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.

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

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

A Canadian Medical Family’s Humanitarian Legacy

By Gautham Krishnaraj, for the Canadian Red Cross Blog

“Over 150 years ago, the Red Cross  Red Crescent Movement was born in the wake of the Battle of Solferino in 1859. Movement founder Henry Dunant was so moved by the immense suffering he saw that he called upon local villagers to come to the aid of the wounded. Among those who responded to the call were the Women of Castiglione, countless European medical professionals and Norman Bethune – a Canadian surgeon from Ontario. Dunant himself spoke of Bethune in A Memory of Solferino, recognizing him by name as “Norman Bettun”.

Nearly a century later, Bethune’s grandson – also named Norman – would follow in his grandfather’s footsteps, playing a critical role in the 1938 Sino (Chinese)-Japanese War. The younger Bethune was an established surgeon, having invented more than a dozen surgical devices, including the Bethune Rib Shears which are used to this day. During the 1936 Spanish Civil War, Bethune organized one of the first mobile blood transfusion services. He later travelled to China with the International Committee of the Red Cross (ICRC) to lead a Canadian-American medical team during the Sino-Japanese War. He wore his Red Cross badge with pride, performing surgeries on the frontline to casualties on both sides of the conflict, as countless Red Cross surgeons continue to do to this day.”

Read more about the Bethune family and their contributions to humanitarian health care through the decades here: http://www.redcross.ca/blog/2018/8/a-family-on-the-frontlines—celebrating-norman-bethune

Reposted from original blog with permission of the author.

 

In Focus: Joan Marston

In Focus: Member Profile

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Joan Marston is based in South Africa and comes from a background in Nursing and Social Science. She is the Global Ambassador of the International Children’s Palliative Care Network (ICPCN) having served as its Chief Executive. She was one of the founding members of the original ICPCN Steering Committee in 2005. More recently, she has also been part of the group that developed the new Guidelines for Persisting Pain in Children, as well as Guidelines for Disclosure in Children for the World Health Organization.

With twenty-nineyears of experience in palliative care for children, she has provided this specialized care in the roles as Executive Director of Bloemfontein Hospice and as founder of the Sunflower Children’s Hospice in 1998 in Bloemfontein, South Africa, alongside her work in a regional network for life-limited children, the St. Nicholas Bana Pele Network in 2009. As the national paediatric development manager for the Hospice Palliative Care Association of South Africa from 2007 to 2010, Joan and her team developed a strategy for a national network of services, promoting the considerable growth of the number of paediatric palliative care services for children in South Africa. During that time she was the Project Manager for a programme to develop children’s palliative care Beacon centres in Tanzania, Uganda and South Africa.

A committed advocate for children’s right to palliative care and pain relief, Joan has also  worked towardsresponsive palliative care for children and adultsduring acute and protracted humanitarian crises. When asked about some of the ethical dilemmas humanitarian healthcare workers might face when confronting terminally ill or injured children, she said, these include prioritising of scare resources such as personnel, time and medicines when saving lives is critical, especially when palliative care is seen as non-essential. Withholding or withdrawing treatment that could prolong life, spending time with a dying child when personnel are needed to deal with acute emergencies, and developing/using comforting child-relevant communication are additional ethical issues. Practically, lack of training in and understanding of palliative care and pain relief in children by humanitarian first responders—as few have paediatric formations—and a lack of palliative care workers in humanitarian situations is a main contributing factor to the development of ethical dilemmas. Humanitarian healthcare workers may also find themselves overwhelmed by the number of adults needing care, or by the reality that adults may leave an ill or injured child due to their own inability to face the issue of children dying. Undoubtedly tragic choices along the lines of those listed will need to be made in harrowing circumstances, but collaboratively making those decisions is part of the work Joan Marston and the larger networks she is involved in continue to work on in order to mitigate and minimize their difficulty.

