 1,631 cases across a total population of approximately 38 million. By comparison, Iran’s official count exceeds 85,000 in a population roughly twice that of Iraq. In a recent New York Times article on resistance to coronavirus testing in Iraq, Dr. Hazim al-Jumaili, a deputy health minister, agreed that this makes his job guiding the country’s response challenging. “It is true we have cases that are hidden,” he said, “and that is because people don’t want to come forward and they are afraid of the quarantine and isolation.”

Exactly why this is happening is likely a combination of lack of confidence in Iraq’s anemic health care system and deeply ingrained social norms. Iraq’s health care system is one of the weakest in the region, debilitated by decades of conflict and comprehensive international sanctions, as well as corruption. According to the World Bank, there are 1.4 hospital beds and 0.8 physicians for every 1,000 Iraqis. The World Health Organization notes that, over the last decade, Iraq has spent only $161 per capita on average each year on health (compared to neighboring Lebanon’s $649 and Jordan’s $304).

Medical professionals and human rights groups are increasingly expressing concerns that many families would not send their daughters, even if symptomatic, to hospitals, where they would be unprotected and isolated from family.

Women might be most deeply impacted by the intense stigmatization surrounding the virus. Dr. al-Bayati says this is preventing women even from seeking medical treatment. This is likely due to deeply ingrained social norms and government policies that do not take these norms into account. In many conservative families, for example, there is resistance to wives and daughters being taken out of the family home. A video recently posted on social media showed a man threatening the government if they take his wife to quarantine. Dr Erzooqi noted that when he referred one woman to temporary quarantine, her family tried to convince him that their mother did not have the virus, with no basis in medicine. It was “an attempt to avoid the quarantine,” he added. One doctor working in a health center on the outskirts of Baghdad told PHR about a number of cases where women visited his office against the will of their husbands or brothers.  

Medical professionals and human rights groups are increasingly expressing concerns that many families would not send their daughters, even if symptomatic, to hospitals, where they would be unprotected and isolated from family. Since the government’s response to COVID-19 doesn’t adequately take social distinctions between men and women into account, this might in practice further deprive women of equal access to health care. In many medical settings, men and women awaiting the results of a coronavirus test are forced to share the same room during the 24-48-hour quarantine. According to a doctor at one of Baghdad’s main hospitals, forcing individuals of different genders to share the temporary quarantine rooms can exacerbate families’ concerns about the safety of their female family members.

Although medical authorities in Iraq are overwhelmed and face a fundamental lack of resources and staff to respond to COVID-19, the Iraqi government needs to improve its policies in response to the pandemic and must actively consider a gender lens when it is reforming its response. The Iraqi government and all community leaders should advocate for awareness among the public to respect the rights and confidentiality of patients, especially women.

An orthopedic surgeon by specialty, Dr. Munther al-Khalil is head of the Health Directorate of the northwest Syrian governorate of Idlib, which has been under months of bombardment by Syrian government and Russian forces intent on eliminating the last opposition stronghold in the country.  The Idlib Health Directorate focuses on health governance and public health services in areas where the Syrian government has suspended such services, providing services like forensic medicine, vaccinations, and medical waste management.

On April 5, 2020, PHR contacted Dr. al-Khalil, now based in Gaziantep, Türkiye, for his assessment on the situation in Syria’s northwest as the COVID-19 pandemic looms. Dr. al-Khalil describes the state of the area’s health care system, its readiness to confront the COVID-19 pandemic, and the possible consequences of a rapid spread of the disease. Below is an extract from the interview.

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PHR: How would you describe the condition of the health sector in northwest Syria today?

Dr. al-Khalil: Between April 2019 and today, the [Syrian] regime and Russia have targeted 67 medical structures in northwest Syria. In our assessment, Russia was the primary perpetrator. In most of the attacks on health facilities, we lost equipment, medical personnel – a lot of resources. We were only able to transfer a small amount of equipment to [safety in] the north. Before this latest campaign, the area saw hundreds of attacks on hospitals and clinics, but they weren’t as brutal as the ones we’ve seen more recently; they didn’t seem as bent on clearing entire areas of medical services. Since April 2019, what we have seen is not merely a series of attacks on individual health facilities, but a campaign to totally destroy health infrastructure.

These attacks severely degraded our capacity to provide care. The state of the health care system is reflected in the resources at our disposal. Today, in Idlib, we have 107 ICU beds and 47 ventilators and there are over four million people living in the area. And I don’t have a single vacant ICU bed or ventilator. If I actually repurpose these beds and ventilators to cater to COVID-19 patients, I might save a number of those patients, but others – potentially a higher number – will die [of other causes] in the process.

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PHR: What are the main challenges the health sector in the northwest is facing today?

Dr. al-Khalil: The systematic assault on health facilities also coincided with a sharp fall in funding to health programs in Idlib, which weakened health governance in the area. For example, we at the Idlib Health Directorate are at the forefront of the response to COVID-19. You might be surprised to learn that the directorate’s employees have been working as volunteers for the past seven months. The last time they were paid was at the end of July 2019. Imagine that during these extremely difficult and complex circumstances, I have to lead a response to a pandemic that even the United States is having a difficult time managing, relying entirely on volunteers. 

