Palliative Care in Natural Disaster Response

Reports for humanitarian practitioners & policymakers

Dying alone is hard anywhere in the world”: Palliative care in natural disaster response 

“Dying alone is hard anywhere in the world” (PDF): Palliative care in natural disaster response 

Natural Disasters – Report and Recommendations”: Palliative care in natural disaster response. A research snapshot

 

Key Findings 

The following key findings emerged from the natural disasters sub-study: 

  • Participants described palliative care as a key component of comprehensive humanitarian healthcare involving companionship and psychosocial support for patients and their families, dignity in death and dying, and the management of pain and other distressing symptoms.
  • Barriers to the provision of palliative care in natural disaster settings included damage to health structures; inadequate resources; disrupted supply chains; the invisibility of patients with palliative needs; differences in local cultural norms; the prioritization of acute needs; and challenges of mobility and access to care. 
  • Despite existing limitations, respondents agreed that humanitarian aid organizations have an ethical obligation to provide palliative care.
  • Integration of palliative care may play a role in alleviating distress among disaster responders, particularly those from affected communities. 
  • Participants emphasized that palliative care must be integrated into disaster planning from the beginning; otherwise, it is likely to be neglected during a crisis. 
  • There was a clear consensus concerning the need for palliative care training and protocols to guide practice in natural disaster settings. 

 

Overview: Focus on Natural Disasters Settings  

According to the World Health Organization, a natural disaster is “an act of nature of such magnitude as to create a catastrophic situation in which the day-to-day patterns of life are suddenly disrupted and people are plunged into helplessness and suffering, and, as a result, need food, clothing, shelter, medical and nursing care and other necessities of life, and protection against unfavourable environmental actors and conditions.” [1] While we use the term “natural disasters” in this sub-study, it is widely recognized that the impacts of natural disasters such as earthquakes and tsunamis are shaped by human activity, degrees of vulnerability of certain communities, and action or inaction to mitigate natural hazards. [2] The annual death rate due to natural disasters is around 90,000 people worldwide, with approximately 160 million others also affected. [3] Over the last 10 years, 95% of the nearly two billion people affected by natural disasters were affected by a weather-related event. [4] 

Like conflict settings and public health emergencies, natural disasters can overwhelm the capacity of health systems to meet the needs of the general population. This constitutes a humanitarian crisis, wherein the health and well-being of large groups of people are threatened due to factors such as lack of access to care, infrastructure damage, and resource scarcity. In recent years, many nations, including Haiti, Nepal, Pakistan, India, and Japan have experienced significant losses of life and devastation to infrastructure due to natural disasters. 

Natural disasters, including famine, can exacerbate conditions in regions experiencing conflict, and are often a factor in the development or escalation of violence. Likewise, ongoing conflict in disaster-affected countries can further limit or hinder disaster response. This perpetuates a continuous cycle of poverty and instability for such countries and constrains the possibilities for disaster preparedness and response by local and international care providers.

 

Natural Disasters Sub-Study Objectives 

  1. To develop evidence clarifying the ethical and practical possibilities, challenges, and consequences of palliative care needs following natural disasters. 
  2. To inform realistic, context-sensitive guidance, education, and practices for the provision of palliative care during natural disaster response. 

 

Summary of our Approach

In-depth, semi-structured interviews (N = 20) were conducted with international and local healthcare providers who had responded to a variety of natural disasters. For this sub-study, we included natural disasters that often strike without warning (earthquakes, landslides, and flash floods); those with a short warning time frame (tsunamis, hurricanes, typhoons and flooding); and protracted or foreseeable disasters (famine). The relationship between conflict and natural disasters was also explored. 

Natural Disasters Team 

Team Lead:  

RYantzi_photo

 

Rachel Yantzi RN, MSN/MPH – PhD student in Health Research Methodology, McMaster University, Hamilton, Canada 

 

IMG_7773.jpeg

 

Takhliq Amir, BHSc – MD student at the Michael G. DeGroote School of Medicine, McMaster University, Hamilton, Canada 

 

Matthew Hunt, PhD, PPT – Professor, School of Physical and Occupational Therapy, McGill University, Montreal, Canada  

Lisa Schwartz,PhD – Professor & Arnold L. Johnson Chair in Healthcare Ethics, McMaster University, Hamilton Canada 

Sonya de Laat, PhD – Academic Advisor & Global Health Scholar, Global Health Program, McMaster University, Hamilton, Canada 

Carrie Bernard MD MPH CCFP FCFP – Assistant Professor, Department of Family and Community Medicine, University of Toronto, Toronto, Canada 

Laurie Elit, MD – Professor of Obstetrics and Gynecology, McMaster University, Gynecologic Oncologist, Hamilton Health Sciences, Hamilton, Canada 

