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

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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

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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. 

 

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.

 

Epistemic Injustice and Humanitarian Action: The case of language and translation

Ryoa Chung is an Associate Professor in the Department of Philosophy at the Université de Montréal.

Matthew Hunt is an Associate Professor and the Director of Research in the School of Physical and Occupational Therapy at McGill University.

This article originally appears on the University of Edinburgh Law’s Justice in Global Health Emergencies & Humanitarian Crises Blog. 

“Access to information has been described as a humanitarian good, alongside other basic needs such as food, water, shelter and healthcare [1]. Accountability is a major priority in the humanitarian sector, including accountability of non-governmental organizations toward the communities they serve. Coordination of aid between humanitarian organizations, and with local governments and agencies, has been identified as a key concern for effective crisis response [2]. And yet, All three of these activities – sharing information, practicing accountability and coordinating aid responses – are predicated upon the mobilization and exchange of knowledge, and serve to illustrate their centrality to humanitarian action. Important ethical concerns exist, however, when some individuals or groups are excluded from the pooling and exchange of knowledge. One source of exclusion relates to the linguistic dimensions of humanitarian aid: what languages are spoken by whom and for which purposes, what language barriers exist, what credibility or authority is or is not associated with people speaking certain languages, and whether translation is available….”

READ MORE AT: https://www.ghe.law.ed.ac.uk/epistemic-injustice-and-humanitarian-action-the-case-of-language-and-translation/

[1] Greenwood F, Howarth C, Poole D, Raymond N, Scarnecchia D. The Signal Code: A Human Rights Approach to Information During Crisis. Cambridge; 2016.

[2] Stephenson, Jr, M. (2005). Making humanitarian relief networks more effective: operational coordination, trust and sense making. Disasters, 29(4), 337-350.

Can a Television Change Perceptions of Ebola?

13942782618113Fear and dread of Ebola is shared by patients, healthcare providers and the general public. Some of this fear comes from a lack of understanding of how the disease is experienced combatted. Follow this link to read a commentary by HHERG’s Sonya de Laat, Postdoctoral Fellow in Humanitarian Health Ethics at McMaster University, on the role of a television set in contributing to a change in perception about Ebola Virus Disease.

Television and Ebola. How televisions can change disease perception & reduce stigma

 

 

 

Cultural history of the flu: reducing the stigma of Ebola.

Follow the link for a blog post by HHERG’s Sonya de Laat, Postdoctoral Fellow in Humanitarian Health Ethics at McMaster University.

How can cultural history of ‘health’ change disease perception & reduce stigmaA brief comparison of Influenza, 1918-1919, and Ebola, 2014-2015

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What might ‘dying in honour’ mean in Guinea during an EVD outbreak?

Follow the link to a blog post by Sekou Kouyate, Research Assistant on the projects “Aid When There is ‘Nothing Left to Offer‘” and “Perceptions of Research During the 2014-15 Ebola Virus Disease (EVD) Outbreak“, about the meaning of ‘to die in honour’ during  the EVD public health emergency in Guinea.

http://www.elrha.org/r2hc-blog/ideas-on-dying-in-honor-in-guinea/

Here is the blog post in French / voici la poster en français:

IDEES DE MOURIR DANS L’HONNEUR EN GUINEE

L’étude «L’aide quand il n’ya plus rien à offrir» comprenait une étude de cas sur les soins palliatifs dans les centres de traitement Ebola en Guinée lors de l’épidémie de 2014-2016. Son objectif était de capturer les points de vue des professionels de santé, des décideurs publics et des membres de la communauté afin de mieux soutenir les soins de fin de vie. Des entretiens semi-structurés ont permis d’explorer les besoins, les attentes, les perceptions et les défis associés aux soins de fin de vie dans le pays pendant la crise Ebola dans le pays ETC.

En tant que coordinateur de la recherche guinéenne pour le groupe de recherche sur l’éthique en santé humanitaire, j’ai mené des entretiens avec des participants de mon pays sur leurs expériences en matière de soins de fin de vie et de soins palliatifs au cours de l’épidémie. Malgré l’intensité de la situation, l’idée de mourir honorablement a été maintes fois soulignée comme importante.

Ce blog décrit les perceptions des Guinéens de ce qu’ils appellent «mourir en honneur», ou de ce que nous comprenons maintenant comme des soins prodigués aux patients mourants, ainsi que des symboles, actes et rites consacrés à cet événement.

Contexte:

Sekou_Kouyate
Sékou Kouyaté

La République de Guinée est un pays laïc. Bien que cette laïcité soit garantie par la Constitution, elle s’inspire de la pluralité et du respect des croyances traditionnelles.

