Information ecosystem disrupting health, Ex #8: Exacerbating violence against health workers

A never event is the "kind of mistake (medical error) that should never happen" in the field of medical treatment.

That's also how I feel about the occurrence of violence, harassment, and intimidation of health workers when they're doing their jobs. They're also a never event. Health policy, workplaces and society should treat them as such.

As I write the last in the series of notes about how pushing buttons in the information environment plays out on health and well-being, my thoughts circle to the "Peshawar incident" in 2019. It is one of the first stories I heard from my UNICEF colleagues in early 2020 when we were comparing experiences and notes on misinformation affecting health services. It refers to the national polio immunization campaign in Pakistan that was suspended within 24 hours of its start because an inaccurate video gone viral on WhatsApp spurred attacks on hospitals and massive resistance in communities.

Rise of social media, social disharmony and intensified violence against health workers

I think that the intolerance and aggression started jumping from social media platforms into the physical real world during the 2010s, and have only gotten worse since.

• The internet platforms evolved (to mobile platforms and targeted ads exploiting user emotion) and changed their designs, content and algorithmic content promotion during that time.
• 2010s was the time of adoption of social media, video and podcasts, mobile devices, layoffs at traditional news media, #metoo movement, misinformation, and data misuse.
• Social-media-driven misinformation was impacting elections and other social issues so much that the 2010s also saw a rise in efforts to counter it. Among others, the International Fact-Checking Network was established in 2015, and the seminal paper that described the challenge of the Information Disorder and what can be done about it by Claire Wardle and Hossein Derakhshan was published in 2017.

The polio Peshawar incident in 2019 was definitely not the first acute health event where health workers were attacked while doing their jobs, where social media misinformation played a role. Some other examples are:

• Since the 2014/15 Ebola outbreak, responders were battling community mistrust and sometimes attacks, fueled also by the spread of concerns and misinformation on social media. In subsequent outbreaks, including the multi-country 2018-2020 Ebola outbreak, social media and mistrust only made violence against responders worse.
• Similar challenges to measles immunization campaigns were happening in India, where WhatsApp's increased use facilitated rapid and viral spread of misinformation in health and other social topics.
• During the COVID-19 pandemic, misinformation and concerns related to the risk of severe disease, recommended treatments, and vaccines had fueled protests targeting hospitals and attacking their staff (like in Mexico and Canada), and propagated hate speech against nurses and doctors. Austrian society experienced a very sad suicide by a doctor due to harassment and doxxing she experienced by anti-vaxxers, which reverberated across the German-speaking Europe. Online harassment of American health workers during the pandemic was also alarmingly pervasive.
• A tragicomic example of how online misinformation swirled in new ways in the US is the example of a nurse who passed out when receiving a COVID-19 vaccine TV. Afterwards, conspiracy theories claimed that she had died from the vaccine. It led to attacks and harassment of the hospital and its staff as people who believed the conspiracy were trying to prove that the nurse had died, despite the hospital's attempts to debunk the claims.
• Attacks on health care facilities and health workers have only been increasing globally, especially in relation to vaccination and reproductive health services.

Violence against health workers has been increasing dramatically since before the pandemic

In other examples I've discussed in this series of notes, I've tried to explain the context of how the information environment is punching holes at the health system's ability to deliver on its mission.

When it comes to violence against health workers, this is a larger and more complex trend, although confusion, misinformation, distrust, and lack of resources, protections and policies are not helping prevent the harm to health workers.

We are not talking enough about the rapidly escalating levels of attacks, harassment and intimidation of health workers that we are recording across the globe. I was shocked when I read that American hospitals are distributing panic buttons to hospital workers. I was able to find other concerns from all over the world:

