Fear

The governments’ pandemic contingency plans, quarantine policies, and lockdown measures may lead to enhanced fear of income loss and losing jobs. This is certainly the case in diseases that are not yet well known and where a cure or vaccine is still unavailable. When the plague disrupted Italy in the 16th century, “cities like Palermo, Milan, Padua, and Venice recognized the difficulties that quarantine and blockade imposed on commerce and the employment of artisans and labourers.” ^{Reference Cohn8} Mutatis mutandis, just the same, is happening in managing the COVID-19 pandemic: Governments are struggling to find the best way to deal with the pandemic without negatively affecting the economy and civil rights.

Inaccurate information of the government can play a role in the distrust of citizens toward HCWs. This is especially the case when health care lacks resources (eg, insufficient available intensive care beds) or if knowledge about the novel pathogen is lacking, notwithstanding government officials proclaiming that the pandemic is completely under control. ⁹

Fear for the unknown can lead to civil unrest, stigmatizing patients and HCWs, ultimately leading to attacks against HCWs or hospitals. This was demonstrated during earlier epidemics like Ebola in Africa and SARS in Hong Kong, and the hosting of refugees in Western Europe. ^{7,Reference Lee, Chan and Chau10}

L’ Histoire se répète. Even historical pandemics like the Black Death (14th century) and cholera (19th century) were defaced with riots and violence against HCWs, quarantine buildings and hospitals, in both America and Europe. ^{Reference Cohn8}

During a pandemic, HCWs face many stress factors, such as fear of contracting the disease themselves and fear of passing the disease on to their beloved ones. Both the patients and HCWs can be considered as possible sources of infection. ^{Reference Jones-Berry11} This was also the case with HCWs returning home from a mission abroad to fight Ebola. ^{Reference Gee and Skovdal12} In 2020, HCWs in Mexico were refused access to public transport, and nurses and doctors were pelted with eggs and physically assaulted. Similar attacks were reported in the Philippines, India, the United States, and Australia. ^{13,Reference Semple14} In January 2020, Hong Kong hotels/hospitals predestined for the reception of SARS-CoV-2-infected patients were besieged for fear of contagion of residents. ^{Reference Ramzy15} In India and Cameroon, HCWs were harassed by patients or their relatives, not accepting the positive swab results and enforced quarantine. ^{16–Reference Mashal and Yasir18} Similar unrest happened in Nigeria where, after a strike for 2 weeks, nurses returned to work only when armed guards were posted around the clock. ^{Reference Wieffering and Housing19} Protesters in Abidjan, Ivory Coast, destroyed a COVID-19 center because of fears that HCWs might spread the disease. ²⁰

Even outside their work setting, HCWs are confronted with COVID-19-related stigma. There are numerous examples of HCWs being assaulted or evicted by fearful landlords in the United Kingdom, United States, Pakistan, India, Myanmar, and the Philippines. ^{Reference Roborg and Fast1,Reference Semple14,20–Reference McKay, Heisler and Mishori22} In Italy, there was a fatal case of domestic violence. A medical student was killed by her partner who falsely accused her of exposing him to SARS-CoV-2. ^{Reference Roborg and Fast1}

Religious and Sociocultural Motives

In Cameroon, the remains of COVID-19 deceased persons were exhumed by relatives to give them a “proper” burial. ^{Reference Kindzeka17} Earlier, in Sierre Leone during the Ebola virus disease epidemic, unsafe (washing the body of the deceased) burial practices became a route of Ebola virus transmission. There were not enough trained burial teams to manage the number of reported deaths. ^{Reference Nielsen, Kidd and Sillah28}

Some ultra-conservative religion groups tend to reject vaccines more often ^{Reference Scott, Stein and Brown29} while being exposed to a higher risk for COVID-19 due to the intimacy of their religious practice. ^{Reference Schattner and Klepfish30} A study by Corcoran et al. found that Christian nationalism in the United States is one of the strongest predictors of COVID-19 vaccine hesitancy and is negatively associated with vaccine uptake. ^{Reference Corcoran, Scheitle and DiGregorio31}

Many religious communities did move to online services to stay in contact with their followers during the COVID-19 pandemic, ^{Reference Nortey32} but some conservative or fundamentalist groups continued their on-site services. This happened, for example, in the Bible Belt region in the Netherlands. ^{Reference Hoekman, Smits and Koolman33} Of note, these services were provided without violence against HCWs.

