Eubios Journal of Asian and International Bioethics EJAIB Vol. 30 (5) June 2020 www.eubios.info ISSN 1173-2571 (Print) ISSN 2350-3106 (Online) Official Journal of the Asian Bioethics Association (ABA) Copyright ©2020 Eubios Ethics Institute (All rights reserved, for commercial reproductions). Healthcare professionals acting ethically under the risk of stigmatization and violence during COVID-19 from media reports in Turkey Sukran Sevimli Department of Medical History and Medical Ethics, Dursun Odabas Research Hospital, Faculty of Medicine, Van Yuzuncu Yıl University, Turkey Email: sukransevimli@gmail.com Abstract Aim: The COVID-19 infection is transmitted either by human-to-human contact, social-physical contact, and respiratory droplets or by touching items touched by the infected. This has triggered some conflicted behaviors such as stigma, violence and opposite behavior applause. The aim of this study is to explore several newspaper articles about stigma, violence, or insensitive behavior against healthcare professionals and to analyze reason of these behaviors during these COVID-19 pandemic. Method: The website of the Turkish Medical Association "Press Releases News" and online newspaper articles have been scanned using keywords and have been classified and analyzed according to the content of articles between the periods of March 11 to April 28, 2020. This is a qualitative study with content analysis. No official ethical permission was obtained as the study was conducted through open access internet news sites. Result: 16 reports were selected from online reports that matched the keywords of the study. 13 of these reports included desensitization, violence, lack of precaution, stigmatization, and applause, and 3 reports included doctors' statements. After being categorized, content analyses were conducted. Conclusion: This study revealed the necessity of multi-faceted evaluation of the problems faced by healthcare professionals who are at the forefront of the COVID-19 outbreak. This study has a primary role in the detection, diagnosis and treatment of the pandemic and reveals that doctors are trying to fulfill their duties in an ethical framework despite stigmatized behavior. Authorities should provide various supports to protect healthcare professionals before, during and after the epidemic for the success of COVID-19 outbreak struggle. Introduction Pandemics are actually not new; the world has experienced pandemics about every 10 or 50 years since the 16th century (WHO, 2005). However, the novel coronavirus is affecting the world more now despite advanced medicinal advancements. Coronavirus, first described in the 1960s and found to be very common, has the ability to be passed from animal to human which is why most people have encountered it at some point in their life (WHO, 2007). The human coronavirus often causes mild to moderate upper respiratory diseases; it can cause a variety of diseases, from the common cold to more serious diseases such as the Middle East Respiratory Syndrome (MERS-CoV) and Severe Acute Respiratory Syndrome (SARS-CoV) (WHO, 2005). 207 Previous cases of pneumonia of unknown etiology in Wuhan city of Hubei province, China were reported to the World Health Organization (WHO) on December 31, 2019. It was then when WHO announced the discovery of the novel coronavirus (2019-nCoV) and labeled it as the sixth "international public health emergency" on January 30, 2020 and later publicly announced a pandemic on March 12, 2020 (WHO, 2020). The COVID-19 infection is transmitted by human-to-human contact, social-physical contact, and respiratory droplets or by touching items touched by the infected. It has been identified as having a median incubation time of 4-5 days, yet the ability for transmission of the disease may extend up to 14 days. These findings for COVID-19 and its infection methods are still the same; however, research may present new information that deepens the understanding of this virus. Health stigmatization, humiliation, insensitivity and violence: The basis of health stigma is perception of the sick person as an object that is contaminated and becomes dangerous. This perception can lead to easily giving up on helping people who are stigmatized without any conscience and ethical concern. Health stigma has been seen throughout history, where people display negative and discriminatory attitudes, stereotyping a person or group of people experiencing a particular disease, where the disease occurs, and things related to the infected diseases (e.g., HIV/AIDS, Ebola, SARS-CoV, MERS etc.) (WHO, 2007). Unfortunately, the extent of labeling patients has expanded during the COVID-19 pandemic, because COVID-19 has infected people in very fast and easy ways, and transmission can occur in a variety of forms, including through air, social distance under 2m and exposed clothing. It has led to high morbidity and mortality around the world, and has seriously affected interpersonal relationships. For this reason, the high risk of contamination has increased stigmatization towards patients (both confirmed and under investigation), including healthcare professionals (HCPs) who treat COVID-19 patients. People's approach to stigmatizing infectious diseases has become more intense in the COVID-19 period, to the extent of stigmatization healthcare workers. Pandemics and ethics in Turkey: The Hippocratic oath, medical deontology regulations (Türk Bakanlar Kurulu: Turkish Council of Ministers, January 13, 1960), medical ethics practices, and patients' rights regulation (Turkish Republic Ministry of Health, 1998) describe