Joan Marston is an active member of the Anglican Church and a Lay Minister in the Cathedral in Bloemfontein. She is also an Honorary Lay Canon of Blackburn Cathedral in Lancashire, England. She can be reached at joanmarymarston@gmail.com

[Sources: http://www.icpcn.org/joan-marston/, and personal communication]

Lost generation: The case of Rohingya children

Featured Commentary


by Jhalok Talukdar

Lost generation: The case of Rohingya children

The Rohingya people have been living in Myanmar for generations, however, they are not recognized as citizens there. The government consider them as migrant labourers who came from India and Bangladesh during British rule. When the Myanmar government passed the Union Citizenship Act in 1948 they did not give citizenship status to Rohingya, only providing them with foreign identity cards. They were also excluded when the government passed the new citizenship laws in 1982. The government restrained their movement and limited their right to work, study or access health care services. The Myanmar military  cracked-down on the Rohingya several times in the name of controlling the Arakan Rohingya Salvation Army (ARSA) terrorist group. The ARSA, however, are not exclusively seen as terrorists; they consider themselves as protector of the Rohingya community.

From Eh to Z(ambia) – Reflections of Canadian’s First Time in the Field

Photo by Gautham Krishnaraj in Kapiri Mposhi, Zambia


Gautham Krishnaraj is a 2017–2018 Aga Khan Foundation Canada International Youth Fellow, 2016–2017 RBC Students Leading Change Scholar, and recent MSc Global Health Graduate (McMaster University). He currently resides in Mombasa, Kenya where he is working with the Madrasa Early Childhood Program, an Aga Khan Development Network Initiative.


There’s something special about the “Z” countries. Often overlooked despite tremendous sights for tourists and rich potential for cultural exchange, they are unique places that not everyone sets out to see. Zambia was an unexpected destination (with a layover in Zimbabwe, but I’m not quite crossing that off my list) during my eight month journey as an Aga Khan Foundation Canada (AKFC) International Youth Fellow, working with the Madrasa Early Childhood Program – Kenya (MECP-K). I am here to provide documentation and reporting support while two MECP-K colleagues are conducting the final support visit in a Care for Childhood Development (CCD) consultancy project with the Luapula and Firelight Foundations. Our work centres around teaching new caregivers (with children 0-3 years old) the importance of play, touch, and stimulation in the critical early years of life. We do so through community based CCD Counsellors, who have been trained in CCD and have engaged their local communities over the past year.

Over the past two weeks, we have observed and mentored our CCD Counsellors interacting with caregivers in Lusaka, Kitwe & Kabwe, as well as more rural communities in Ndola, Rufansa, and Kapiri Mposhi. Covering three provinces and hundreds of kilometers, I can attest to the fact that Zambia is very much, as our local partners have noted, a country under construction. Crimson sunsets are dazzling through the copper dust of the daily grind. It is a beautiful place to have my first true “field experience” of conducting research, although it has not been without its challenges.

On Aid

This is an internal ethical dilemma that long predates my arrival in the field. My aspirations are, primarily, humanitarian. I believe that humanitarian health care is the bleeding edge of the aid sector, engaging when local systems are completely overwhelmed by a disaster; man-made or natural. It feels somewhat easier to justify the thousands of dollars spent on humanitarians’ travel, insurance, prophylaxis, R&R, lodging etc., when you know that the local providers are acutely in need of immediate external support.While I recognize and grapple with the challenges of this short-term dialogue of urgency, I struggle far more with the challenges that arise in the context of International Development. Many large organizations, even those starting with the good intentions of building sustainable programs, inevitably fill roles that make it impossible to leave. But eventually they must. Vacuums follow. While I am certain that these questions have have been raised countless times prior, and will be raised countless times to come, it begs the question of a better alternative. I remember reading once that Aid is a sector we all wish didn’t exist, because it recognizes our collective failure to create an equitous global society. Can we do more than wish? How do we contribute without feeling/being complicit?