Governments Acting Against Whistleblowers, HCWs, and Scientists

In China, Malaysia, the United States, Russia, and Egypt, HCWs were fired or even imprisoned because they demanded personal protective equipment or launched critical notes via social media. Dr Li Wenliang (1986-2020) was the most prominent whistleblower in the Chinese COVID-19 epidemic and was initially silenced and humiliated by the government. ^{9,Reference Nie and Elliott35} The Brazilian president fired his health minister for speaking in favor of anti-pandemic measures. ^{Reference Williams, Kestenbaum and Meier36} The Belgian former Minister of Health declared in February 2021 that “the experts are now announcing a third, fourth and fifth wave. The population is disgusted by this information and communication, which does not offer any perspective.” ³⁷

Much of the same rhetoric was used by the former US president when he addressed his supporters: “People are tired of COVID. I have these huge rallies. Just leave us alone. People are tired of hearing Fauci and all these idiots.” Anthony Fauci, the key advisor in the US response to COVID-19, received death threats accusing him of contradicting the president and politicizing the response. The turbulent relationship with the former president played an essential role in this dynamic. ^{Reference Roborg and Fast1,Reference Tanne38}

Williams and co-workers conclude that these politicians, and other populist political leaders, denied the catastrophic impact of the COVID-19 pandemic, censored HCWs and scientists when speaking about the pandemic and government failures, and decimated the national COVID-19 response. ^{Reference Williams, Kestenbaum and Meier36}

Ethnical Considerations, Racism, Hatred

The right-wing extremist narrative (also see the following section) mixes racist motives, apocalyptic thinking, and conspiracy theories (eg, anti-vaccination and anti-5G campaigns). In 2020 and 2021, the right-wing narrative was fueled by the QAnon movement and the former US president who repeatedly called SARS-CoV-2 the “Chinese Virus.” In Italy, it was reported that Chinese restaurants were avoided and that parents were reluctant to send their children to class if they had a classmate of Chinese origin. ^{Reference Roborg and Fast1,Reference Viala-Gaudefroy and Lindaman41–Reference Chopra and Arora43} In the same narrative on right-wing inspired blogs, Israel and others were regarded as the scapegoat for creating SARS-CoV-2 and asylum seekers and immigrants (especially Jews and Muslims) for wanting to spread the virus. ^{Reference Viala-Gaudefroy and Lindaman41–Reference Chopra and Arora43} Another phenomenon during the COVID-19 pandemic is the deliberate spread of misinformation by Russian cyber-propaganda. For example, the COVID-19 response in Russia is praised while fake news is spread about outcome figures in other countries, again with the stigmatization of certain population groups. ⁴

The history of pandemics taught us that ethnical groups or specific professions were targeted in successive pandemics. The Black Death of 1347-1351 resulted in the murder of Catalans in Sicily, clerics and beggars in Narbonne and other regions, and the pogroms against Jews. In subsequent strikes of the Black Death in the 16th and 17th centuries, the anti-Jew narrative was less pronounced. Instead, HCWs were in the line of fire and were accused of perpetuating the contagion. ^{Reference Cohn8}

In the 20th century, the human immunodeficiency virus (HIV) pandemic resulted in homophobia. ^{Reference Hagopian, Rao and Katz44} Haitians were blamed for bringing HIV to the United States. ^{Reference Galarneau45} Similarly, unsubstantiated anti-Haitian stigma during a cholera epidemic jeopardized the contingency measures. ^{Reference Keys, Kaiser and Foster46} Even nowadays, anti-homosexual legislation hampers the medical care of HIV.