• Violence against health care staff in France is at its 20-year high, even recording a killing of a nurse at her workplace.
• In the 2022 survey of the American College of Emergency Physicians, 55% of ER physicians and 70% of ER nurses reported that they had experienced a physical attack at work in the past year.
• The UK has doubled sentences for people convicted of violence against first responders, including doctors and nurses. Moreover, emergency departments are piloting use of bodycams by staff.
• In Europe, doctors and nurses associations warned that the reported amount of violence is steadily rising and according to the European Federation of Nurses (EFN), 23% of the EUs health workers “experienced at least one form of negative social behaviour during the last 12 months of work”. EFN also referenced studies showing “that health professionals are 16 times more at risk of violence than other professionals”.
• Medical unions in Kyrgyzstan have been advocating for policies and laws that would protect health workers from attacks by patients and their relatives.
• Working groups in Singapore found that health workers vastly underreported instances of abuse and attacks and that they have to some extent, normalized the violence they experience at work.
• If you'd like to dive further into the topic, see this review for a synthesis of current evidence on workplace violence against the primary healthcare workforce worldwide.

When health workers are harassed, doxxed and attacked, this should ring highest-priority alarm bells for the health system

Every worker deserves to work in a workplace free of violence, harassment and intimidation.

When there are attacks against the health workforce, this should be the lastminute wake up call for the health system that something has gone really wrong between the health system and communities it serves.

To observe such egregious treatment of health workers, many things needed to have fallen short in the health system: its services to patients and communities, trainings and support to its staff, and its policies.

At the very least, measures must be put in place to protect health workers from harm and create protective systems and capacities to prevent violence.

In addition, any preventive measures would require the health system to rethink what has eroded people's trust and confidence to the point where people feel that they can attack and harass health workers.

Bottom line, more needs to be done to protect health workers from harm and foster safe and fulfilling workplaces in the health system

I always try to end my notes with recommendations on what could be done to address the identified problem. In this case, you might have better and more ideas than me, and I'd like to hear from you.

I somehow don't think that staff trainings and police forces in hospitals will solve this crisis or address the underlying reasons why violence keeps pouring over health workers.

• As I was reading up on the topic, I found various examples of staff trainings in conflict de-escalation and violence response, the so called "code black" scenarios. In Australia, VR is being used to train health workers with these additional skillsets. In the US, similar trainings are part of a wider threat assessment approach supported by the FBI.
• In the US, some hospitals have also established hospital police forces. While proponents argue that these forces address patient aggression, critics worry about unintended consequences of introducing law enforcement in the middle of a healthcare setting. I think it's still too early to tell what the impact on the care-seeking by patients and communities is, especially those from vulnerable populations.

The strongest and most coherent policy action there is to address violence against workers in the health sector is to strengthen and implement occupational safety and health programmes. These are important because they not only define direct prevention and protection action, but also impact worker's compensation and insurance, and address systemic failures and capacities.

1/ Strengthening occupational safety and health programmes

To protect health workers against violence, WHO and International Labor Organization, it published a "Guide for the development and implementation of occupational health and safety programmes for health workers".

• It recommends creating and implementing sustainable programs to protect the health and safety of healthcare workers. These programs should cover various workplace hazards, including infections, physical strain, chemicals, and mental well-being.
• Reading the guide left me feeling that health policymakers have a major blindspot in understanding where there's a lack of tools and policies in relation to the protection of health workers from the dynamics of the digital information environment. This is especially important at a time when health workers are encouraged to go online and engage their patients and communities in online spaces they participate in. They should be protected by the health systems if they experience retaliation from trolls and harassers.
• Tools for occupational health and safety planning would therefore need to consider doxing, online harassment and measures health organizations would even need to put in place to protect their own staff from digital identity and reputational harm. For example, Harvard's Digital Safety Kit for Public Health Workers is a start. But other institutional policies are needed to define actions of digital communications and legal and safety teams to respond when healthcare staff are in such situations.

2/ Signing on to the ILO convention 190 on violence and harassment

In 2019, ILO Member States agreed the international convention number 190 on Violence and Harassment Convention, and an accompanying Recommendation (No. 206). In 2022 the International Labour Conference strengthened this commitment by including a safe and healthy working environment among the fundamental rights covered in the ILO Declaration on Fundamental Principles and Rights at Work.

Unfortunately, only 39 countries have ratified the convention to date.

One concrete action that countries can do is to take steps to ratify and implement it.