Corinne Schuster-Wallace, PhD – Associate Professor, Faculty of Geography & Planning, University of Saskatchewan, Saskatoon, SK

Lynda Redwood-Campbell, MD, FCFP, DTM&H, MPH, Canadian Red Cross International Emergency Response Unit, Professor of Family Medicine, McMaster University, Hamilton, Canada

 

Outputs 

Conference Oral Presentations: 

  • Schwartz L, de Laat S, Yantzi R, Nouvet E, Bezanson K, Amir T, et al. Refugee experiences of palliative care in humanitarian settings: Views from conflict and disaster. 30th Annual Canadian Bioethics Society Conference; 2019 May 22-24; Banff, Canada.  
  • Yantzi R. Dying in the margins: Palliative care, humanitarian crises and the intersection of global and local health systems. Presented at: 16th Annual HEI Research Day, McMaster University; 2019 Mar 14; Hamilton, ON.  

Conference Poster Presentations: 

References 

  1. Assar, M. Guide to sanitation in natural disasters. World Health Organization. 1971. Available from: https://apps.who.int/iris/bitstream/handle/10665/41031/10678_eng.pdf;jsessionid =890EB054FAB45D038B5BC2F479F6E813?sequence=1 
  2. World Health Organization. Definitions: emergencies. 2020. Available from: https://www.who.int/hac/about/definitions/en/ 
  3. World Health Organization. Environmental health in emergencies. 2020. Available from: https://www.who.int/environmental_health_emergencies/natural_events/en/ 
  4. International Federation of Red Cross and Red Crescent Societies. (2018). World disaster report: Leaving no one behind. Available from: https://media.ifrc.org/ifrc/world-disaster-report-2018/ 

Online Seminar – Beyond “Good Enough”: How to Engage Communities with COVID-19 Research Quickly and Effectively

13:00-14:00 GMT+1 (London), June 15th, 2020

Register here: Zoom Registration – Beyond “Good Enough”

This seminar, chaired by HHE’s Dr. Lisa Schwartz will explore the response to COVID-19 and the need for rapid research to develop vaccines, treatments and other kinds of urgently needed knowledge. Previous public health emergencies have demonstrated that good community engagement helps move research forward, ensures it is feasible, relevant, and accepted, and that its findings are taken up. But how can it be done quickly, and in the midst of lockdowns? On this webinar we will explore these questions, and hear from the experts how to bring Good Participatory Practices to COVID-19 research.

Click here for more information

June9WebinarScreengrab

New Report: “Dying alone is hard anywhere in the world” – palliative care in natural disaster response

READ THE FULL REPORT: Natural Disasters – Report and Recommendations

In response to the emerging recognition of the need for palliative care, the Humanitarian Health Ethics Research Group undertook a program of research in order to understand the ethical dimensions of palliative care during humanitarian action. Here, we present key findings of the sub-study focused on natural disaster settings that was part of this larger program of research. Through this series of reports, we hope to present the perspectives of those engaged in humanitarian healthcare firsthand – as patients, host community members, policymakers, and local and international healthcare providers – in order to clarify how humanitarian organizations and humanitarian healthcare providers might best support ethically and contextually-appropriate palliative care in a range of humanitarian crises.

KEY FINDINGS:

  1. Participants described palliative care as a key component of comprehensive humanitarian healthcare involving companionship and psychosocial support for patients and their families, dignity in death and dying, and the management of pain and other distressing symptoms.
  2. Barriers to the provision of palliative care in natural disaster settings included damage to health structures; inadequate resources; disrupted supply chains; the invisibility of patients with palliative needs; differences in local cultural norms; the prioritization of acute needs; and challenges of mobility and access to care.
  3. Despite existing limitations, respondents agreed that humanitarian aid organizations have an ethical obligation to provide palliative care.
  4. Integration of palliative care may play a role in alleviating distress among disaster responders, particularly those from affected communities.
  5. Participants emphasized that palliative care must be integrated into disaster planning from the beginning; otherwise, it is likely to be neglected during a crisis.
  6. There was a clear consensus concerning the need for palliative care training and protocols to guide practice in natural disaster settings.

Suggested citation: Amir, T., Yantzi, R., de Laat, S., Bernard, C., Elit, L., Schuster-Wallace, C., Redwood Campbell, L., Hunt, M. & Schwartz, L. (2020). “Dying alone is hard anywhere in the world”: Palliative care in natural disaster response. Isis A. Harvey designer. Available online at http://www.humanitairanhealthethics.net.