the physician-patient relationship and require physicians to place the patients' welfare as their primary consideration in Turkey. Within the framework of these regulations, as a general principle, healthcare professionals are responsible for carrying out health services completely under any risk, including natural disasters or pandemics. As a matter of fact, the Ministry of Health canceled the holiday permits of health professionals across the country immediately after the first COVID-19 cases started to appear (excluding marriage, death, maternity leave and accompanying leave under article 105, and unpaid leave under article 108, and under exclusion article 104 of law No. 657) (Memurlar.net, 13 March 2020). Moreover, all health institutions across the country have started to work to solve medical, social and legal problems that arise with the COVID-19 outbreak in a short time. Therefore, the Ministry of Health prepared new information and consent forms to prevent from issues between patient/patient relatives and doctors on March 13, 2020, e.g. COVID-19 patient/contact follow-up (quarantine) information and consent form, inpatient information and consent form, consent form for patients outside COVID-19 diagnosis, COVID-19 patient relatives/companion information and consent form, and COVID-19 highly suspicious patient information and consent form. In the meantime, the Ministry of Health, the Turkish Medical Association, and television networks started to inform the public with various videos and discussion programs about the COVID-19. However, the pandemic in question was not taken seriously enough; some patients tried to escape from the hospital, some left the quarantine, and COVID-19 suspects expected to quarantine themselves at home went to Mosque, shopping or even funeral ceremonies. Moreover, these preparations were not sufficiently considered by some segments of the society, unfortunately, and stigmatization and attacks on health professionals continued. Research questions This present study aims to explore the following questions: Does COVID-19 reveal stigma and violence? Does the attitude of some authorities or celebrities play an important role in stimulating and normalizing stigmatization and violence? The answers to these questions will contribute to an understanding of the shortcomings and inaccuracies regarding health stigma. Findings and discussion The present study's data is based on reports collected from online media. These reports demonstrated the public knowledge of COVID-19 and the three main attitudes seen as psychological support for HCPs; however, stigma and violence against front line HCPs was still present. Therefore, this study has included comments of HCPs to better analyze the study situation, as they play the most crucial and even the primary role in this pandemic and want to fulfill these roles in the best possible way. There is an interesting perception of HCPs present during the care of a patient as if they belong to another place or class; that HCPs should treat their patients in the best possible way, but they should also be blamed for problems in the healthcare process. There is an incomprehensible attitude as if HCPs are not human. They are human; HCPs also have human rights and the Universal Declaration on Bioethics and Human Rights, UNESCO article 11 provides that "No individual or group should be discriminated against or stigmatized on any grounds in violation of human dignity, human rights, and fundamental freedoms (UNESCO, 2005). Applause on one side, violence, blame, stigmatization on the other I. I.Applause: The morale of an applause campaign for healthcare workers fighting coronavirus started in Europe and was then followed with the recommendations of National Assembly Health Minister Fahrettin Koca of Turkey to be done the same. Turkish people applauded at 9PM to show support to healthcare professionals Figure 1. (BİA Haber Merkezi, 19 March 2020). The President of the Istanbul Chamber of Medicine, Dr. Pınar Saip said: "We are very happy. We really needed this. The HCPs have been battling violence for a long time. We were seen as responsible for changes in the health system and the problems it caused. The excessive intensity that we experienced was challenging us; we were facing patients and their relatives. There was humiliation and disrepute. Now with the 'applause' issue, it was once again understood that we are on the same side." At an open-air meeting, HCPs asked for work and economic conditions to be improved, other than clapping. Two of them were related to COVID-19 as follows: All healthcare providers should have 1 test in 5 days, and COVID-19 should be considered as a work hazard, COVID-19 is an occupational disease (Duvar Gazetesi, April 30 2020). One of the doctors indicated that "this moral applause gives to us happiness. However, I wish that this support should not be limited to the timeframe that we faced the epidemic and breathed death. It should always be." "Are the precautions taken for doctors sufficient?" Dr. Saip' answer is clear: "There were patients we met without realizing it. A pre-diagnosis before the diagnostic tests would have been more beneficial for prevention. Every healthcare institution needs to take action for its employees. There is still a shortage of protective materials in many family health centers, public and university hospitals. Hand sanitizers, liquid soaps, and necessary protective materials must be sufficient according to the work area. "If they do not become permanent, if the healthcare professionals get sick, then we may have difficulty in running