On Breastfeeding

My role here of documenting feedback on the CCD program involves conducting video recorded interviews, and taking plenty of photos. I’ll discuss consent shortly, but every caregiver and counselor signed consent forms before I pulled out my camera. One challenge I did not expect was that during the vast majority of interviews, with the camera clearly visible and me indicating that I had started recording, many  women start to breastfeed. I fully support and believe in the importance of de-stigmatizing and normalizing breastfeeding, as it is a most natural part of life. However, all but one of the participants were interviewed were young (16-21 year old) mothers, so using video footage that very clearly shows the whole breast introduces some problems. Am I complicit in the stigmatization of breastfeeding by not using that footage, especially as breastfeeding is a critically important aspect of care for Early Childhood Development? The legal age of consent here is 16, but what happens if the reporting video I will make is circulated elsewhere in the larger Aga Khan Development Network (AKDN)?

On Communicating Consent

Finally, and most critically, few of the rural caregivers had a strong grasp of English. Despite the consistent presence of a translator, and despite all of the CCD Counsellors speaking English fluently, one cannot help but wonder how much is lost in translation. This is particularly important when considering consent. Explaining the purpose and/or potential applications of research can be difficult even in a common language; add in translation and the situation is rife with chances of miscommunication. I have never felt entirely sure that the participant understood why three people had come all the way from Kenya “just to see how they play with their baby”. Indeed, the mere fact that we had come from afar may pressure the participant’s perceived ability to decline participation, further exacerbated by a potential sense of obligation based on existing relationships with the CCD Counsellors. It is hard enough to rapidly build rapport and comfort between researcher and participant in English, and immeasurably more so in a few scattered words of Bemba.

While it’s not possible to fully address ethical challenges A-Z, I did my best to keep my camera stowed until the forms were signed, to sit on the ground with the participants, and to capture them in their best light. Under the brilliant Zambian sun, the latter wasn’t hard at all.

The views expressed here are entirely those of the author, and do not represent the views or opinions of the Humanitarian Health Ethics Network, Aga Khan Development Network, Aga Khan Foundation Canada, Madrasa Early Childhood Program Kenya,

 

Call for Abstracts

1st World Congress on Migration, Ethnicity, Race and Health (MERH)
The MERH 2018 Congress is hosted by an independent, non-profit making company working under the auspices of The University of Edinburgh, the European Public Health Association and NHS Health Scotland.  We intend to deliver to you a memorable, affordable, academic and social programme in one of the most spectacular cities in the world.
Congress aims :
  • To improve research, population health and health care for migrants and other discriminated-against populations
  • To bring together policy, social science, clinical, social service and public health perspectives and share and transfer learning within and across countries.
  • To examine contemporary problems across the globe and debate suggested solutions
  • To Consider health effects of social, environmental and demographic change associated with population migration, and the effects on diseases and their causes
  • To find ways to overcome differences in concepts and terminology so the field can be understood internationally in acceptable language.
  • To provide opportunities for people to showcase their work and to meet to share experience and motivations
  • To build networks that will last beyond the Congress itself
Abstract Submission and Registration is now open. 
Deadline for submissions is October 6, 2017.

http://www.merhcongress.com

Colleagues at CERAH ask: How do you speak humanitarian?

From the creators of the The Humanitarian Encyclopedia:

The Humanitarian Encyclopedia is a collaborative project with humanitarian and academic partners, based on co-creation, combining theory and practice to support the growing ranks of humanitarian stakeholders in their strategic thinking, design and implementation of humanitarian responses.

It responds to the documented need to interrogate how terms and concepts used in humanitarian action are understood and applied across time, cultures, and organizations. This shall support the reflective involvement of an expanding range of stakeholders while building on the existing theoretical and empirical knowledge and practical experiences at local and regional levels.

Visit the site often and see how you can be involved in continue to build a humanitarian language.