Introduction
Outbreaks of virulent communicable diseases such as severe acute respiratory syndrome (SARS), Ebola virus disease (EVD), and coronavirus disease 2019 (COVID-19) give rise to multiple and competing pressures driving the actions of health workers, such as their duty to patients, concern for their family’s well-being, professional responsibility toward their colleagues, social responsibility toward the community, and, importantly, a fundamental need to protect themselves and preserve their own lives.Reference Simonds and Sokol 1
The aggregation of these co-existing duties, responsibilities, and basic needs, alongside frequently insufficient measures to protect and support health workers in balancing these various pressures during public health emergencies, generates important ethical tensions as health workers carry out their duties. For example, health workers may shy away from certain higher-risk responsibilities to care for acutely ill patients out of concerns to protect themselves from exposure to the contagion and to preserve their lives.Reference Sokol 2 , Reference Narasimhulu, Edwards, Chazotte, Bhatt, Weedon and Minkoff 3 Others may worry that being exposed to the contagion while carrying out their clinical duties could result in harm to their own families, were they to pass the infection on to them, or concerns that if they themselves become sick or die after getting infected, they would no longer be able to take on their familial responsibilities.Reference Hsin and Macer 4 During localized epidemics or global pandemics, these ethical tensions, and the resulting moral distress, contribute to a very high toll on the mental health and well-being of health workers, as evidenced by elevated rates of depression, anxiety, and post-traumatic stress disorder, often with little or no access to remediation or psychological support services during or after the crisis.Reference Billings, Ching, Gkofa, Greene and Bloomfield 5 –Reference Rossi, Socci and Pacitti 10
Multiple initiatives on pandemic preparedness have proposed recommendations to support health workers navigate such ethical tensions.Reference Narasimhulu, Edwards, Chazotte, Bhatt, Weedon and Minkoff 3 , 11 –Reference Upshur, Faith and Gibson 15 According to the guidance document of the University of Toronto Joint Centre for Bioethics’ Pandemic Influenza Working Group, “the ability of physicians and health care workers to provide care is greater than that of the public, thus increasing their obligation to provide care.”Reference Upshur, Faith and Gibson 15 The guidance document identifies that, based on the principle of reciprocity, society also has a responsibility to support those who face a disproportionate burden or who are exposed to greater risk as they carry out their professional responsibilities and seek to save lives and protect the public good during a crisis.Reference Upshur, Faith and Gibson 15 Besides taking actions to minimize risks, like providing personal protective equipment, the principle of reciprocity should lead governments and other stakeholders to provide disability insurance to health workers adversely affected in the line of duty, and pay death benefits to their families in the event of death.Reference Narasimhulu, Edwards, Chazotte, Bhatt, Weedon and Minkoff 3 , 11 –Reference Upshur, Faith and Gibson 15
Most of the primary research studies on this topic, and many of the knowledge syntheses of this research, have focused on health workers’ duty of care during infectious disease outbreaks in high-income countries (HICs).Reference Billings, Ching, Gkofa, Greene and Bloomfield 5 , Reference Upshur, Faith and Gibson 15 –Reference Chew, Wei, Vasoo and Sim 22 As a result of this focus, this body of knowledge has primarily informed guideline development and, in turn, responses implemented by international non-governmental or intergovernmental organizations, or militaries.Reference Sokol 2 Reference Narasimhulu, Edwards, Chazotte, Bhatt, Weedon and Minkoff 3 – 27 Less attention has been given to the ethical tensions experienced by health workers employed within national health systems in low- and middle-income countries (LMICs). While the COVID-19 pandemic has clearly shown that such tensions are inherent to crisis situations, there are important structural differences between high-income settings and lower-resourced health systems that are likely to impact health workers’ experiences of ethical tensions and possible solutions. This review therefore explored the ethical tensions experienced by health workers in LMICs responding to situations of infectious disease outbreaks, with the goal of delineating and better understanding these tensions, as well as systemic and institutional features that might contribute to them.Reference Moitra, Rahman and Collins 28 , Reference Rosenthal and Waitzberg 29
Methods
Critical Interpretive Review
This study employed a critical interpretive review (CIR) methodology developed by McDougall (2015), drawing on the work of Dixon-Woods et al. (2006).Reference McDougall 30 , Reference Dixon-Woods, Cavers and Agarwal 31 CIR involves an interactive and iterative process to collect and critically appraise information from the literature to answer a research question that may be refined in the course of the knowledge synthesis exercise.Reference Barnett-Page and Thomas 32 , 33 It aims to map key ideas and perspectives in the literature related to a particular area of inquiry, and critically appraise the collected literature to enrich concepts, generate theory, or develop lines of argument in relation to the literature.Reference McDougall 30 The research question guiding this review was: What are the ethical tensions that health workers experience during infectious disease outbreaks in LMICs?
