Moral Injury on the Frontlines in Public Health: Balancing the Needs of Our Communities and Ourselves

Moral Injury on the Frontlines

Today, as the pandemic enters yet another phase, the frontline public health workforce faces a different threat: moral injury.

The COVID-19 pandemic has been battering the hearts and souls of public health workers for over a year and a half. Many of us on the frontline felt a hint of relief when we were able to see the Herculean vaccination efforts we undertook throughout the late winter and all through spring pay off. As summer emerged, our case counts dropped to manageable levels, we took off our masks, and we began to significantly re-engage in non-COVID 19 activities. Then Delta variant hit… Yes, we knew it was coming, but the ferocity and the velocity with which it has hit, even in those communities we worked so hard to vaccinate, has taken many of us off guard.

In the past year, frontline public health workers have endured extraordinarily long hours, personal threats, and an overwhelming sense of responsibility for the health of those we serve. In June 2021, an MMWR article outlined the toll that the pandemic has taken on the mental health of public health workers including depression, anxiety, post-traumatic stress disorder, and suicidal ideation. Furthermore, how many of us have seen our beloved colleagues retire or resign, burned out by the seemingly never-ending demands of their positions? Today, as the pandemic enters yet another phase, we face a different threat: moral injury.

In healthcare, there has been growing attention to the concept of “moral injury,” a term that refers to “the psychological, behavioral, social, and/or spiritual distress experienced by individuals who are performing or exposed to actions that contradict their moral values.” It is distinct from “burn out.” While the concept of “occupational moral injury” may have originated with combat medicine and treatment of war veterans, the COVID-19 pandemic has brought attention to its applicability to other fields.

With respect to moral injury in public health, public health workers are trained to listen to learn, and to do so without judgement so that we can fully engage and be the trusted chief health strategists our communities need and deserve. Throughout the COVID-19 pandemic, the concurrent misinformation pandemic has significantly contributed to moral injury as public health workers struggle to try to understand and connect with people who have strongly held beliefs that directly contradict what we know to be true. We know our job is to meet people where they are, yet in our core, today many of us are outraged. We should not be here. We should not be seeing record numbers of children being hospitalized with COVID-19. We should not be running out of ICU beds. We should not be reassembling our army of case investigators and contact tracers. And we should not have to endlessly defend the tools of our trade: vaccinations and community mitigation strategies.

But we are here. As we struggle with the mental health toll of the pandemic, we are planning how we will efficiently, effectively, and safely scale our vaccination efforts back up to be able to offer a third dose of mRNA vaccines to the millions of Americans who may qualify for and want it when it is approved for the general population. And we are so thankful that our supply and our capacity have dramatically improved. We are anxiously awaiting approval to be able to vaccinate our children younger than 12 years. And we are thankful for the partnerships that we have built and solidified with our schools and our health systems. We still have so much work ahead of us and it is overwhelming. Under the extremely challenging circumstances in which we currently live, it is natural for us to feel angry, hopeless, helpless. We are tired. We are conflicted. We are injured. So where do we go from here?

Moral injury is real. Some suggestions for action from experts in moral injury include:

  1. Acknowledging, naming, and recognizing moral injury.
  2. Providing safe spaces for our workforce to be able to talk about their anger, frustration, distress, conflict.
  3. Providing social and psychologic support to our team members.
  4. Encouraging supervisors to proactively check-in with their teams.
  5. And facilitating and encouraging our teams to prioritize self-care.

I am not good at self-care. I am guessing many of you are not either–we have made a career out of caring for our communities. A week ago, I took a deep breath and began my morning with sun salutations with a renewed commitment to self-care. It’s only been a week, but I am optimistic that this step is the beginning of a journey to better self-care. As we talk to our community members about the importance of getting vaccinated for themselves and their loved ones, let’s consider how we re-frame self-care. We owe it to ourselves, to our loved ones, and to our co-workers to keep working on it. We are in the business of prevention, promotion, and protection; let us practice what we preach when it comes to moral injury.     

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Author Profile

Cynthia Morrow
Dr. Cynthia Morrow is the health district director for the Roanoke City and Alleghany Health Districts in Virginia and the co-Domain leader for Health Systems Science at the Virginia Tech Carilion School of Medicine. Previously, she was the Commissioner of Health for Onondaga County, NY and the Lerner Chair for Health Promotion at Syracuse University. Her prior academic positions include Professor of Practice in the Department of Public Administration and International Affairs at Syracuse University and an assistant professor with the Center for Bioethics and Humanities as well as with the Department of Public Health and Preventive Medicine at Upstate Medical University. She is a consulting editor for the Journal of Public Health Management and Practice and is also a co-editor/co-author of five books, including Essentials of Public Health, Fourth Edition (2020); Public Health: What it is and How it Works,7th Edition (2020); Bioethics, Public Health, and the Social Sciences for the Medical Professions (2019); JPHMP’s 21 Public Health Case Studies on Policy & Administration (2018); and Public Health Administration: Principles for Population-Based Management (2008). She is a graduate of Swarthmore College (BA) and Tufts University School of Medicine (MD, MPH).

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