The COVID-19 pandemic has affected all of our lives around the world. As surgeons, we proudly work on the front lines of any local, regional, or global disaster. We care for vulnerable and injured patients in our trauma bays and our critically ill patients in the Intensive Care Unit (ICU), regardless of their background, socioeconomic position, or COVID-19 status. During the current pandemic, we remain steadfast and dedicated to excellence in the clinical care of our patients, furthering research and evidence-informed practice while improving the surgical workplace environment by addressing issues of injustice and inequity. The COVID-19 pandemic has now forced us, as surgeons, to shift our ethical focus from individual patient-centered care to a more public health, population-centered care approach. Instead of maximizing individual patient outcomes we must instead seek to maximize outcomes for the greater population and society where we live and work. While surgical and critical care societies have been appropriately creating urgently-needed clinical guidelines (based on scarce but emerging data), there is little guidance regarding the ethics and equity population issues that surgeons face when working in this new era of COVID-19. As the authors each have a long history of equity work in their various fields, we propose an ethical framework in which to consider these issues affecting us, our patients and our larger local and global communities.
Since many of us are Acute Care Surgeons, it is important to highlight that we practice Trauma-Informed Care (TIC), which acknowledges the high prevalence of trauma in society.(1) (2) Trauma has continued during the COVID-19 pandemic, unabated throughout the country. TIC is centered around the consciousness that people come into any encounter with a set of experiences that greatly impact their ability to feel safe and to interact constructively with healthcare.
Physicians are trained in medical school to apply universal precautions. This means that we assume that all patients have been exposed to transmissible pathogens, as they may have been Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. exposed to previous trauma. Thus, TIC includes a commitment to both protect physicians from the patient with appropriate personal protective equipment (PPE) while creating a healthcare encounter that protects the patient from us by avoiding re-traumatization during the encounter. We pride ourselves in caring not just for the patient, but their families, our trainees and ourselves as we deal with our own histories of trauma while recognizing the larger historic and political structures shaping healthcare. We view TIC as the confluence of three overarching themes ( Figure 1 ). These themes are as applicable to COVID-19 disease as they are to firearm violence or other etiologies of trauma.
1. Healthcare worker wellness and mitigating moral distress 2. Societal issues of equity and inclusion
We, as a siblingship of surgeons and physicians, emphatically state the following:
a. We acknowledge the stress of working during a pandemic that increases risk to our own personal health, increases risk amongst family members and other contacts and leads to isolation from loved ones. This sentiment has been captured very well by the New Yorker April 06, 2020 cover ( Figure 2 ). HCWs are forced to make difficult ethical and moral decisions under extremely difficult circumstances that can lead to moral distress. All frontline HCWs should have easy access to emotional and psychological first aid as in any disaster zone or area. (3) Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Environmental Protection Agency after 9/11 about water and air safety at Ground Zero, which ultimately endangered the lives of frontline emergency and HCWs.(8) Similarly, we feel that the current CDC recommendations place HCWs at an increased risk of preventable illness and even death. We believe that these guidelines, which could mean the difference between the life and death of HCWs, their patients, or their families, should be biased heavily toward maximal protection versus less effective or unproven compromises.
d. As such, we call for the President of the United States to both invoke the Defense Production Act (DPA) by executive order and enforce it to direct the nation-wide manufacture in the interest of the American people of i) COVID-19 test kits, ii) ventilators and iii) PPE. We do not support inciting free-market competition or Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited.
further partisan politicization between states at this time of our national and global public health crisis. (9) We do not support inciting free-market competition between states at this time of public health crisis. The DPA will also protect citizens, state governors and county-level officials against any price gouging that is occurring by corporations when negotiating the mass purchases of the above three items.
We recognize that the threat highlighted by the Federal Bureau of Investigation of hate crimes against Asian and Asian-Americans is increasing across the United States. (10) We call for all citizens to protect each other against such occurrences by calling out and reporting hate crimes when and wherever they may occur. We are concerned that biases already inherent in our healthcare system may worsen during the COVID-19 pandemic and that freedom of speech is of paramount importance when identifying potential and real risks to public health. a. We condemn the use of racism-inciting, non-scientific terms or colloquialisms when referring to this and other pandemics, to eliminate stigmatization or blame 
Given the various, necessary shelter-in-place orders across the nation and the halting of the U.S. economy, we recognize the disproportionate economic burden that this will have on both individuals and families. We recognize that even the ability to shelter in place and Copyright © 2020 Wolters Kluwer Health, Inc. Unauthorized reproduction of this article is prohibited. Undocumented individuals, homeless and incarcerated individuals in correctional facilities are at a particularly increased risk of large-scale disease transmission and illness. We anticipate that many vulnerable populations have already been severely impacted by the farreaching effects of this pandemic due to numerous mental, physical, and financial factors.
We recommend immediate economic relief for families and individuals proportionate to their needs and economic vulnerability, and not a flat sum payment to all Americans regardless of social class or income bracket. We also call for the elimination of all structures and mechanisms of systemic racism and discrimination (for example redlining) and immediate economic redress and compensation for those most affected. a. We recognize the devastating and all too common parallel burdens of concomitant loss of employment and thus loss of healthcare insurance and access. We recommend comprehensive, free testing and medical care for all COVID-19 positive individuals without fear of subsequent economic hardship or bankruptcy.
In addition to testing, contact tracing must be prioritized and conducted by public health officials to mitigate further spread among vulnerable communities. We call for a robust, nationally-coordinated universal health care system to protect all Americans from financial ruin or disaster in times of illness, with emphasis on preventive care. We also call for a robust system of public health to protect citizens from current and future public health crises such as the COVID-19 pandemic and its possible resurgence. x. individuals struggling with mental illness or substance abuse xi. sex trade workers vulnerable to exploitation and homelessness Urgent and well-coordinated action at the local, state, and federal levels must be taken to protect these vulnerable populations to prevent the rapid spread of COVID-19 and any risk of intentional, interpersonal violence or death.
c. There will be an anticipated greater than 30% unemployment rate in the United States as a result of the COVID-19 pandemic, which will surpass the unemployment rate of the Great Depression of 1929. We support a nationally sponsored economic response plan, similar to president Franklin D. Roosevelt's New Deal almost 100 years ago, which will prioritize public work projects, financial reforms and regulations with an emphasis on economic recovery for vulnerable populations.
The COVID-19 pandemic has pushed our national and global communities to a critical and unprecedented moment for humanity. We find ourselves asking what kind of society we want for 