Search Strategy
Three electronic databases, Scopus, PsycINFO (OVID), and Web of Science Core Collection, were searched to identify potential resources using free-text keywords and a mixture of regulated terminologies linked to the concepts of 1) health workers, 2) disease outbreak, and 3) ethics (see Table 1).
Search terms and indexed words
These databases were selected for their wide scope of multidisciplinary peer-reviewed articles across health care, social and behavioral sciences, and arts and humanities. 34
To be selected, the articles had to be: i) peer-reviewed; ii) report qualitative research findings; iii) explore ethical challenges experienced by health workers working within national health care systems (not international organizations) during epidemics; iv) be published between 2003 and 2022; v) be written in English; and vi) report research conducted in countries categorized as LMICs according to the World Bank 2023 Country Classification.Reference Hamadeh, Van Rompaey, Metreau and Eapen 35
Initial searches returned a total of 36,020 articles, from the 3 databases searched: Scopus (n = 4,265), Web of Science Core Collection (n = 29,147), and PsycINFO (n = 2,608). After applying limits according to article type, language, and year, as well as refining the words reported in Table 1, a total of 4,445 articles were exported to Rayyan.Reference Ouzzani, Hammady, Fedorowicz and Elmagarmid 36 , 37 After deduplication, 4,119 articles were screened by the first author based on the title and abstract which yielded the following results: 95 articles were marked “Yes,” 13 articles were checked as “Maybe,” and 4011 were tagged “No.” Next, 2 other team members independently reviewed the 13 “Maybe” articles and subsequently met with the first author to compare results, and where there were disagreements, they were resolved through discussions with three of the “Maybe” articles included in the “Yes” group. At this stage, the geographic limitation focusing on LMICs was implemented, and of the 98 full texts that were reviewed, 25 were retained for analysis. This process is reported in a modified PRISMA table in Figure 1.
Preferred Reporting Items for Systematic Reviews and Meta‐analyses (PRISMA) flow chart of search, screening, and selection of articles for the critical interpretive literature review.
Analysis
Data was extracted from the collected articles into an Excel table with 3 sections: bibliometrics (e.g., authors, journal, year of publication), contextual and methodological information (e.g., disease, study participants, methods), and substantive (recommendations, conclusions, relevance to clinical practice) information. Content and thematic analysis techniques outlined by Dixon et al. (2005) were used to examine the selected articles and identify key ideas in relation to the primary research question.Reference Barnett-Page and Thomas 32 , Reference Dixon-Woods, Agarwal, Jones, Young and Sutton 38 Data display tables, concept mapping, and close reading of the collected texts were used to identify common ethical tensions experienced by health workers and the competing duties that gave rise to these tensions, as well as subsequent secondary tensions, and contextual and structural features that shaped these tensions.Reference Dixon-Woods, Agarwal, Jones, Young and Sutton 38
Results
Study Characteristics
The 25 studies (Table 2) included in the review provide first-hand reports of health workers’ experiences during Ebola epidemics (n = 2) or the COVID-19 pandemic (n = 23).Reference Abdulah, Mohammedsadiq and Liamputtong 39 –Reference Zhang, Wei and Li 63 Multiple studies regarding the COVID-19 pandemic were conducted in China (n = 6); Turkey and Iran (n = 3); Bangladesh, India, and Pakistan (n = 2); and Iraq, South Africa, Nigeria, Botswana, and Sri Lanka (n = 1).Reference Abdulah, Mohammedsadiq and Liamputtong 39 –Reference He, Li, Su and Luan 44 , Reference Kealeboga, Ntsayagae and Tsima 46 –Reference Muz and Yüce 55 , Reference Rathnayake, Dasanayake, Maithreepala, Ekanayake and Basnayake 57 –Reference Zhang, Wei and Li 63 One of the studies on Ebola epidemics was conducted in Uganda, the Democratic Republic of Congo and the Republic of Congo, and the other in Uganda.Reference Hewlett and Hewlett 45 , Reference Okello Wonyima, Fowler-Kerry and Nambozi 56
Characteristics of the studies included in the critical interpretive review
* Population interviewed includes by semi-structured interviews, by focus groups and by all other forms of qualitative data collection; ** Multiple countries includes: Uganda, Democratic Republic of Congo, and Republic of Congo; a) Other specified as: Social constructive analysis; b) Other specified as: Case study analysis; 1) Health workers include: Physicians, nurses, formal caregivers with paramedic training; 2) Health workers include: Physicians, nurses, laboratory scientists, hygienists; 3) Health workers include: Clinical nurse practitioners, social workers, physiotherapists, operational nursing managers, nutritionists, pharmacy managers, professional nurses, clinical associates, community caregivers, enrolled nurses, enrolled nursing auxiliary; 4) Health workers include: Emergency medical technicians, emergency ambulance drivers.
