Beyond the lockdown we must sustain a long term culture of care for others

Last week Wuhan reported its first new cases of Corvid 19 since early April. The Economist also reports a new cluster of cases linked to nightclubs in Seoul. Disneyland in Shanghai insists that visitors must have a digital health code.

Anyone who thinks this thing will be over soon has another thing coming. Robin Swann’s announcement that testing in residential care homes (without doubt place re-infection risks are higher than anywhere) is coming in June is just a step to new normal.

This has been the weak spot in national and regional defences all over Europe, even in Sweden where their partial lockdown had given them the bandwidth to prioritise the protection of older and more vulnerable patients.

This is in part because most resources have been funnelled into the primary healthcare system, from PPE to oxygen ventilators and testing. We’ve even seen advice shift from “masks don’t make any difference” to “using anything to cover exhalation” will help.

In the east wearing masks is interpreted as a courtesy, whilst in the west, at the beginning of the outbreak (according to one Asian friend) wearing a mask on a long haul flight was likely to get a couple of free seats as people assumed you were infected.

As Atule Gawande has already noted, Culture is a huge feature of our handling and mishandling of the pandemic.  The culture he identifies is one of learning and positive re-enforcement of new norms that will have to continue long after the lockdown is over.

He talked to Anne Doyle who runs a retirement village with about 250 residents and 200 staff, and reflects on the fact that whilst the logistical considerations of PPE etc, are important, we also need to change the way we all behave not to protect ourselves…

In hospitals, we have had to learn how to bring the stringent antiseptic standards of the operating room into the professional culture of other parts of our institutions. This requires absorbing the detailed practices that keep us from transmitting germs in a given setting—like the rule at the operating table that, once you’re scrubbed in, you never let your hands fall below your waist. Even more, this requires developing norms about how to address lapses in rules, so you can comfortably call one another out when you see a standard slipping and still enjoy working together. This isn’t simple; I’ve seen surgical colleagues in the hallway pop their masks down below their noses to talk, which they never would have done across an operating table, yet I am hesitant to call out the lapse.

Culture is the fifth, and arguably the most difficult, pillar of a new combination therapy to stop the coronavirus. People tend to focus on two desires: safety and freedom; keep me safe and leave me alone. What Doyle says she needs her people—both staff and residents—to embrace is the desire to keep others safe, not just themselves. She needs them to say, “I’m worried about my sore throat, and I am going to stay home.” Or “I am O.K. with being reminded to pull my mask up.” That is the culture of the operating room. It’s about wanting, among other things, never to be the one to make someone else sick.

At Lasell Village, Doyle is doing what she can to create cultural change under pressure. She has made sure that all her staff has enough paid sick time. “Most people have a ton of sick days. For those who don’t, we make it clear that we’ll top up whatever they have in order for them to adhere to precautions around the coronavirus,” she said. She’s worked to foster an atmosphere in which everyone will take a runny nose seriously. Residents, however, often have outside aides. When it became clear to Doyle that these aides weren’t necessarily getting adequate support, she had her team track them down, and made sure they had masks and training. In March, feeling flu-like symptoms, Doyle set an example by putting herself into self-quarantine. Her symptoms worsened, and it was a full three weeks until she was able to be tested and to return to work.

Every day, there’s a new problem to solve, and she asks employees and residents alike to figure out how to rise to the challenge. “When you have a community that cares about each other, then people are interested in adhering [to the guidelines] for other people,” Doyle told me. All the effort appears to be making a difference. The frequency of cases among residents fell substantially after the initial outbreak. Lasell Village went from five cases per week down to two and then one.

This is an ongoing fight that will not require all of us to remain indoors permanently, but which does require us to continue taking the virus seriously long after the personal danger to each of us recedes.

As I’ve noted before… good habits are hard to acquire, and the bad ones hard to get rid of. It’s not about saving ourselves so much as not passing it on to others.

Photo by sasint is licensed under CC BY-NC-SA