Doom Thinking and Conspiracy Theories

Doom thinking and conspiracy theories of left-wing as well as right-wing extremism use the COVID-19 pandemic to proclaim their ideology, undermine the state, and recruit new members. Specific social media platforms acting in a gray zone are mainly used for spreading their propaganda. They aim to attack police officers, politicians, and hospitals. ^{4,Reference De Cauwer and Somville42} Studies have shown that, although they have different motives, both far-left and far-right ideologies are associated with a tendency to reject vaccines for COVID-19. ^{Reference Debus and Tosun49} It should be acknowledged that left-wing attacks against HCWs are generally less violent and may therefore be reported less frequently in news reports and research articles. ^{Reference Dongen50}

Right-wing extremists mix racist motives, apocalyptic thinking, conspiracy theories, and anti-science and anti-vaccination theories. Denying the pandemic, non-adherence to lockdown measures, and declining vaccination could hamper the COVID-19 response. ^{Reference Hotez51} Furthermore, subgroups believe that the government wants to control the people with the global rollout of the 5G network and to track people by inserting microchips via vaccinations. ^{4,Reference De Cauwer and Somville42}

Conspiracy theories inspire so-called lone wolves and may lead to social unrest and protests, resulting in assaults against HCWs and attacks against health care facilities. In the Netherlands, several COVID-19 testing and vaccination facilities were targeted. ^{Reference Plevier52,53} Attacks included the ignition of an explosive device, arson attacks, harassments, and vandalism. In January 2021, protesters tried to enter an emergency department and maternity hospital and torched COVID-19 testing centers during riots against COVID-19 curfew in the Netherlands. ^{Reference Holligan54}

Some lone wolves took it a step further. In Michigan, United States, a man was convicted of spitting on HCWs in 2 hospitals, trying to infect them with SARS-CoV-2. ⁵⁵ In 2020, another man from Michigan, United States, was planning to steal a helicopter and use it to fire on a hospital to “liberate” COVID-19 patients. ^{Reference Hutchinson56} In April 2021, a train engineer intentionally crashed his locomotive at high speed near the USNS Mercy hospital ship in Los Angeles in an attempt to expose “an alternate purpose related to COVID-19 or a government takeover.” ⁵⁷ The engineer was later convicted for terrorism charges. In Missouri, United States, a man planning an attack on a school with African Americans, a mosque, a synagogue, and preparing a bombing of a hospital was shot by the Federal Bureau of Investigation, after resisting arrest. ⁵⁸ In Denmark, a vaccination center in Silkeborg was targeted in an attempted arson. Earlier, firebombs were thrown at a test center in Ballerup, north of Copenhagen. ^{Reference Jensen59} In Belgium, May 2021, a manhunt was started after a soldier with far-right ideas uttered threats to the armed forces, the government, a mosque, and virologists in a goodbye letter to his wife. He took several heavy arms from the army barracks with him and was seen posting at the apartment of a Belgian main virologist, and then disappeared. The soldier’s body was found in June 2021, and suicide was assumed to be the cause of death. ^{Reference Torfs60}

Anti-Government and Anti-Foreigner Involvement

HCWs working for non-governmental organizations (NGOs), such as Médecins Sans Frontières (MSF), generally face more threats than regular HCWs, mainly because they work in countries facing internal conflicts. These humanitarian-aid organizations are neutral, which is not always recognized by local communities. Some states jeopardize NGOs by mixing foreign policy and humanitarian aid. In 2004, during the “War on Terrorism,” the United States sent military troops to Afghanistan, calling it a humanitarian mission. A Taliban spokesperson justified the murder of 5 MSF staff members: “Organizations like MSF work for American interests and are therefore targets for us.” If military organizations operate under a humanitarian banner, HCWs of NGOs are at great risk of being attacked. Eventually, MSF was forced to evacuate their teams from Afghanistan. ^{Reference Weissman66}