Ethical Tensions During Infectious Disease Outbreaks
Through inductive analysis, 6 main themes were identified and are described in the sections that follow (Table 3). The first 3 themes are classified as primary ethical tensions and represent experiences of conflicts between health workers’ professional duty to care for patients, to support colleagues and to serve local communities, and how these professional duties were at times at odds with other important personal needs, concerns, and responsibilities, including the need for protecting your own personal safety, the personal responsibility one has for one’s family’s well-being, and the concern for avoiding exposure to stigma and discrimination in the wider community. The two secondary ethical tensions relate to whether to disclose or withhold information about one’s professional responsibilities to protect family members from emotional distress and excessive concern, and whether to withhold information from neighbours to avoid stigma and ostracization. The final theme was related to all the above themes and includes important modulating factors whereby ethical tensions could either be amplified or mitigated. Specifically, this theme involved various institutional features, such as shortages or availability of personal protective equipment, that either amplified or lessened the ethical tensions.
Examples of primary and secondary ethical tensions during epidemics
Tension 1: Professional Responsibilities versus the Need for Personal Safety
Eleven studies reported health workers’ fears of exposing themselves to potential dangers while responding to their professional duty of care during an epidemic outbreak.Reference Galehdar, Kamran, Toulabi and Heydari 43 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Kwaghe, Kwaghe and Habib 48 –Reference Mehedi and Hossain 52 , Reference Muz and Yüce 55 , Reference Xu, Tang, Lu, Fang, Dong and Zhou 60 , Reference Zhang, Montayre, Ho, Yuan and Chang 62 , Reference Zhang, Wei and Li 63 They grappled with tensions between upholding their professional obligations to provide quality patient care amidst the elevated risks of themselves becoming sick or dying after contracting the disease while performing their clinical duties.
In a study on the physical, psychological, social, and professional experiences of health workers during the COVID-19 pandemic in Turkey, Muz and Erdogan (2021) reported that participants were hesitant in providing care to patients because of their fear of contracting the disease.Reference Muz and Yüce 55 In this regard, one participant stated that: “During this period, I had to say ‘me first’ because if I wasn’t there, there would be no one to care for the patient. This was the first time in my life that I said ‘me first,’ it was very difficult.”Reference Muz and Yüce 55 (p1030)
In a study in China, nurses reported fear and uncertainty in treating COVID-19 patients.Reference Liu, Xu and Chen 49 One participant expressed that: “The first few days that I worked in the ward; I was really afraid of being infected because all of the treatments are close operation.”Reference Liu, Xu and Chen 49 (p11) The authors described participants struggling to uphold professional duties associated with nursing ethics amidst the emerging highly infectious disease context of COVID which created unfamiliar challenges for the participants.Reference Liu, Xu and Chen 49 Participants in a study by Kwaghe et al. (2021) described how this tension was further heightened due to a lack of insurance provisions or health care coverage for health workers who became sick due to exposure to an infectious disease in the course of their work.Reference Kwaghe, Kwaghe and Habib 48 This sentiment is highlighted in the following quote of a participant: “Sometimes I get depressed and depression sets in when I see one or two of my colleagues who we started this work with coming down with infection…. So, at some point in time, when I am faced with some of these experiences, it really, weighs me down and I start thinking that maybe I should have a rethink on the whole thing.”Reference Kwaghe, Kwaghe and Habib 48 (p89) These tensions contributed to psychological strain on health workers.Reference Kwaghe, Kwaghe and Habib 48
