COVID-19 is the symptom. Chronic oppressive job conditions are the disease.

The COVID-19 crisis has highlighted the dysfunction of our health care systems, from dramatic racial disparities in mortality rates to the abuses of health care workers. As a health care staff working on inpatient floors during the pandemic, the medical system’s inequities have never been more clear — and they hurt the safety of both patients and health care workers.

A few years ago, I (ABO) wrote an essay on how physicians were becoming the new working class. Part 1 described the issue and was widely shared, while Part 2, addressing the solution (to organize our profession), wasn’t as popular. Since then, several voices have revived this topic and called for greater class consciousness and increased political activism.

Granted, the nation could indeed have prepared better for the pandemic. Still, an even more pressing issue right now for the professions is the way hospital management is dealing with the fallout. While there will be a lot of blame to go around once the dust settles, one thing is clear: hospitals are increasingly over-managed and under-led.

If, after years of quality improvement (QI) and medical errors “speak-up” culture, we fire the first one who points out dangerous work conditions, I am not sure that we have truly made the environment safer for patients and providers.

There are many parallels between the current COVID reality and war theaters. Health care providers are becoming the new veterans, as seen by the “thank you for your service” banners and the “heroes” slogans. The talk of selfless dedication and sacrifice, so similar to descriptions of veterans, hides the ugly reality that doctors are being sent to fight an “unwinnable war” with no preparation.

So how might we conceptualize this dynamic between management and the workforce? The concept of oppression seems very useful here: “Oppression is the systemic and institutional abuse of power by one group at the expense of others, and the use of force to maintain this dynamic.” Oppression allows others to have access to resources (e.g., protective gear, safety at home) while depriving the oppressed from such access, leaving them exposed to infection, punishment, and death.

The mental health consequences of oppression are clear: victims of discrimination, violence, and fear with no safety or security, experience increased stress and a deterioration in mental health and wellbeing.

So what do we do when people are suffering, not from clinical depression, but systematic distress due to exploitation, which cannot be addressed through individual fixes?

If what we are seeing is not clinical depression en masse, but health care staff reacting in a rational way to losing their sense of security, safety, meaning, and their jobs? What is the appropriate response?

Simply understanding that an unjust, exploitative system might cause this distress will not be sufficient in remedying the condition: one cannot be saved through awareness alone. Having an understanding of injustice will only fuel anger, which might then be used in destructive ways on a personal and professional level. The key is to direct this anger towards positive action, to use collective power to gain an advantage that secures safety and security. One can summarize the psychological processes that lead to liberation (more control over one’s life and context) under three domains: personal, relational, and political.

The personal level is quite familiar. It is the focus of the traditional mental health approach, involving practices that either treat mental illnesses or prevent and strengthen mental health and wellbeing through individual efforts regarding the self (i.e., wellness classes, meditation apps, more access to mental health programs). These are all important but not sufficient to address these issues.

The second domain is relational.

It is known that oppressive/exploitative structures often intensify the divisions within groups, as members are seen as competitors for the small number of resources available (e.g., managers getting better masks or schedules than staff or residents).

To counter such divisiveness, solidarity is crucial for mental health.

Solidarity is not just about fighting the system, but also about creating networks of people who can connect, outside their specific job description, to break the monopoly of those who control the flow of actual and social capital and who benefit from keeping the oppressed groups separate and at odds with each other.

The third domain is political.

Political work usually means the workings of the state and its various branches. It has a poor reputation in health care, in general, as a “dirty word.” Augusto Boal, the founder of Theatre of the Oppressed, conceptualized internal oppression as the “cop in the head,” regulating our approaches to the world and our imagination of what is possible through liberation.

In medicine, the guise of “professionalism” is an example of how an oppressive system has led us to believe that we ought not to advocate for our rights. It would be “unprofessional” to organize for a better health care system for both patients and workers. To work towards personal liberation, Boal calls for a transformational process to bypass the censorship of habit and find ‘antibodies’ to oppression. With this situation so clearly revealed, the COVID-19 crisis has become an unprecedented moment for physician organizing.

Where does this leave the mental health profession and their role in managing this current crisis? We are very much equipped to address individual concerns. But addressing systemic issues does not come naturally to the mental health profession, which was founded in large part on individually-based approaches.

But any approach to mental health today must recognize that if the system we work in is making us sick, then it is not enough to change ourselves.

To heal, we also need to change the system that is responsible for our distress. To relieve distress and burnout, we must promote solidarity, eliminate alienation through collective effort and personal mental health treatment. For ultimately, what is mental health work, if not a desire for people to exercise greater agency, feel in control of their professional development and improve their wellbeing?

Andres Barkil-Oteo is a psychiatrist and can be reached on Twitter @andre06511. Eden Almasude is a psychiatry resident.

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