"They were in pain. They were hollering. They were calling on God for help," Ragoonanan said. "They were vomiting, their teeth showing."
Nursing assistant Kwesi Ablordeppey said the veterans were like family to him. "One night I put five of them in body bags," he said. "That will never leave my mind."
Four years have passed, but he said he still has trouble sleeping and sometimes cries in his bedroom after work. "I wipe the tears away so that my kids don't know."
A third of health care workers reported symptoms of PTSD related to the pandemic, according to surveys between January 2020 and May 2022 covering 24,000 workers worldwide. The disorder predisposes people to dementia and Alzheimer's. It can lead to substance use and self-harm.
Since COVID began, Laura van Dernoot Lipsky, director of the Trauma Stewardship Institute, has been inundated by emails from health care workers considering suicide. "More than I have ever received in my career," she said. Their cries for help have not diminished, she said, because trauma often creeps up long after the acute emergency has quieted.
Another factor contributing to these workers' trauma is "moral injury," a term first applied to soldiers who experienced intense guilt after carrying out orders that betrayed their values. It became common among health care workers in the pandemic who weren't given ample resources to provide care.
"Folks who don't make as much money in health care deal with high job demands and low autonomy at work, both of which make their positions even more stressful," said Rachel Hoopsick, a public health researcher at the University of Illinois at Urbana-Champaign. "They also have fewer resources to cope with that stress," she added.
People in lower income brackets have less access to mental health treatment. And health care workers with less education and financial security are less able to take extended time off, to relocate for jobs elsewhere, or to shift careers to avoid retriggering their traumas.
Such memories can feel as intense as the original event. "If there's not a change in circumstances, it can be really, really, really hard for the brain and nervous system to recalibrate," van Dernoot Lipsky said. Rather than focusing on self-care alone, she pushes for policies to ensure adequate staffing at health facilities and accommodations for mental health issues.
In 2021, Massachusetts legislators acknowledged the plight of the Soldiers' Home residents and staff in a joint committee report saying the events would "impact their well-being for many years."
But only veterans have received compensation. "Their sacrifices for our freedom should never be forgotten or taken for granted," the state's veterans services director, Jon Santiago, said at an event announcing a memorial for veterans who died in the Soldiers' Home outbreak. The state's $56 million settlement followed a class-action lawsuit brought by about 80 veterans who were sickened by COVID and a roughly equal number of families of veterans who died.
The state's attorney general also brought criminal charges against Walsh and the home's former medical director, David Clinton, in connection with their handling of the crisis. The two averted a trial and possible jail time this March by changing their not-guilty pleas, instead acknowledging that the facts of the case were sufficient to warrant a guilty finding.
An attorney representing Walsh and Clinton, Michael Jennings, declined to comment on queries from KFF Health News. He instead referred to legal proceedings in March, in which Jennings argued that "many nursing homes proved inadequate in the nascent days of the pandemic" and that "criminalizing blame will do nothing to prevent further tragedy."
Nursing assistants sued the home's leadership, too. The lawsuit alleged that, in addition to their symptoms of long COVID, what the aides witnessed "left them emotionally traumatized, and they continue to suffer from post-traumatic stress disorder."
The case was dismissed before trial, with courts ruling that the caretakers could have simply left their jobs. "Plaintiff could have resigned his employment at any time," Judge Mark Mastroianni wrote, referring to Ablordeppey, the nursing assistants' named representative in the case.
But the choice was never that simple, said Erica Brody, a lawyer who represented the nursing assistants. "What makes this so heartbreaking is that they couldn't have quit, because they needed this job to provide for their families."
Brody didn't know of any cases in which staff at long-term nursing facilities successfully held their employers accountable for labor conditions in COVID outbreaks that left them with mental and physical ailments. KFF Health News pored through lawsuits and called about a dozen lawyers but could not identify any such cases in which workers prevailed.
A Massachusetts chapter of the Service Employees International Union, SEIU Local 888, is looking outside the justice system for help. It has pushed for a bill -- proposed last year by Judith García, a Democratic state representative -- to allow workers at the state veterans home in Holyoke, along with its sister facility in Chelsea, to receive their retirement benefits five to 10 years earlier than usual. The bill's fate will be decided in December.
Full retirement benefits for Massachusetts state employees amount to 80% of a person's salary. Workers qualify at different times, depending on the job. Police officers get theirs at age 55. Nursing assistants qualify once the sum of their time working at a government facility and their age comes to around 100 years. This means that Soldier's Home caretakers only get their full retirement at age 60 if they've been working there since they were 20 years old. Those who are 65 must have worked at the home since they were 33. The state stalls the clock if these workers take off more than their allotted days for sickness or vacation.
Several nursing assistants at the Holyoke veterans home exceeded their allotments because of long-lasting COVID symptoms, post-traumatic stress, and, in Ragoonanan's case, a brain aneurysm. Even five years would make a difference, Ragoonanan said, because, at age 56, she fears her life is being shortened. When asked what should be done, she said, "Help us to retire. We have bad PTSD. We're crying, contemplating suicide."
Certain careers are linked with shorter life spans. Similarly, economists have shown that, on average, people with lower incomes in the United States die earlier than those with more. Nearly 60% of long-term care workers are among the bottom earners in the country, paid less than $30,000 -- or about $15 per hour -- in 2018, according to analyses by the Department of Health and Human Services and KFF, a health policy research, polling, and news organization that includes KFF Health News.
Fair pay was among the solutions listed in the surgeon general's report on burnout. Another was "hazard compensation during public health emergencies."
If employers offer disability benefits, that generally entails a pay cut. Nursing assistants at the Holyoke veterans home said it would halve their wages, a loss they couldn't afford.
"Low-wage workers are in an impossible position, because they're scraping by with their full salaries," said John Magner, SEIU Local 888's legal director.
Despite some public displays of gratitude early in the pandemic, essential workers haven't received the attention devoted to veterans or to emergency personnel who worked at Ground Zero in the aftermath of 9/11. Talk show host Jon Stewart, for example, has lobbied for this group for over a decade, successfully pushing Congress to compensate them for their sacrifices.
"People need to understand how high the stakes are," van Dernoot Lipsky said. "It's so important that society doesn't put this on individual workers and then walk away."