the process"(Soybaş, 21 March 2020). This support was meaningful for health workers, but unfortunately, violence, stigmatization, blame, humiliation and disrepute towards health workers did not end. People should think that COVID-19 cases have increased in a short time in Turkey, and HCPs have endeavored to treat patients although their lives were at risk. Figure1. We applaud the health workers https://www.gazetebirlik.com/haber/uc-gun-saglik-calisanlarini-alkisliyoruz- Stigmatization and blame: Stigmatization and blame continued by celebrities, a governor and some people. There were statements of M. Anlı encouraging "violence to physicians". M.Anlı targeted the doctors because she was not given an injection! She wanted to have an injection in the car. M. Anlı told her Tatlı Sert program at ATV, that she went to the hospital due to migraine pain and that she was not given an injection though she called the doctor to inject in her car. However, the doctor rejected her request and invited her to go inside the hospital. Anlı stated on her television show program, after telling her story: "Then we say, doctors are not nice ... then we close the hospitals"(Habervakti, March 30 2020). Anlı's comments were viewed as clear violence against healthcare workers. Following some statements by public doctors, nurses and other healthcare professionals working in the hospital that you do not want to enter, and with the public's opinion being negative, Anlı apologized after receiving criticisms; however, her apology was not clear. A city Governor said: "137 of 567 cases were HCPs, they could not protect themselves". He spoke at a press conference: "Normally we would be talking about comeback today if it wasn't for the burden that our healthcare workers brought us. This was really difficult. We hosted our HCPs in the guesthouse. We did not charge for their meals. We also tried to provide them services. But because they were not careful enough in their relations there, they put both themselves and us in danger. They did not protect themselves, and they became a burden to us as well" (A3haber, 17 April 2020). After he was criticized for this statement he said sorry. But still after that HCPs left the guesthouse they were staying, allocated for them in order not to infect their families. However, they continued to provide healthcare services, despite the risk of contamination and being accused of getting sick. The above description did not reflect the facts, because healthcare professionals are serving patients with COVID-19, and the infected person in question was detected late, since HCPs were not tested frequently. Healthcare workers were devotedly working in hard conditions because of the coronavirus. A dentist was dismayed after seeing a message hanging at the entrance of his apartment building. In the message, which was written on a piece of paper and hung at the entrance of the apartment: "To the dentist residing in this apartment, do not to touch the doors and stairwells while entering and leaving the apartment (DHA, April 5 2020). In Sinop, a site manager posted a decision that healthcare professionals must use the rear elevators and not the front elevators. Two female healthcare workers living in the apartment answered the article with the note: "Your discriminatory words break our working desires. We are trying to treat you without discrimination in the hospital while you separate us as a healthcare provider. Even though you know that our spouses are on duty abroad, we leave our little children alone at home, and go to watch for you, your discriminative attitude is far from solidarity and breaks both our professional dignity and the determination to work. Your attitude is never acceptable in these difficult days that the whole world should be in unity, solidarity and solidarity. We will take all precautions to check in and out. Let the residents who are disturbed by this, use the staircase option". The warning letter of the site management that was shared on social media was removed upon the reactions (Habertürk Gazetesi, April 7, 2020). The Health Communication Association President said: "Violence is not just physical. Psychological and verbal violence also creates a trauma as much as the physical one on healthcare workers and doctors. Most of these people do not go to their homes, they stay in the hospital. However, believing that returning home and seeing such an article one evening is no different than a fist. "(Soybaş, April 6 2020) Unfortunately, violent incidents happen at various levels and degrees such as insults, shouting, humiliation, and threats in hospitals which have become normal in the health system. This attitude has also been adopted by some governors of cities, celebrities and politicians making the current situation worse. As seen in the online reports above, the accusation, humiliation, and labeling behaviors towards healthcare professionals who provide healthcare services at the time of the pandemic continue. Unfortunately, this attitude belittles healthcare workers far from appreciating their value. It is important to interact with risky patients and those who are concerned about losing a much loved relative, and this pandemic worsens the problem. The reports above reveal that the lack of communication skills is a fundamental problem on all sides. Of course, the patient-physician relationship occasionally experiences communication problems. However, a solution can be realized with improvement of the communication skills of the healthcare professionals, as well as individuals who have influence upon people whom can help