Moral injury and COVID-19

By Omar Mahboob BMSc and Elysée Nouvet PhD

On April 25, 2020, John Mondello, a recently graduated Emergency Medical Technician stationed in New York City, died by suicide. Mondello was on the front lines of the COVID-19 response as the city faced an overwhelming number of cases and fatalities. Prior to passing, Mondello had described experiencing anxiety to his friends and colleagues, which he attributed to the high call volume, and the witnessing of so much death (1). 

As many countries begin re-opening from their lockdowns, and cases are once again projected to rise, it is imperative to understand the experiences of front-line workers providing care. Over the past month, a team of researchers from Western University, the University of Turin, and McMaster University have been speaking with individuals on the front lines of the pandemic response across the globe. The larger purpose of the study is to: elucidate plans for and concerns related to the provision of care to patients at risk of dying, should critical care needs outweigh available resources;  to discern if and how such triage guidance should be communicated to affected populations; and, identify key social and cultural considerations for this communication and for the provision of care to the critically ill during this pandemic. Although we are in the primary stages of our analysis, and it is too early to make decisive statements on our findings, one thing is clear: many of the participants have described their own stress or expressed concerns regarding the psychological impact associated with being on the front lines during this pandemic. 

Even from the relative comfort of our homes, it is not difficult to imagine why that would be the case. With so many patients in need, hours have been longer than usual for many healthcare workers. The atmosphere is tense as stakes are high: for patients, for providers, for healthcare facilities, for governments and communities. In high-income countries, most have never witnessed so many deaths in such a short time period. Watching patients come in, grow sicker, and in some cases even die without family present feels bad. Personal protective equipment is limited in many contexts. This means that with every shift comes a risk of infection, and passing on that infection to loved ones at home (or sacrificing time with family to limit their exposure and keep them safe). Countless news reports, especially out of Italy in March of this year, and then New York City in April, have recounted the heavy and sometimes psychologically shattering decisions faced by front line providers confronting critical care resource shortages. The need to decide or implement decisions that involve denying potentially life-saving interventions to some patients is not an experience many have faced in our study, but it is one they can imagine and dread. Patient prioritization decision-making, where needs outweigh resources, presents a particular risk of moral injury. 

Moral injury is a term defined by Litz et al. (2009) as an experience that encompasses the following: “[p]erpetrating, failing to prevent, bearing witness to, or learning about acts that transgress deeply held moral beliefs and expectations” (2). Although the term was first applied in a military context, extending its use to this pandemic can provide valuable insight into the potential concerns embedded within triage decision-making processes.

In a healthcare setting, this suggests that those involved in or witness to the prioritization of certain patients for treatment, to the exclusion of others whom they believe could benefit, are at an increased risk of moral injury. Allocation of limited resources, such as nursing staff and ICU-care for COVID-19 patients, has been and continues to be a reality in many localities. For critically ill patients, access to immediate medical attention and/or ventilator care can be the difference between life and death. Although some organizations and experts have released guidance on who has priority for a ventilator if and when the need surpasses capacity (3), guidance does not release healthcare teams at the bedside from the burden of ultimate decision-making and action.  Beyond the bedside, there is the impact on the patient and their family. The moral implications and potentially injurious consequences of making or being a party to such decisions is a reality for many health care workers on the front lines of this crisis. A May 13 2020 WHO report on the mental health impacts of COVID-19 cites studies in Canada, China, and Pakistan confirming increased self-reported depression, anxiety, insomnia, and psychological needs (4).

Across the globe, communities are showing their appreciation for health care workers on the front lines. Through the blaring of horns, the clapping and banging of pots and pans, the message is unmistakable; many are willing to stand with and for those who are risking their lives on the front lines. These gestures are important; however, they are not enough. Understanding how the provision of care during this pandemic affects different health care providers and investing in ongoing psychological support must also be prioritized. 

References:

  1. Edelman S, Moore T, Narizhnaya K, Balsamini D. EMT John Mondello kills himself after less than three months on the job [Internet]. New York Post. 2020 [cited 2020 May 20]. Available from: https://nypost.com/2020/04/25/nyc-emt-commits-suicide-with-gun-belonging-to-his-dad/ 
  2. Litz BT, Stein N, Delaney E, Lebowitz L, Nash WP, Silva C, et al. Moral injury and moral repair in war veterans: A preliminary model and intervention strategy. Clinical Psychology Review. 2009 Dec;29(8):695–706.
  3. Emanuel EJ, Persad G, Upshur R, Thome B, Parker M, Glickman A, et al. Fair Allocation of Scarce Medical Resources in the Time of Covid-19. N Engl J Med [Internet]. 2020 Mar 23 [cited 2020 May 20]; Available from: https://doi.org/10.1056/NEJMsb2005114
  4. United Nations. Policy Brief: COVID-19 and the Need for Action on Mental Health [Internet]. 2020. Available from: https://www.un.org/sites/un2.un.org/files/un_policy_brief-covid_and_mental_health_final.pdf

picture (1)

Omar Mahboob completed a BMSc in Interdisciplinary Medical Sciences from the Schulich School of Medicine and Dentistry at Western University. He is a research assistant with the Humanitarian Health Ethics research group.