“Since April 2019, what we have seen is not merely a series of attacks on individual health facilities, but a campaign to totally destroy health infrastructure.”

I see this as part of a politicization of funding to the area. There seems to be a lack of desire by international donors to support institutions here. Of course, there’s funding coming into the area in the form of support to individual facilities and organizations. But that doesn’t allow us to build a health system. You cannot build a health system without having a common health information database, without a drugs control system, without waste management, without a referral system. All these activities fall under the label of health governance and are receiving no funding. That’s highly problematic.

The problem is compounded by the general lack of governance and governmental institutions in the area. In other contexts, we have seen that the response to COVID-19 is not lead only by the health sector. It’s usually a shared responsibility, where the army, the police, municipalities, civil defense, and all other public institutions work hand-in-hand to create an effective response. We in Idlib do not have any of those support structures.

The weakness of the response so far, and the dip in funding, makes us think that we’ve been entirely abandoned.

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PHR: How are people in Idlib dealing with the threat of COVID-19?

Dr. al-Khalil: One of the biggest challenges we’re facing when raising awareness about social distancing and self-isolation is that we’re confronted with displaced people who are telling us they don’t have homes to stay in. About 65 percent of the current population of Idlib was displaced from one area or another and we have nearly one million people living in camps. Some of these camps are hosting above four times their capacity. People come to us and tell us “we’re ten to a tent.” How do I tell that person to socially distance? In addition, people can’t afford to stay at home. They live day to day. If they stay in isolation for two or three weeks, they’ll go hungry. There’s a different kind of calculus at play here.

“The weakness of the response so far, and the dip in funding, makes us think that we’ve been entirely abandoned.”

“Stay at home” is the main prescription the world over. So, what are we to do when cases start appearing? We can’t take them into our hospitals and the very notion of social distancing or isolation is ludicrous. This is what will drive the disaster that is heading our way. 

Another challenge we’re encountering is the hopelessness that permeates the population. They tell us, “We’ve died a thousand times over. From chemical attacks, and barrel bombs, and rockets, and hunger, and torture, and freezing weather. The virus can’t do more than that.” Death has become something too familiar to people in this area and they have lost the will to resist. The Syrian regime is fully responsible for that.

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PHR: What are the possible implications of COVID-19 on health workers in the northwest?

Dr. al-Khalil: The targeting of our health care has led to significant material losses. But our health workers have been hit very hard too. Some were detained, many were killed, and others left the country. Those who chose to stay behind are completely exhausted and many are starting to consider leaving. The coming period is going to be extremely challenging for them. Until now, we don’t have adequate personal protective equipment. If we see a spread of COVID-19, the majority of our health workers will become infected and we will lose many of them because we haven’t been able to provide them with the necessary gear. The consequences of losing health workers will be irreversible. There is no way we can compensate for the loss of a single doctor.

“They tell us, ‘We’ve died a thousand times over. From chemical attacks, and barrel bombs, and rockets, and hunger, and torture, and freezing weather. The virus can’t do more than that.’ Death has become something too familiar to people in this area and they have lost the will to resist.”

Imagine ten, twenty or a hundred people dying outside a hospital that just cannot give them beds, or medication, or oxygen. I can tell you, even back in the days of the regime, when we were active as doctors in Aleppo and other locations, we used to be targeted by people who thought we weren’t prioritizing their needs. The security implications for health workers of not being able to provide services will be very significant and might lead many them to decide to quit.

That being said, the volunteers who are leading the response are ethically committed to seeing it through. I work 17 hours a day and haven’t taken a day off in years. Not a Saturday, not a Sunday, not a Friday – not one day. I’m a doctor and I’ve been postponing an operation I must undergo for three years because I can’t afford to take three days off. This applies to all my colleagues here. We’re committed, but we can’t carry the whole responsibility alone.

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PHR: Can you describe your plan to respond to COVID-19?

Dr. al-Khalil: Our strategy to respond to the pandemic is multi-faceted and starts with ensuring the protection of health workers. We prioritized this point because we believe that the consequences of any blow to health workers will linger well beyond the current challenge we’re facing. The second point is concentrating on delivering care to the non-critical cases, specifically those who will need oxygen and medication. Third, we intend to focus on the social aspects of prevention – primarily on raising awareness and attempting to procure and distribute facial masks, which might be the best countermeasure in our context.

Our fourth objective is raising the capacity of the health system. We are hoping to delay as much as possible the entry of the virus into the area and to flatten its spread once it does enter so that the health system is able to cope. If we can buy time and push the apex of the spread until the summer, we might be able to learn some lessons from other contexts. We might also see that those countries that are today in the midst of their own COVID-19 crises are over them and are in a better position to offer us their support. We certainly cannot bet on the virus not making its way into the area.

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PHR: What is the worst-case scenario, in your opinion?

Dr. al-Khalil: All those in need of critical care, of ventilators, will die because of our inability to admit them and care for them. The proportion of patients who require oxygen therapy and medication will eventually need critical care because we don’t have the resources to treat them. Many of them will also die. Logically, if nothing changes, we might see up to 100,000 people die in the area.