Tension 2: Professional Responsibility versus Personal Responsibility for Family Well-Being
Seven studies explored health workers’ concerns about whether exposure to contagion during their clinical work would result in exposing their families to the epidemic if they became vectors for spreading the disease.Reference Abdulah, Mohammedsadiq and Liamputtong 39 , Reference He, Li, Su and Luan 44 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Konduru, Das, Kothari-Speakman and Behura 47 , Reference Liu, Zhai, Han, Liu, Liu and Hu 50 , Reference Mehedi and Hossain 52 , Reference Muz and Yüce 55 These studies described how many health workers, for fear of transmitting the disease to their families, either minimized or completely avoided close contact with them. Konduru et al. (2022) discussed this issue in relation to the strain it placed on participants who feared exposing their families to danger, and the disruptive impact this had on family life.Reference Konduru, Das, Kothari-Speakman and Behura 47 For example, a participant described that “We only have one bedroom, so to avoid passing the infection to my husband, I have been sleeping in the kitchen since the pandemic started.”Reference Konduru, Das, Kothari-Speakman and Behura 47 (p7)
Muz and Erdogan (2021) reported that some health workers felt destabilized and uncertain about the impact on their families.Reference Muz and Yüce 55 A participant stated that: “I was worried at the beginning of course. Although I was wearing all the equipment, I thought if I get infected with this virus and transmitted it to my family, if people would be hurt and die because of me.”Reference Muz and Yüce 55 (p1028) Many health workers were also worried about the fate of their families in the event of their death in the line of duty.Reference He, Li, Su and Luan 44 , Reference Mehedi and Hossain 52 A participant in a study conducted in Bangladesh said: “I’ve been working in a hospital for five years. I’ve never seen such a high patient load as I’ve seen recently. The COVID-19 virus has infected even physicians. My family will have to suffer if I become sick and die as a result of the illness.”Reference Mehedi and Hossain 52 (p4) Some participants in this study also felt torn between avoiding work to protect their families or risk losing their jobs, which would also negatively impact their families.Reference Mehedi and Hossain 52
Tension 3: Professional Responsibilities versus Avoiding Stigma and Discrimination
Eleven studies discussed stigmatization and discrimination that health workers faced as a result of responding to their professional duties during disease outbreaks.Reference Abdulah, Mohammedsadiq and Liamputtong 39 –Reference Pooja, Nandonik, Ahmed and Kabir 42 , Reference Hewlett and Hewlett 45 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Kwaghe, Kwaghe and Habib 48 , Reference Mehedi and Hossain 52 , Reference Muz and Yüce 55 –Reference Rathnayake, Dasanayake, Maithreepala, Ekanayake and Basnayake 57 , Reference Turgut, Öz, Akgün, Boz and Yangın 59 Health workers complained that some of their colleagues, family members, neighbors, or society shunned them for working in COVID-19 or Ebola centers.Reference Hewlett and Hewlett 45 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Kwaghe, Kwaghe and Habib 48 , Reference Muz and Yüce 55 , Reference Rathnayake, Dasanayake, Maithreepala, Ekanayake and Basnayake 57 , Reference Turgut, Öz, Akgün, Boz and Yangın 59 Participants in these studies reported experiencing humiliation, isolation, or ill-treatment as a result,Reference Hewlett and Hewlett 45 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Kwaghe, Kwaghe and Habib 48 , Reference Muz and Yüce 55 , Reference Rathnayake, Dasanayake, Maithreepala, Ekanayake and Basnayake 57 , Reference Turgut, Öz, Akgün, Boz and Yangın 59 and tensions between carrying out professional responsibilities and being subjected to negative social consequences.