Dr. Elysée Nouvet is a medical anthropologist and assistant professor in the School of Health Studies at the University of Western Ontario, Canada. She has a particular interest in the moral experiences and ethics of care and research in humanitarian and public health emergencies.

COVID-19 in Ethiopia: Challenges, best practices, and prospects

IMG_3714 (1)

By Gojjam Limenih

Gojjam Limenih, is a senior lecturer and researcher of Public Health, The University of Gondar and an Advisory Council Member, Ministry of Science and Higher Education of Ethiopia (MoSHE). 

 

Ethiopia may not yet have witnessed the worst of this pandemic. In times of health crisis, such as the COVID-19 pandemic, we need our health systems to be working at their very best. This means that we need to trust our health system; health workers must have the equipment they need to do their job while protecting themselves and others, and healthcare must be accessible for all. Ethiopia’s health system and infrastructure is weak. The latest readiness assessments from the WHO indicate that there is extremely limited intensive care capacity for the treatment of severe COVID-19 cases if the surge comes[4]. The ability to treat severe forms of COVID-19 will depend on the availability of ventilators, electricity, and oxygen, all of which are scarce in Ethiopia. As the Ministry of Health reports, currently, there are only 600 ventilators for over 100 million people [1,2]. Even securing a supply of personal protective equipment (PPE), the first line of defence at the individual level, remains a major challenge.

Strategies and innovation in the face of the unprecedented    

The challenges our country faces in mitigating the spread of COVID-19 are enormous – however, there have been a range of proactive and coordinated efforts to respond to the pandemic. The government has been mobilizing different stakeholders and devising strategies to contain the virus through aggressive health measures and law enforcement. In order to reverse the rising numbers of infections, broader suppression measures were put in place, including closing schools and universities, prohibiting gatherings and promoting “social distancing” to the entire population. The current focus is reducing transmission of COVID-19 through individual and population-level measures, including personal hygiene, physical distancing, testing, isolating and tracking contacts and travel restrictions.

Ministry of Health (MOH) and National Public Health Institute (EPHI), provide regular updates (i.e. held press conferences) to inform the public. The Ministry is also working with a network of experts to coordinate regional surveillance efforts, diagnostics, clinical care and treatment, and other ways to identify, manage the disease and limit transmission. But hospitals are struggling to cope with COVID-19 as they face bed shortages, ICU equipment and testing facilities. To ease this pressure, shelter hospitals are ready and taken as a crucial step to isolate, treat, and triage patients with mild to moderate COVID-19. Hence, large, temporary hospitals are prepared by converting public venues, such as exhibition centres, into health-care facilities to isolate patients with mild to moderate symptoms of an infectious disease from their families and communities, while providing medical care, disease monitoring, food, shelter, and social activities. In Addis Ababa, Millennium Hall and other large avenues are ready for this purpose, which will help to isolate and treat more people who are infected. Many investors are lending their hotels to be prepared as quarantine centres and hospitals which will be crucial to contain the virus. 

Social cohesion and social gatherings are of great importance for Ethiopian society. Churches and Mosques are now closed to limit the spread of the virus. Instead, the government and religious authorities have worked together to launch a television program for all major religions to broadcast their spiritual education so that their followers can continue to observe their faith while staying at home. Nevertheless, the battle is real to keep people at home when the one thing that is so meaningful to most—their spiritual engagement— has been taken away by the pandemic. 

The arrival of the virus in Ethiopia has also given rise to local innovation. There are promising efforts to promote home-grown production of PPE to manage the spread of the virus. Factories in Addis Ababa and other manufacturing hubs have started producing alcohol-based cleaning solutions and hand sanitizer for distribution to high-risk areas. Textile factories are now focused on producing more face masks. Most of the universities are producing hand sanitizers and distributing them to the nearby communities. Researchers and students at Addis Ababa Technology University and manufacturers are working to assemble ventilators from locally sourced components. Notably, all these fast-moving efforts help to stay ahead of the virus long enough to put into place testing, contact tracing, and isolation, as well as temporary intensive care facilities. However, there is a need to better coordinate these scattered innovations towards the goal of greater long-term effectiveness and efficiency in fighting against COVID-19.

Recognizing limitations and uneven impacts

The present efforts to limit the spread of the virus are very encouraging. However, physical distancing and hand washing, globally adopted interventions to combat the spread of COVID-19, remain a major challenge in the context of overcrowding, poverty, and weak health-care systems.