NGOs play an important role in the fight against pandemics and epidemics, with the fight against Ebola being one of the most important challenges of the past decade. According to the WHO, 85 HCWs have been wounded or killed in 42 attacks on health facilities during the Kivu Ebola epidemic since January 2019. Up until March 2021, there have been 445 Ebola-related incidents globally. In these incidents, 50 health facilities were damaged and 28 HCWs killed and 72 injured. The vast majority took place in the Democratic Republic of Congo. ⁶⁷ Furthermore, the Global Terrorism Database (GTD) lists 24 terrorist attacks (resulting in 23 people killed and another 16 injured) on treatment facilities during the Kivu Ebola epidemic until December 31, 2019. ⁷ In February 2019, the attacks started with 2 major attacks on Ebola treatment centers in Butembo and Katwa. A community radio broadcaster was stabbed to death in his home. He had been working with the Ministry of Health broadcasting information about Ebola. Subsequently, the treatment centers and the radio station were closed. ^{7,Reference Elliot68}

A study by Vinck et al. showed that of the 961 participating adults in North Kivu, 25.5% did not believe the Ebola outbreak was real. Low institutional trust and belief in misinformation were associated with a decreased likelihood of adopting preventive behaviors, including acceptance of Ebola vaccines and seeking formal health care. These factors increase the risk of the spread of the virus. ^{Reference Vinck, Pham and Bindu69} Misinformation played a significant role in this mistrust. The Harvard Humanitarian Initiative analyzed more than 80 000 WhatsApp messages sent across 8 large group chats between August 28 and October 1, 2018, in Congo. They found that 13%—some 10 400 messages—either referenced or spread rumors and misinformation about Ebola. Combatting misinformation became a key element in the fight against Ebola in North Kivu. ^{Reference Elliot68} Furthermore, a military conflict in the region that had begun in January 2015 also hindered treatment and prevention efforts due to armed conflicts. Not surprisingly, 70% of the Ebola-related attacks found in the GTD were attributed to militia groups. ⁷ Also, due to this ongoing conflict, people were already distrustful of the government.

Other pandemic-related terrorist attacks that are listed in the GTD were an armed assault at government troops conducting an anti-dengue fever advocacy campaign in the Philippines, an armed assault at police officers escorting a measles vaccination team in Pakistan, and a rocket launch at a Center for Prevention of Malaria and Leishmaniasis in Afghanistan. ⁷ In 2014, most HIV/AIDS health centers in Kenya had to be closed down due to the fear of attacks related to new anti-gay legislation in their neighboring country, Uganda. ^{Reference Hagopian, Rao and Katz44,Reference Stewart70}

The GTD lists 169 attacks on HCWs or police officers related to polio vaccination teams or centers, starting as early as 1999 to December 2019. ⁷ Most of these attacks were claimed by Tehrik-e Taliban Pakistan, a militant group claiming the polio vaccine is a Western conspiracy to sterilize children. ⁷¹

The COVID-19 pandemic also highlights the threats that HCWs face. The International Committee of the Red Cross (ICRC) recorded 611 violent incidents against HCWs from February to July 2020. This was about 50% higher than average. Fear of the disease, lacking basic knowledge about COVID-19, and misinformation played an important role in these attacks. ⁷²

Suggested preventive strategies

• The ICRC head of health, Dr Esperanza Martinez, sums the most important preventive strategies in his 2020 news release: “To protect healthcare staff, medical facilities and patients from violence, it is of paramount importance to disseminate accurate information regarding the origin and modes of transmission and prevention of COVID-19. HCWs, patients or specific groups must not to be stigmatized or blamed for the presence or spread of the virus. We need to strengthen our collective sense of humanity if we are to make it through this pandemic.” ⁷² These resulted in a checklist for the risk stratification and implementation of measures recommended by the ICRC. ⁷³

• The WHO presents a shorter list of 10 lessons learned from the Ebola outbreak management, that can also be applied to address the COVID-19 pandemic (Table 1). ^{Reference Anoko, Barry and Boiro74}

Table 1. Ten lessons learned from Ebola, responses that can strengthen community engagement in the fight against COVID-19

Source: Anoko JN, Barry BR, Boiro H, et al. Community engagement for successful COVID-19 pandemic response: 10 lessons from Ebola outbreak responses in Africa. BMJ Global Health 2020;4:e003121. doi:10.1136/bmjgh-2020-003121.