Turgut et al. (2022) described how participants who cared for COVID-19 patients in Antalya, Turkey, experienced social exclusion and were viewed as potential vectors of disease to be shunned, even by some friends and family.Reference Turgut, Öz, Akgün, Boz and Yangın 59 A participant remarked that: “They regarded us as if we were sick, so much so that there were friends of mine who did not respond to my greetings… people or neighbours, who knew that I am a healthcare worker, were walking by putting a distance.”Reference Turgut, Öz, Akgün, Boz and Yangın 59 (p2115) Some of the health workers also reported experiencing this behaviour from their colleagues and directors of their facility.Reference Turgut, Öz, Akgün, Boz and Yangın 59
In some instances, stigma was also experienced by health workers’ family members. Participants in a study by Okello et al. (2022) reported that their families also experienced stigmatization during the Ebola epidemic.Reference Okello Wonyima, Fowler-Kerry and Nambozi 56 A participant stated that: “People first feared to come near me, even my children they never wanted them to play with their children. They prevented my children from fetching water. After I was discharged from the hospital, people abandoned and feared me, even my relatives and neighbours. The community feared they would contract Ebola.”Reference Okello Wonyima, Fowler-Kerry and Nambozi 56 (p76) The consequence of this associative stigma was that the family members of health workers were denied access to social amenities that belong to the entire community.
A particularly challenging consequence of the stigma associated with working in the health care sector in several LMICs during a disease outbreak was discrimination related to housing. Alizadeh et al. (2020) reported that health workers were subjected to discrimination as a result of providing care during the COVID-19 pandemic.Reference Alizadeh, Khankeh, Barati, Ahmadi, Hadian and Azizi 40 A participant stated that: “I am worried that the society will not accept us anymore. We even wanted to extend the rent of the house last month but they said that we are nurses and they did not accept us.”Reference Alizadeh, Khankeh, Barati, Ahmadi, Hadian and Azizi 40 (p6) Other participants reported that property owners threatened to evict them or refused to renew their rental contract upon expiration.Reference Alizadeh, Khankeh, Barati, Ahmadi, Hadian and Azizi 40 These actions are more likely to occur in settings where there are fewer laws regulating housing or less enforcement of regulations, as is the case in some LMICs.Reference Gilbert 64 , Reference Gilbert and Augustinus 65
Secondary Ethical Tensions: Withholding Information to Protect Family and Avoid Stigma
Two studies reported situations in which health workers experienced a secondary form of tension. In relation to concern for causing anxiety for their families due to their role as health workers (ethical tension 2) and fear of exposure to stigmatizing behaviors (ethical tension 3), they felt torn between fully disclosing to their families and neighbours about their level of involvement in patient care during the epidemic versus withholding such information.Reference Pooja, Nandonik, Ahmed and Kabir 42 , Reference Munawar and Choudhry 54
For example, participants in a study by Das Pooja et al. (2022) were fearful of possible hostile reactions from family members and neighbors, as well as exposing their families to public resentment. Consequently, some of the participants hid their role as front-line health workers from their neighbours during the COVID-19 pandemic.Reference Pooja, Nandonik, Ahmed and Kabir 42 Munawar and Choudhry (2021) reported that some health workers chose to withhold details of their work from their families.Reference Munawar and Choudhry 54 As one participant stated: “If I reveal that how many hours, I am engaged in dealing/shifting the coronavirus patients, my family may get sick with the fear and it will increase their stress.”Reference Munawar and Choudhry 54 (p289) The health workers explained that they hid the information from their families to avoid causing them distress.Reference Munawar and Choudhry 54
Modulating Factors: Institutional and Administrative Features
Seven of the studies reported health workers’ concerns about the availability of material, logistical, psychosocial, and other forms of support from the state and relevant authorities (see Table 4).Reference Kwaghe, Kwaghe and Habib 48 , Reference Mchunu, Harris and Nxumalo 51 , Reference Moghaddam-Tabrizi and Sodeify 53 , Reference Muz and Yüce 55 , Reference Raza, Matloob and Rahim 58 , Reference Xu, Tang, Lu, Fang, Dong and Zhou 60 , Reference Yıldırım, Aydoğan and Bulut 61 In conditions where support for health workers caring for patients during a disease outbreak was perceived as limited or absent, ethical tensions were exacerbated and amplified. For example, Yildirim et al. (2021) reported that the nurses who participated in their study saw their duty to provide care during the pandemic as akin to being “on a battlefield.” They felt neglected by authorities since they lacked the necessary resources, such as personal protective equipment.Reference Yıldırım, Aydoğan and Bulut 61 A respondent extended this metaphor to lament the lack of support: “It’s like entering the middle of a war without a sword and a shield, how am I going to survive it? I felt like. I was shocked.”Reference Yıldırım, Aydoğan and Bulut 61 (p1370) These health workers reported feeling helpless and neglected.Reference Yıldırım, Aydoğan and Bulut 61