The different measures in place are also urban-centric educational campaigns through media outlets that don’t consider the reality of rural society. It is only those with the privilege of access to radio and television that may hear about coronavirus risks, but not in great detail. Reaching out to the most vulnerable population in rural areas is vital. 75% percent of the Ethiopian people live in scattered rural villages. It requires special attention to prevent the spread before it gets to the villages. If it gets there, there may not be much room for intervention. Access to safe water and sanitation is low in Ethiopia, which inhibits people’s abilities to limit the infection. For now, the isolation of rural villages might shield them from the worst of COVID-19. But the absence of facilities and services makes the possibility of an outbreak in such areas particularly troubling. 

Another challenge for Ethiopia concerns the feasibility of the pandemic suppression strategies being applied. While Ethiopia didn’t decree a complete lockdown, forcing all but the most essential businesses to close down or operate online makes sense to control the spread. But such approaches will hit some people much harder than others. Self–isolation and staying at home mechanisms work very well to a certain extent if there is regular money coming in, but it doesn’t work as well when so many are living on the edge of poverty. Poverty maintains its deep grip. Many live on what they earn each day, and won’t eat if they can’t work. 

The pandemic has left many Ethiopians with the unenviable choice of either feeding their families or protecting them from COVID-19. The problem with approaches that do not take into account inequities is that these can end up limiting sustainable interventions. Evidently, more community engagement to develop culturally and contextually feasible health promotion activities is crucial in the fight against a disease such as COVID-19 and beyond. 

While infection control and mitigation strategies have uneven impacts across Ethiopian society, the COVID-19 pandemic is underlining the fragility of Ethiopia’s health system. Access to basic health services remains the exception rather than the norm. Access to health care is severely limited, especially in rural areas. The spread of COVID-19 in Ethiopia is as much the product of its fragile health system and social inequalities as it is about epidemic dynamics. 

The pandemic has created social panic, as contagious and dangerous as COVID-19 itself. As the sharp increase in infections is observed, worries ranging from the ability of strained healthcare systems to handle a severe outbreak, to the effect of the restrictions will have on those in the informal economy, play on people’s minds. Unless properly handled, the situation will create social unrest in the near future. COVID-19 is profoundly affecting people’s finances, with mental, physical and social health implications that will linger for years to come. As we anticipate the long-term social, economic and health effects of the pandemic, Ethiopia needs to address vulnerability and inequity to ensure communities rebound. 

The grand lesson? COVID-19 has presented the world with myriad opportunities for revising, rebuilding and renewing health systems. What we need now is a firm resolve and global action to rectify inequity. While it is hard to overhaul systems in the middle of a crisis, it is evident that health system strengthening in Ethiopia has to be a top priority. It is an unprecedented opportunity for the country to dig deeper into what really needs to be done, for the future health of Ethiopian society.

References

  1. Ethiopian public health Institute COVID-19 daily update (EPHI), www.ephi.gov.et May 17 2020.
  2. Ethiopian Ministry of Health COVID-19 daily update; www.moh.gov.et/ejcc/en, May 17 2020
  3. Africa Joint Continental Strategy for COVID-19 outbreak: AU, Africa CDC, 2020 
  4. WHO COVID-19, situational report, 1-3  www.who.int/emergencies/diseases/novel-coronavirus-may 8, 2020/situation-reports

 

Collateral impacts of Covid-19, or, The Forgotten 

April 17, 2020

By: Nago Humbert (Translation from the French by: Elysée Nouvet)

In the midst of this pandemic, as is the norm in humanitarian catastrophes, those suffering from chronic illnesses (diabetes, pulmonary disease, hypertension, kidney failure, mental health, kidney) or cancer often pay the heaviest price. Those responsible at political or public health levels constantly refocus our attention on the immediate and newest catastrophe, and in the process so many other and previously at-risk populations become “the forgotten”.

It is crucial to remember that despite the public health emergency provoked by Covid-19, and the considerable financial and social means activated (with reason) to combat its impact on global health, many have entered this emergency already managing complex health issues. Their precarious health status, their risk of death, their suffering in some cases, predates Covid-19. We have not heard from this population enough in the media. We have not, arguably, been thinking globally even in the midst of a global health emergency.

What is the impact of quasi-confinement, if not imposed isolation and quarantine, on those already seriously ill, frail, or medically vulnerable, before this emergency? What is the impact on this population, of messages from the authorities and experts related to the responsibility to stay home, the possibility or reality of triaging who will get access to hospitals? What is happening to ensure ongoing supply of life-saving medications, such as insulin, or supplies to those who are dependent on these in their homes, especially in low- and middle-income countries where patients and families may have relied on public transit or income from now interrupted wages, to secure these? What support is being provided to families and communities in the midst of lock-downs or risks of links in chains (neighbors, family) of support being unable all of sudden to provide the day to day or weekly care they have? 