solve the problem. Healthcare professionals are not the one who bring the disease; they try to treat the patient with serious risks involved. However, this situation has been reversed, and healthcare workers who have the knowledge and experience in the treatment of COVID-19 are perceived as ignorant-malicious persons and threats are now being thrown at them. Such events show that some people have a negative perception against HCPs. Actually, the threat of the apartment manager included a hidden humiliation both to HCPs and to medical education. As it is known, infectious diseases threaten not only the patient but also the healthcare team. It is known that many healthcare workers have been infected while treating patients throughout history. This undesirable situation sometimes happens despite all the precautions. According to the Ministry of Health, 7428 HCPs were infected during the COVID-19 health service as of April 29 (Medimagazin, 2020b). This situation is not only in Turkey but also in all countries struggling with COVID-19 (e.g., Israel, Italy, China, UK, France, Spain, Iran, the U.S., Greece, Poland, Pakistan) where many HCPs have been infected, and unfortunately some of them have already died (Newsweek, 04.03.220). Violence against healthcare professionals: Despite new regulations violence against doctors and health professionals continues. For health professionals in Turkey, parliament adopted 'Violence in the Health Act', on April 15 2020. This law covers "deliberately injuring, threats, insulting and resisting not to perform duty" in the Turkish Criminal Code, committed against healthcare personnel and auxiliary workers in public and private health institutions and organizations. The penalties to be determined according to the relevant laws will be increased by half (Sayın, 2020). In another case, S.A., who came to hospital with a headache complaint, said that he wanted to be treated urgently. Okan K., the doctor in charge of the emergency room, told S.A. that his health condition was not serious, that the hospital was risky due to the coronavirus and that his home was safer. Thereupon, S.A. punched the doctor, and grabbed his throat (Medimagazin, 23 March 2020). Another incident occurred in Samsun around 3:30 PM of 24 March 2020. According to the information obtained, D.A. and his cousin Gamze K. went to Gazi State Hospital. The secretary in the hospital cautioned them saying, 'Just stay there' because of the coronavirus measures. The cousins wanted to be examined by a specialist but to no avail they were referred to the general practitioner Z.K. where D.A. was examined. When the doctor touched D.A. he exclaimed, 'You're hurting me, what kind of doctor are you?' and he started shouting. Meanwhile, Gamze K. started hitting Z.K's head, which they squeezed between the examination table and the wall Figure 2. After the commotion in the room, doctor Z.K. reported the incident to the police (İnan, 23 March 2020). Figure 2. Girls attacked the doctor https://www.sozcu.com.tr/2020/gundem /genc-kizlar-doktora-boylesaldirdi-5711625/ In another incident, the sons of a patient, who was treated for suspected coronavirus, battered the nurse and the security guard. The sons of the patient who was treated in a private hospital with the suspicion of a novel type of coronavirus (COVID-19) in Konya, A.A. and İ.A battered a nurse and a security guard. The two suspects were arrested and detained (AA, 2020). Shocking images of the attack on the nurse who struggled with the corona virus appeared in Izmir! D.Y. wanted to report for her child. However, she did not give her child's periodic report because she was not her family doctor. Thereupon, Dr. D.Y., who went to the family health center where Akkus worked, allegedly tried to head to the room of the nurse A. Kavuklu, who was a witness in the case. Despite the interference of health center employees, D.Y., who was walking on Kavuklu, battered the nurse there. (Sabah Gazetesi, 04.04.2020). A doctor, who was attacked by the patient's relatives, rebelled: I'm afraid, do you hear me? Doctor EE. Genç, who worked at KTÜ Farabi Hospital, was attacked after a patient with lung cancer and breathing difficulties died. They entered the COVID-19 ward, with masks and overalls, waving their hands and kicking left and right, over the patient who passed away. Sharing her fearful moments from her social media account, Doctor Genç said, "What will happen next time, will I be able to return home to my family? Figure 3. I don't know" she said (Akduman, 2020) Figure 3. "I Don't Feel Safe" https://www.bursa.com/kendimi-guvende hissetmiyorum -n425090/ There was an attack against field investigation team on the street. The Ministry of Health formed an "infectious diseases and fighting guide (Regulation 22/2018)" to prevent and reduce infectious diseases (T.C. Sağlık Bakanlığı, 2018). The field investigation team's first aim is to find the source and the effect after the notification of the case and/or taking protection and control measures including the contacts. Wearing protective overalls, masks and gloves, the team goes to specified addresses and takes samples from the people to be tested. The teams deliver the samples they take to the reference laboratories. The results of the field investigation team's work in the field are evaluated by a committee of public health experts. The last step is to keep persons under investigations (PUIs) and/or persons under monitoring (PUMs) for 14 days in a hospital or in their house, to break the chain of the pandemic. This method leads to early diagnosis of COVID-19 patients or