I think that within 20 days of identifying the first COVID-19 case, our health system will collapse. When we have hundreds of patients in need of critical care at hospital doors, that flood will create massive social disturbances. We’re in a state of chaos here and there is a variety of armed groups – including extremist elements – in the area. Our medical cadre is completely exposed. I don’t how long the system can hold after we see the first death of a doctor as a result of the virus or a security incident linked to it.  

In early April, Physicians for Human Rights hosted a webinar featuring psychiatrists and PHR Board Members Gail Saltz, MD and Kerry J. Sulkowicz, MD on the mental health impacts of the coronavirus pandemic, as part of our ongoing series “Science-driven Solutions for Combating COVID-19.” Here is an extract of their discussion.

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As COVID-19 continues its relentless spread across the globe, the mental health impacts of the novel coronavirus are becoming clear. In many places, we are facing not one but two pandemics: the pandemic of COVID-19 and the pandemic of anxiety.

There are a lot of things to be anxious about: contracting the virus, an uncertain economic future, and even uncertainty itself. Anxiety compromises our ability to plan, make decisions, exercise empathy, and envision future recovery. But while it’s difficult to predict whether we will become sickened with COVID-19, coping strategies can allow us to adjust to our present situation, make good choices, and have hope for the future.

Anxiety compromises our ability to plan, make decisions, exercise empathy, and envision future recovery.

One of the best ways of coping with anxiety around life changes like this pandemic – talking to each other – is impeded by the requirements of social distancing. Yet we are still able to talk by phone and, through technology, face-to-face. We should check in on each other, on our families and colleagues. We know that human touch is hard to replace and being deprived of it has consequences. But a hug is an expression of feeling, and verbalizing these feelings – “I care about you,” “I want to comfort you,” even “I wish I could hold you” – is a profound way of injecting meaningfulness into a conversation. If people come out of this more willing to express love and vulnerability, that would be a tremendous thing.

Setting a routine and taking care of yourself at home is incredibly important. Work-from-home is grueling. You need to take breaks, walk around, put the screen away. Now is also a time to be flexible: your colleagues might be dealing with the stress of living alone, having children home from school, or living in over-crowded homes. It is essential to make room for calming techniques throughout your day to stop the accumulation of anxiety. Take some time for deep breathing, muscle relaxation techniques, or a warm bath. Thirty minutes of aerobic exercise will make a huge difference in your day.

You should also limit your intake of news. Check just one or twice a day, turn off your push notifications, and avoid social media – it fuels anxiety, and, frankly, there is a lot of misinformation going around.

Something else to keep in mind is that there has been a huge uptick in the availability of telemedicine and phone therapy services; if you feel you need professional help, you should seek it out. One question that doctors hear a lot is: am I anxious, or do I have the virus? That’s very understandable; anxiety is a physiological experience and a lot of the symptoms of coronavirus and anxiety are the same. Yet there are significant differences: one does not have a fever with anxiety, and one does not typically have a cough. If you are feeling particularly anxious and short of breath, you can use the app Pulse Oximeter to check your blood oxygen level. If you are oxygenating above 95% you don’t need to go to a hospital. Some people who feel short of breath due to anxiety, whether or not they are ill, feel reassured by being able to see that they are oxygenating well.

If you are a health care worker, it is important to recognize that this is an acutely difficult time for you in particular. We are used to being the helpers, so needing to ask for help is hard; yet it is essential that we reach out as well.

Children, too, can become very anxious, as they have experienced the same life changes in the past month that adults have. Undeniably, when your children become overwrought it makes it much more difficult for you to contain your anxiety. Helping your child starts with your own self-care, because if you are worried, your child will see your anxiety and mirror it. You can let children know what is happening in broad terms, but generally, kids want to know that the people they love will be OK. They want to feel that they are safe and that your family has a plan to ride this out together. Your child should be engaged in the work of setting up structure in your home. They should be engaging in educational activity, having structured play time, and socializing with friends – try a Zoom playdate! Get creative together.

Finally, if you are a health care worker, it is important to recognize that this is an acutely difficult time for you in particular. We are used to being the helpers, so needing to ask for help is hard; yet it is essential that we reach out as well. The heath care workers on the front lines of this pandemic need to eat healthily, get exercise, and be on a regular schedule just like the rest of the population. Social connection is vital, whether through connections at the workplace, virtual lunches, or other means. It is crucial that health care workers open up about the burdens we are carrying. Likewise, recognizing trauma in the medical staff under your supervision is critical. It is hard to see someone struggling without availing themselves of available resources. Ask your coworkers how they are doing, and if someone lets on that they are struggling, follow up. Don’t be shy about suggesting that somebody seek more treatment. Medical workers and people who have been sick in the hospital are going through extraordinary circumstances and are likely to experience acute stress reactions afterwards; the more social connection and support they can get, the less likely it is that this stress reaction will become post-traumatic stress disorder.

While the ultimate personal and societal impact of the COVID-19 pandemic is hard to predict, these are some steps we can take to mitigate the anxiety caused by the strange new reality coronavirus has brought on.