Medically, we can expect pandemic limits on healthcare services to reverberate in the short and long term. Such impacts were well documented during the Ebola outbreak in West Africa, and this time it is health jurisdictions everywhere that will feel those reverberations.  The impact of interrupting standard but efficient diagnostic, preventative, or therapeutic procedures such as mammograms and colonoscopies, may reverberate for years to come at a yet to be measured cost, such as reduced early detection and treatment of common cancers. For some, there are more immediate impacts and risks of increased pain, as sometimes life-transforming surgical procedures, such as hip and knee replacements, are on hold. For those already at risk of dying from chronic disease before the pandemic, added may be the anxiety of dying alone, since families are not allowed to visit their loved ones at their home, in nursing homes, or in intensive care units.

How information is presented and disseminated during this major public health and social crisis is also troubling to me. Media is focused almost entirely on the pandemic. Radio and television, in Switzerland as in France, seems to have only one story.  What, other than provoking and maintaining a generalized anxiety, is being accomplished by running images such as those coming out of Bergamo at the end of March, or ICUs in Swiss hospitals non-stop? I pose the question without having the answer. I wonder: “Should we not limit images and reports from hospitals to that which is strictly necessary to public health purposes? For example, key information about how to prevent further spread of Covid-19, and thus limit further cases? While internationally, where Covid-19 remains to hit as hard as here in Switzerland, mass depiction of healthcare provider distress and overwhelmed hospitals may serve as an important warning, what do these stories and images accomplish, at the local level, during the pandemic? I am not one for censorship, and yet I do wonder what exactly such stories of raw grief, of body bags, and abandoned patients produce? There is one thing these images from pandemic epicentres produce. With the hypervisibility of pandemic horrors, what we have seen is the eclipsing of medical conditions and biomedically dependent lives. These were rarely if ever media-worthy, but this cannot justify their total erasure.

I cannot finish these few reflections on the collateral effects of this pandemic, without thinking of the vulnerable populations, particularly those in Africa, who will pay a double price in this disaster. This is, on the one hand, because of the lack of health structures, means, and health personnel. It is also, however, due to so many comorbidities including  poverty (even if poverty is not in itself a disease) endemic to so many on the African continent. The risk of social abandonment of those most vulnerable is both global and local. 

Prof Nago Humbert is Adjunct Professor in the Department of Pediatrics of the Faculty of Medicine of the University of Montreal, and Founding President of Médecins du Monde Switzerland. He is a consultant in pediatric palliative care and he is also President of the French-speaking Network in pediatric palliative care. 

 

Virtual Conference: Resisting Borders

Abstract Submissions: https://resistingbordersconference.wpcomstaging.com/call-for-abstracts/

Refugees and many migrants suffer from limits on their abilities to move around the world, even in pressing or urgent circumstances. They are often forced to leave their homes for reasons beyond their control, including war and civil unrest, political and religious persecution, economics, or famine and other natural or man-made disasters. Once displaced, whether internally or externally, they face pressing needs for food, water, shelter, and health care. Local governments, international agencies and non-governmental organizations often struggle with providing for their needs, particularly in resource-poor regions of the world. Recent socio-political changes in the United States, Western Europe and elsewhere have placed additional restrictions on the rights of migrants and refugees.

To explore these and overlapping issues, in solidarity with these refugees and migrants, on June 15th, 16th, 17th and 18th 2020, 7 am – 9 am Eastern Standard Time, we hosted a no-travel virtual conference to explore the ethical, legal, philosophical, and social issues associated with refugee and migrant health in a world of economic, geopolitical, and psychological borders.

In the coming weeks and months, this website will be updated with more information from the conference. Please note that the submission must be made before May 1st , 2020.

If you have any questions about the conference, want to register and/or participate, please send an email to ieb@unige.ch

Triage and COVID-19: global preparedness, socio-cultural considerations, and communication

Principal Investigators: Elysee Nouvet PhD, Lisa Schwartz PhD

Link to Survey: https://uwo.eu.qualtrics.com/jfe/form/SV_e2QyBOV2dBa9ECp

Triage – The process of deciding the order of treatment of a large number of patients based on the severity of each case. In severe cases can result in treatment of only the sickest due to scarcity of resources.