War Zone, Regional Conflicts, and Terrorism

We usually think of attacks on health care as something that happens in the context of war or political repression. However, the previous sections showed that incidents also happen during peacetime. The ICRC published an extensive list of attacks on HCWs. ⁷⁵

Previous studies have also revealed the vulnerability of health care facilities and HCWs to terrorist attacks. Between 1970 and 2019, there were 454 terrorist attacks against hospitals and 184 attacks against emergency medical services, causing 2381 fatalities and 4016 injured. ^{Reference Ulmer, Barten and De Cauwer76,Reference Schmeitz, Barten and Van Barneveld77} The incidence of attacks increased during the latest years. In the same period, vaccinators have been targeted 133 times, most of which occurred since 2010. ^{Reference Jasani, Alfalasi and Cavaliere78} While the COVID-19 pandemic is a breeding ground for extremism, (local) governments have been weakened, allowing violent extremism and terrorism to regain influence. ^{Reference De Cauwer and Somville42} Therefore, the health care risks of terrorism remain an important concern.

War-related attacks on HCWs did not stop during the COVID-19 pandemic and were reported in Yemen, Afghanistan, Syria, the Democratic Republic of Congo, and Sudan. In these cases, the attackers are usually aiming to gain a military advantage or to deny health care to enemy forces and civilian populations. ^{Reference Roborg and Fast1} In fragile and conflict-affected countries, acts of violence during the COVID-19 pandemic have already deprived hundreds of medical services and severely hindered the response. Among others, the bombardment and destruction of a 400-bed facility in Libya further reduced the ability of health authorities and aid agencies to prepare for a full-blown epidemic. ¹³ In other countries where war was already ongoing, hospitals were especially targeted by the warring factions: A maternity hospital in Kabul, Afghanistan, was attacked, as well as hospitals in Tripoli and Benghazi, Libya, where the intensive care units were destroyed. ^{Reference De Cauwer and Somville42}

During the turmoil (May 2021) between Israel and the Palestinians, a trauma clinic of MSF was damaged, and, during the raids in Gaza, 2 doctors were killed. This happened in difficult times where hospitals of MSF and the Palestinian Red Crescent Society were already overwhelmed by COVID-19 patients, and even frontline workers had not yet been vaccinated. ^79,80

Suggested preventive strategies

• The ICRC’s Health Care in Danger initiative has developed a strategy to protect health care from attacks in situations of armed conflict. They provide a checklist in preventing, reducing, and mitigating violence against HCWs. ⁷³

• Efforts to reduce violence in health care facilities do work. The ICRC partnered with hospital administrators in a South Asian country to reduce the number of guns carried into the emergency room. After 5 months of the program’s implementation, the number of guns intercepted before being brought into the ward increased from 2 to 42 per month, reducing risk for staff and patients. ⁷⁵

• On May 3, 2016, the UN Security Council implemented Resolution 2286, supported by 80 states, including steps these states could take for the protection of health care during conflicts, but, in the end, implementation of this resolution was weak. ⁸¹

• Health care organizations are potential soft targets for terrorism. Therefore, it is of pivotal importance that these organizations increase their preparedness and resilience to threats of terrorism and violence. They should be aware of the possibilities to harden hospital defenses, so that these measures can be implemented in risk areas, during periods of conflict or when there is a terrorist threat in the vicinity of the hospital. ^{Reference Tin, Hart and Ciottone61,Reference Ulmer, Barten and De Cauwer76}

These factors are summarized in Figure 1.

Figure 1. Attacks against health care during pandemic.