La diversité des croyances et le fait que seulement 19,1% de la population a atteint le secondaire ou le secondaire ou que seulement 1,2% d’entre eux savent lire une phrase complète, ont une incidence sur la perception qu’ont les Guinéens de la maladie, des types et des lieux de soins, de la personnalité des soignants et des lieux et les circonstances de la mort.

L’histoire, les conditions économiques et les épidémies passées guinéennes influencent d’une manière ou d’une autre la perception de l’idée de mourir dans l’honneur. La représentation et les symboles de «l’honneur» sont également perçus différemment en raison des conditions économiques préexistantes personnelles, valeur accordée aux cérémonies funéraires ou importance accordée aux visites des membres de la famille proche.

Malgré la diversité des perceptions, comparé aux soins médicaux des patients, le soutien psycho-social fourni par les membres de la famille au patient mourant est considéré comme l’élément le plus «honorable» de la mort et est considéré comme plus important que toute capacité financière d’acheter des médicaments.

Perceptions des participants à l’étude explorant les soins palliatifs dans les centres de traitement de base guinéens

Débordant de patients dans les ETC, peu de temps a été consacré aux soins des patients, dont beaucoup mouraient. Normalement, on ne passait pas plus de 45 minutes à la fois dans l’unite de patient. De plus, de nombreux membres du personnel recrutés sur le plan national ne se sentaient pas à l’aise avec l’administration de morphine pour soulager la douleur. Il y avait aussi beaucoup de méfiance vis-à-vis des soins fournis dans les ETC à cause de diverses rumeurs. Dans ce contexte, le respect du concept de «mourir dans l’honneur» a nécessairement pris de nouvelles formes. Cependant, on a toujours considéré que le soutien personnel, généralement de la part des membres de la famille, était d’une importance capitale.

Ces déclarations d’anciens patients atteints d’ETC fournissent une preuve remarquable de l’importance de la signification de la famille dans l’idée de mourir en honneur pour les Guinéens. Selon les participants:

Participant2 :-Moi je pense qu’on doit être entouré par des personnes qu’on aime qui  soutiennent moralement et que tu te sentes aimé avant  que Dieu ne te retire ce qu’il t’a confié.

Particpant2 : – la famille fait partie de ces personnes les médecins traitants ; la famille pourquoi, c’est pour ne pas que tu te sentes abandonné. Le medecin pourquoi ? Par ce que , un patient même si un patient doit mourir, il se dit que son medecin  est son remède.

Participant 8 : -c’est de faire des bénédictions au mourant. C’est ce qu’il a besoin pour que son âme lui enlevé dans la douceur.

Participant14 : -Ceux qui viendront vont s’occuper de toi. Ils vont rendre propre et vont faire les ablutions avant de toucher à un cadavre – tu vas mourir avec presque tous les membres de la famille, c’est-à-dire tu es assisté moralement sur tous les plans. Donc sur le plan social, tout est là.

Respirant le dernier souffle sous le soutien moral des membres de la famille et / ou du personnel de santé, les bénédictions ainsi que les conversations données par les parents avant et après la mort sont des éléments essentiels de la mort en honneur en Guinée.

En fin de compte, malgré la diversité des points de vue et des opinions parmi les Guinéens, la grande majorité des Guinéens observent des normes sociales. Les patients à l’hôpital peuvent être visités moins souvent, mais à partir du moment de la mort, les cérémonies funéraires sont organisées par un grand nombre de membres de la famille du monde entier: des bœufs sont tués, des sacs de riz arrivent pour un festin. Il a peut-être fallu un quart de ces investissements pour acheter une ordonnance au patient, cette dépense économique symbolize que la mort n’est pas facilement acceptée, des questions sont posées sur la raison ou la raison en signe de respect et de dévotion. L’appui moral par le biais de l’interaction familiale avant la mort d’une personne et de ses (re) liens familiaux après la mort contribue à soutenir l’idée de «mourir d’honneur» en Guinée.

 

Photo credit: https://www.pexels.com/photo/hands-people-friends-communication-45842/

Becoming an anthropologist in post-Ebola Giunea

Follow this link to the blog authored by Sekou Kouyate on the opportunities and challenges of becoming an anthropologist and a qualitative researcher in post-Ebola Guinea.

Kouyate is the research assistant and coordinator for HHERG’s two R2HC funded studies in Guinea: on perceptions of research and on the provision of palliative care during the 2014-16 Ebola Virus Disease outbreak.

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