Examples of modulating factors that either exacerbate and worsen ethical tensions or mitigate and ease ethical tensions during epidemics
Raza et al. (2020) described health workers’ concerns about the lack of psychosocial support services to assist them in navigating through social, psychological, and emotional challenges while caring for COVID-19 patients.Reference Raza, Matloob and Rahim 58 These sentiments were captured by one participant who said: “Literally no one ever thinks of what we are facing in our daily lives. There is no actual channel or helpline for psychologically drained health workers.”Reference Raza, Matloob and Rahim 58 (p7) These professionals expected authorities to provide them with mental health services for their well-being.Reference Raza, Matloob and Rahim 58
In addition to exacerbating and mitigating factors in relation to ethical tension 1 described above, there were also examples of actions that authorities could take to ease the ethical tensions and resulting moral distress in relation to ethical tension 2 and ethical tension 3.Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Liu, Xu and Chen 49 , Reference Yıldırım, Aydoğan and Bulut 61
Kealeboga et al. (2022) reported that health workers were satisfied with the provision of counselling services that were made available to them, as this intervention helped them navigate the ethical tensions they were confronted with.Reference Kealeboga, Ntsayagae and Tsima 46 A participant stated that: “We had a counselling office, where we dropped in to talk to someone. There was support from management. They gave us almost anything we needed. There were so many educational materials. Hand washing was also encouraged.”Reference Kealeboga, Ntsayagae and Tsima 46 (p3089) Liu et al. (2021) described a state policy to support families of health workers during the health crisis, which boosted the morale and engagement of health workers toward their assigned duties.Reference Liu, Xu and Chen 49 As narrated by a participant: “Thanks to my government, for helping my family settle down, so that we can focus on the campaign and devote ourselves to work.”Reference Liu, Xu and Chen 49 (p14) These comments underscore health workers’ perceptions of the importance that relevant authorities, as well as the broader society, support them to address the ethical tensions they experience during public health crises.Reference Yıldırım, Aydoğan and Bulut 61
Discussion
Findings from this review reveal different forms of ethical tensions encountered by health workers in LMICs during Ebola epidemics and the COVID-19 pandemic. Each of these tensions contributed to incidents of fear, anxiety, loneliness, or moral distress that were reported by many of the studies’ participants.Reference Abdulah, Mohammedsadiq and Liamputtong 39 –Reference Zhang, Wei and Li 63 These incidents are consistent with a systematic review and meta-synthesis which explored the experiences of health workers during previous epidemics and the COVID-19 pandemic events across HICs and LMICs.Reference Billings, Ching, Gkofa, Greene and Bloomfield 5 The review reported that each of the outbreaks impacted negatively on the mental well-being of health personnel.Reference Billings, Ching, Gkofa, Greene and Bloomfield 5 The authors described health workers as having complex relationships with their families, colleagues, institutions, and the media since health workers reported that in some instances these entities either provided them with support or helpful information, and in other occasions either discouraged them from working or facilitated an environment of stigma.Reference Billings, Ching, Gkofa, Greene and Bloomfield 5
Health workers’ familial, collegial, and communal relationships were affected by their work in disease outbreak settings, including some who experienced stigma and discriminatory acts from family members, colleagues, and the general community. This review shows that though many health workers spoke about how the incidents of stigma and shunning contributed to their mental fatigue, it appeared their complaints were often under-recognized by local authorities which might have contributed to the apparent lack of interventions to address them.Reference Hewlett and Hewlett 45 , Reference Kwaghe, Kwaghe and Habib 48 , Reference Muz and Yüce 55 , Reference Turgut, Öz, Akgün, Boz and Yangın 59An article by Jecker and Takahashi (2021) which explored how Japanese health workers were shamed and ostracized during the COVID-19 pandemic, stated that what made these hostile behaviors especially worrying and confounding for the health workers was that they occurred at the time the caregivers were risking their lives to save patients and protect the health care system.Reference Jecker and Takahashi 66 This dynamic was also reported in