suspects, helping to start treatment at the initial stage of the disease. The field investigation team provide important information such as whether the danger still continues and whether other people are at risk can be obtained. Therefore, this team is taking a crucial role in fighting all infectious disease, and so it makes the fight against COVID-19 more effectively. The violence against field investigation team who are in the riskiest position group in the coronavirus epidemic and who lost many of their colleagues is not ending. One of the field investigation team members A.I. and B.A. with the driver of the institution, were attacked on the street on their way to the field investigation house in Bursa (Duvar Gazetesi, April 29, 2020). Figure 3. the field investigation team(Duvar Gazetesi, April 29, 2020) There was also an alleged 'threat to death' to a family doctor in Izmir. In a statement made by the Izmir Chamber of Medicine the person was invited to the family health center for his child's vaccinations. The family physician explained that vaccination procedures were carried out while maintaining social distance. However, the family physician was threatened with death by child' relatives for having to wait in line (AA Haber, May 2 2020). It is seen that the accusation against healthcare professionals and the violence continues and remains unchanged. It may be thought that the psychological balance of the society is affected by the deterioration of coronavirus, but there was violence towards healthcare professionals even before the coronavirus. Meanwhile, the law for prevention of violence in healthcare has finally been adopted in the period of COVID-19. This is a good development, but in the law, delays in the punishment of the violator against healthcare professionals will reduce the impact of this law. In fact, it is necessary to determine a serious policy for the prevention of violence throughout the country and to implement it seriously. In order to eliminate the problems brought by the system, this system needs to be revised. The commercialization of health undermines the community's trust in the country's health system. Citizen M. Güleryüz said, "I had a cough for two or three days. My cough did not pass. I went to a private hospital for the COVID-19 test. It was the nearest hospital to me. They demanded 476 dollar for the test. There was a controversy over it. Güleryüz, who went out with anger, tried to enter the hospital door with his vehicle (Yeniçağ Gazetesi, 29.04.2020). The COVID-19 pandemic forces a decision on citizens as private hospitals should not request examination fee and additional surcharge from patients undergoing treatment. However, as seen in the case above, COVID-19 test was not included within the scope of this ministry and a serious fee was requested. In this context, complains against private hospitals were made in the past due to many violations. The inquiries have been opened for many hospitals, as many of these private hospitals have asked for unnecessary tests or examinations, and the strategy of increasing the patient's income seriously damages both the patient and the state such as 10 percent of cataract surgeries are unnecessary. After a fake treatment to the father of the president of the Social Security Foundation, in private hospitals an investigation was opened into the private hospital, because these hospitals used the identity of former patients to get the minimum wage (Medimagazin, 2020a). Briefly, the commercialization of the healthcare system affects many private hospitals, and raises new problems and harm on health equality. Limitations of study The present study data were collected from online Turkish newspapers by Google research engine and also from web sites such as Ministry of Health that take official regulation into consideration. Collected reports were taken by key words between March 11 and 30 April 2020. These reports were discussed in the public and on social media and made in some judicial proceedings. Of course, online report can be evaluated in various ways in different contexts or interpretation. Acknowledgement I would like to thank all healthcare professionals who continue to provide healthcare services with ethical attitude despite some negative backlash and the COVID-19 outbreak and also to journalists who continue to report the facts. Conflict of interest None Conclusion This study is about stigmatization and violence against HCPs in Turkey during the COVID-19 pandemic. This world crisis has seriously exerted great pressure on healthcare facilities and healthcare professionals, and society. Although healthcare professionals have presented healthcare service in the frame of the Hippocratic Oath, Medical Deontology Regulation, medical and public health ethics, and patients' rights, they have encountered stigmatization and violence. Stigmatization is an urgent issue because it triggers some negative perceptions such as prejudice, discrimination, and negative stereotypes. These perceptions cause the stigmatized people to be subjected to various acts of violence. The online reports events included in the study prove this situation. Therefore, stigmatization should be considered as an urgent issue and a serious and feasible policy should be developed to prevent stigmatization and violence. In this way, we can protect the healthcare professionals who are committed to protecting and improving the public health, and therefore the society. We should endeavor more to remove violence in health from the agenda in Turkey. 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