This study aims to understand (1) what health care workers consider crucial to the
treatment of patients that will not be prioritized for care during the COVID-19 pandemic, (2) if and how such triage plans will be shared with the affected populations, as well as (3) what social and cultural considerations are important during such communication. We will be conducting virtual interviews with 50 healthcare workers around the world that are involved in triage guideline implementation during the current COVID-19 pandemic. Alternatively, participants can submit written reflections to key questions via LimeSurvey. Descriptive analysis will be employed to identify patterns and differences in the data collected. An open-access report will be published with the results and a webinar produced in partnership with the World Health Organization (WHO) Global Outbreak Alert and Response Network (GOARN) Research working group. These findings will help healthcare organizations and governments across the world develop and implement triage guidelines and relevant communication strategies that take into account contextual differences. This study is a collaboration between Western
University, Humanitarian Healthcare Ethics Research Group, and the WHO COVID-19 social sciences research committee.

 

Shifting Trust in Outbreak Control

March 14, 2020

Sekou Kouyaté (MA) and Elysée Nouvet (PhD)

COVID-19 will not spare Africa. Many of the continent’s health systems are severely under-resourced. These are overwhelmed in the face of outbreaks. Political leaders and individuals responsible for the health of Africans have good cause to worry in the face of this new threat. But for the more general population, at least in Guinea, news of COVID-19 is provoking a different sort of reflection as well. 

Coverage of today’s global pandemic in this African country is a clear reminder of the 2013-16 Ebola Virus Disease (EVD) epidemic. On August 14, 2014, the Guinean government declared a state of public health emergency. Socio-economic consequences were immediate and dramatic. These included a reduction of flights coming into the country, the closure of businesses, the departure of European expatriates, and, with the consequent slow-down in economic activities and lay-offs in the mining sector. This was a period of undeniable hardship. Some did not accept this hardship as necessary. Many viewed the WHO guidelines for epidemic control that were implemented here as exaggerated and discriminatory:  “It’s because we’re Africans”. Some rejected the measures on the basis of those implementing these at the national and sub-national levels : representatives from the national government, public health authorities, the army responsible, foreign NGOs. In Guinea, as in many countries, trust in national and global authorities is consistently fragile. This is the result of several factors, including long-standing political and social divisions, and histories of colonial and outsider domination and exploitation. 

There is reason to be hopeful that trust of national public health infection control strategies will be different with COVID-19.  We have noticed in the last weeks that many of our Guinean colleagues and, in the case of the first author, co-citizens, are remarking on the outbreak control measures taken first by China, neighbouring countries of China, and now by an increasing number of countries in the face of the very real COVID-19 pandemic. What is underlined as notable is that these measures replicate those imposed in West Africa during Ebola: quarantine, reduced flights, limits on the movement of individuals out of affected areas, bans on public gatherings above certain numbers, closure of schools, universities, and places of worship. This is being interpreted and held up by many in the country as a powerful truth: such measures were never reserved for Africans. The dramatic response to COVID-19 by countries far from Africa – Italy, Canada, China – may do much more than curb this pandemic. Such measures, witnessed worldwide, may shift in significant and lasting ways narratives of distrust towards epidemic control measures where these exist.

As of March 12th, Guinea has confirmed its first COVID-19 case.  Adherence to infection surveillance and control measures will be key to what happens next. Hopefully, these measures will be recognized in Guinea and elsewhere as necessary, rather than unfair or duplicitous. The populations of countries like Guinea know what stands to be lost under such trying times. They are familiar with recommendations to limit the spread of the disease. It is more than a matter of telling the mice, “The cat is on its way, positions everyone!” Trust is key.  

 

Sekou Kouyate is a social anthropologist and project manager with the Humanitarian Health Ethics research group. He holds a Masters in anthropology and a Masters in development. He is based at the Laboratoire Socio-Anthropologique de la Guinée, in Conakry. 

Elysée Nouvet is an anthropologist and assistant professor in the School of Health Studies at the University of Western Ontario. She is a member of the Humanitarian Health Ethics Research Group, and an advisor to the World Health Organization Social Sciences Research Working group (good participatory practices) for COVID-19.

References:

  1. Wilkinson A, Leach M (2014). Briefing: Ebola-myths, realities, and structural violence. African Affairs 114(454): 136-148. https://doi.org/10.1093/afraf/adu080. Beyond Guinea:
  2. Blair RA et al. 2017. Public health and public trust: Survey evidence from the Ebola Virus Disease epidemic in Liberia. Social Science and Medicine 172: 89-97. https://doi.org/10.1016/j.socscimed.2016.11.016.
  3. Vinck P, et al. 2019. Institutional trust and misinformation in the response to the 2018-19 Ebola outbreak in North Kivu, DR Congo: a population-based survey. DOI: https://doi.org/10.1016/S1473-3099(19)30063-5

Colonial suspicions and hollow partnerships: one African research assistant’s failure to obtain a visa for a research seminar

By: Sekou Kouyaté

“As a member of the Humanitarian Health Ethics Research Group (HHERG), your presence is requested at a Dissemination and Workshop Event in Geneva, Switzerland hosted by CERAH (Centre d’enseignement et de recherche en action humanitaire de Genève – Geneva Centre for Teaching and Research in Humanitarian Action) from 23 September to 28 September 2018…

When I received this letter on July 9th, 2018, I was overcome with joy and hope. First, joy: for the feeling that I will become known by several colleagues I had corresponded with for over a year, and never met, and have the opportunity for them to hear me share my thoughts first-hand. Hope:  to meet international researchers in a renowned city. I immediately agreed because, as an African research assistant, the opportunity to participate in a workshop in Europe that focuses on public health research which affects thousands of Africans is rare and therefore impossible to refuse.