several articles included in this review.Reference Hewlett and Hewlett 45 , Reference Kealeboga, Ntsayagae and Tsima 46 , Reference Kwaghe, Kwaghe and Habib 48 , Reference Muz and Yüce 55 , Reference Rathnayake, Dasanayake, Maithreepala, Ekanayake and Basnayake 57 , Reference Turgut, Öz, Akgün, Boz and Yangın 59 A systematic review and meta-analysis which examined the issue of stigmatization and violence against health workers globally during the COVID-19 pandemic reported that 26% of health workers experienced physical violence and 64% suffered non-physical forms of violence.Reference Saragih, Tarihoran, Rasool, Saragih, Tzeng and Lin 67 Incidents of stigmatization in LMICs were twice as frequent as those reported in HICs. The authors linked this ratio to the lower level of public education about the pandemic among the citizenry in the former environment compared to the latter.Reference Saragih, Tarihoran, Rasool, Saragih, Tzeng and Lin 67 Another reason the review stated for the disproportionality in stigmatization between the two economic settings was that weaker health care systems in LMICs were especially challenged to provide needed care for sick patients.Reference Saragih, Tarihoran, Rasool, Saragih, Tzeng and Lin 67 According to the review, these 2 reasons fueled misconceptions about COVID-19 and the role of health workers in spreading the pandemic. Reference Saragih, Tarihoran, Rasool, Saragih, Tzeng and Lin 67 The current review also points to how other societal structures, such as a lack of housing regulations or enforcement, could contribute to stigmatization. Further research to explore the impact of these systemic features on ethical tensions for health workers would be beneficial.
All governments and relevant stakeholders must learn from best practices around the world on how to better support health workers to deal with issues that could potentially trigger mental health challenges and stigmatization of health workers during contagions. Robust policies and legislation are needed in order to activate practical interventions such as investment in workplace safety, peer support services for their health workers, and timely dissemination of well-grounded information to the public during periods of public health crisis.
In a World Health Organization press release in September 2020, Dr Tedros Ghebreyesus, the Director General, stated that no country, society, or health care facility around the world can keep its patients safe and guarantee a functioning health care system except when the safety of its health workers is secured. 68 In that press statement, the intergovernmental organization also identified elements to be implemented by governments and other stakeholders to support health workers during contagions, including 68: establishing synergies between health workers’ safety and patient safety; improving the mental health and psychological well-being of health workers; and protecting health workers from biological and physical hazards. 68 Developing a roadmap for implementing such recommendations in the short, medium, and long term can guide these processes.
Conclusion
Disease outbreaks are sources of significant ethical tensions for health workers. Various structural features, social norms, and policy decisions can function to reduce or amplify these tensions. Addressing these features and supporting health workers can improve patient outcomes, health worker mental health, and aid the resilience of health care systems. Doing so will require tailored approaches that may present distinctive challenges in resource-limited health systems. Governments and international partners need to take steps so that health workers and health systems are better supported to navigate ethical tensions arising in future epidemics or pandemic events.
Limitation
Findings from this study are limited to 13 LMIC settings during the Ebola epidemic and COVID-19 pandemic. Although these countries are classified under one economic grouping by the World Bank, their socioeconomic indicators and level of infrastructural development are extremely varied. However, the findings offer insights into ethical tensions that health workers in some LMICs faced during these contagions, and the structural features that contributed to shaping them. Future reviews could explore this topic among countries in the same geographical location with similar socioeconomic dynamics.
Acknowledgments
Parnor Madjitey is extremely indebted to the Ghana Education Trust Fund for the award of a doctoral scholarship. The authors also express their sincere gratitude to Genevieve Gore, associate librarian at Schulich Library, McGill University, for the valuable inputs in developing the search strategy. We thank Pardikor Madjitey and Paakow Enyin Bentum Annan for their assistance during the article screening process.
Author Contribution
PM, AA, and MH designed the review. PM ran the database searches, selected articles, and extracted data. PM, MH, and AA contributed to the analysis. PM wrote the initial draft of the manuscript, and AA and MH critically reviewed the manuscript. All authors approved the final manuscript.
Competing Interests
The authors declare none.
Open access