The first step for this trip to Europe, I quickly learnt, posed an immediate challenge. I was to obtain a visa at the Swiss embassy located not in my home country (Guinea), as there was no such embassy in Guinea, but in Ivory Coast. Travelling there was costly. My economic limitations made me begin to lose hope, as travelling there overland would take days, and a plane ticket would cost 300 USD. The visa itself would cost 60 USD. Luckily, these financial concerns were short-lived. As soon as my Canadian supervisor and professor, Elysée Nouvet, heard that I needed to travel out of country for my application, she assured me all costs of this process would be covered by the project, and sent me the funds. I was off to Abidjan.

The submission of the application files, and the discussions that followed did not allow me to expect a departure to Europe. Neither my commitment to return to Africa after the workshop nor the invitation letters from CERAH and HHE, and the authenticity of my own files were sufficient or reassured the Swiss Embassy to grant me the visa. I was granted an interview at the embassy in Abidjan. During interview with more than one official, I was told that I seemed honest enough, but inevitably as a young African (I was 40 at the time), I essentially posed a risk of illegal migration. It seemed impossible, statistically and socially, to the officials, that I would return to Guinea if I made it to Europe. I was stunned, and frankly offended, that it was assumed no African would choose to stay in Africa if given access to Switzerland. I entreated my interlocutors with as many details of my commitments in Guinea. My father had been a diplomat, and I knew the situation was delicate and not in my favor. I learnt that my lack of PhD seemed to evoke distrust in and of itself: how could a socio-anthropologist without a PhD (from Africa) have enough to contribute to a workshop to merit his invitation to such an event? In the end, the interview lasted less than an hour. I felt devalued and judged. I felt I was being seen as a potential criminal and liar, which was like being called a criminal and liar. I am a deeply religious man, and my word was my honor, but this meant nothing. I showed them proof of dependents in Guinea and two small children, as well as research positions that were contingent on my ability to conduct interviews and analysis in Guinea: this was insufficient.  

From the Ivory Coast, grief, shame, and disappointment filled my heart and my head. These combined to create in me a feeling of profound rejection. I did not answer my phone for several days afterwards as I processed what had happened. This failure to obtain a visa was not only a notification of non-participation in the workshop. It was confirmation of the existence of unfair assumptions about the inherent appeal of moving to Europe for all Africans, and the bias of visitor visa granting based in colonial thinking and policy.  It was then that I lost all hope that the symbolic partnership would be transformed into an authentic partnership between researchers from the South and the North.

I write this short piece, because I think it is worthwhile to record. I aim to share my experience with all the decision-makers in health research, in humanities and policies, so that processes for visa applications and approvals for researchers from the south be rethought. Colleagues from the north come to Africa with ease, and with relatively limited worry over visa. Current policies strike me as unfair. They are also extremely costly, stressful, and even depressing. If we are serious about decolonizing research, there has to be more support for the mobility of African researchers to partake in international events where their contributions will be discussed. It is time to replace rhetoric. It is no longer acceptable for Africans to be on the receiving side of lessons from non-Africans. We are not just part of research to color the soup. 

During seminars and workshops in Europe, the consideration of the perception and experience of African researchers beyond Skype is an important element in the re-foundation of this cooperation. In the relationship between southern researchers and colleagues from the European and North American continents, it should be mentioned that the only initiative that can achieve sustainability is the one which facilitates the free movement of researchers.  

It is regrettable to consider that in the 21st century, the remnants of colonization are still visibly persistent in health research, while security, international trade and politics have been able to repaint the board. Nowadays, political advisers, diplomats, and security experts are no longer worried about their status (beginner, intern and senior) for obtaining visas to travel to Europe or America.

In the context of public health, Africa is considered a research site on diseases (infectious, non-infectious, neglected, experimental studies…). For a better understanding and consideration of the experts’ recommendations to policy makers and financial partners, it is necessary for Africans to participate in disseminations and to be given a voice in explaining the perceptions, reactions and representations of diseases. After all, the idea of the principle of justice is one of the pillars of health research ethics.