Caring on the Frontline during

COVID-19: Contributions from Rapid

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Vindrola-Padros
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Caring on the Frontline
during COVID-19
Contributions from Rapid
Qualitative Research
Edited by
Cecilia Vindrola-Padros
Ginger A. Johnson
Caring on the Frontline during COVID-19
 Cecilia Vindrola-Padros
Ginger A. Johnson
Editors

Caring on the
Frontline during
COVID-19
Contributions from Rapid Qualitative Research
Editors
Cecilia Vindrola-Padros Ginger A. Johnson
Department of Targeted Intervention UNICEF
University College London New York, NY, USA
London, UK

ISBN 978-981-16-6485-4    ISBN 978-981-16-6486-1 (eBook)

https://doi.org/10.1007/978-981-16-6486-1

© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
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 Contents

1 Caring on the Frontline: An Introduction  1

Cecilia Vindrola-Padros and Ginger A. Johnson

2 Reflecting and Learning from the Experiences of

Researchers on Gaining Ethics Approval During the
COVID-19 Pandemic 17
Silvie Cooper and Sophie Mulcahy Symmons

3 Policies and Politics: An Analysis of Public Policies Aimed

at the Reorganisation of Healthcare Delivery During the
COVID-19 Pandemic 39
Sasha Lewis-Jackson, Eleonora Iob, Valentina Giunchiglia,
Jose Roberto Cabral, Maria Romeu-Labayen, Silvie Cooper,
Rirhandzu Makamu, Cassandra Dorasamy, Matthew Ncube,
Romeo Chasara, Elysse Bautista-González,
Paulina Pérez-Duarte Mendiola, Victoria Cavero Huapaya,
Megan Davies, Florian Rutz, and Sandra Staudacher

v
vi Contents

4 Protecting and Feeling Protected: HCWs’ Experiences

with Personal Protective Equipment During the
COVID-19 Pandemic (PPE) 65
Maria Romeu-Labayen, Bruna Alvarez, Ellen Block,
José Roberto Cabral, Marème Diallo, Nehla Djellouli,
Paola Galbany-Estragués, Katarina Hoernke, Diana Marre,
Brenda Moglia, Lorena Pasarin, Carolina Remorini,
Priscila Rivera, Martí Subías, Anahi Sy, Glòria Tort-Nasarre,
Eva Vázquez-Segura, and Shirley Yan

5 “Thrown into the Unknown”: Uncertainty and the

Experiences of HCWs During the Pandemic in Chile,
Brazil and Argentina 91
Eugenia Brage, Carolina Remorini, Anahi Sy,
Cristian R. Montenegro, Marcela González-Agüero,
Vera Schattan Coelho, Gabriela Lotta, Lorena Pasarin,
Brenda Moglia, Laura Teves, and Liz Kingston

6 “People Are Not Taking the Outbreak Seriously”:

Interpretations of Religion and Public Health Policy
During the COVID-19 Pandemic113
Ginger A. Johnson, Sam Martin, Sam Vanderslott,
Trésor Zola Matuvanga, Hypolite Muhindo Mavoko,
Patrick Mitashi Mulopo, Emmanuella Togun,
Oyepeju Ogundipe, Dotun Sangoleye, Echezona Udokanma,
and Victoria Cavero Huapaya

7 Healthcare Workers’ Mental Health and Well-Being

During the COVID-19 Pandemic139
Alexia S-Rivera, Ellen Block, Julia Lohmann, Itzel Eguiluz,
Norha Vera San Juan, and Ana González-Guerra

8 Long-Term Care Staff Perceptions of Providing Care

During the COVID-19 Pandemic in the United
States and Switzerland: Balancing Protection and
Social Isolation159
Andrea Freidus, Dena Shenk, Megan Davies,
Christin Wolf, and Sandra Staudacher
 Contents  vii

9 Uncanny Valley: Healthcare Workers in Settings of

Controlled COVID-19 Response179
Cathy Banwell, Sarah Fitzgerald, Chad Kaye, Timothy Walter,
Anna Olsen, Ashwin Swaminathan, and Christine Phillips

10 Testing Times: COVID-19 Testing and Healthcare

Workers in South Africa199
Kezia Lewins, Peter van Heusden, and
Laurel Baldwin-Ragaven

11 Even Death Has Changed: End-of-Life, Burials, and

Bereavement During the COVID-19 Pandemic229
Itzel Eguiluz, Ellen Block, Lucy Mitchinson,
Lorena Núñez Carrasco, and Alexia S-Rivera

12 The “Knock-on” Effects of COVID-19 on Healthcare

Services253
Kezia Lewins, Ann-Marie Morrissey, Carolina Remorini,
Mora Del Pilar Castro, Maria Noonan, Laura Teves,
María Laura Palermo, and Vikram Niranjan

13 Lessons for Current and Future Pandemics293

Ginger A. Johnson and Cecilia Vindrola-Padros

Index307
 Notes on Contributors

Bruna Alvarez is a postdoctoral researcher at AFIN Research Group at

Autonomous University of Barcelona. Her research is about how adults,
families and teachers talk about sexual and reproductive health with chil-
dren at schools in Barcelona (Spain) and Ciudad Juárez (México). She is
also lecturer at UAB, UB and student advisor at UOC.
Laurel Baldwin-Ragaven AB (Smith), MDCM (McGill), CCFP, FCFP
(Canada), FCFP (South Africa) is Professor of Family Medicine at the
University of the Witwatersrand and the Clinical Head of Family Medicine
at the Gauteng Provincial Department of Health. She has over 35 years of
experience as a physician, teacher, academic, administrator and human
rights practitioner across multiple settings in South Africa, Canada and the
United States. She writes extensively on dual loyalty of health care work-
ers, medical participation in torture, health sector complicity with apart-
heid state violence, gender-based violence, feminism and bioethics,
migrant health and human rights training for health professionals.
Cathy Banwell specializes in exploring the socio-cultural contexts of
population weight gain and the nutrition transition in Australia and Asia,
trends in food and health practices, and health risks associated with non-
communicable diseases. She has made major contributions to public health
problems of high community concern: asbestos in the ACT and PFAS in
three affected communities.

ix
x Notes on Contributors

Elysse Bautista-González is a medical doctor, social epidemiologist, and

public health PhD candidate. She has directed and conducted projects
that seek to generate evidence for equitable policies or interventions and
address the social gradient in health in countries like the UK, USA,
Mexico, and four countries in LATAM.
Ellen Block is Associate Professor of Anthropology at the College of
Saint Benedict & Saint John’s University in Minnesota, USA. Her work in
Lesotho, United States and Ghana examines kinship, care, ageing, and ill-
ness. She is co-author of Infected Kin: Orphan Care and AIDS in Lesotho
(Rutgers University Press, 2019).
Eugenia Brage PhD in anthropology (University of Buenos Aires),
Postdoctoral researcher at the Center for Metropolitan Studies (CEM,
Cepid/FAPESP), University of São Paulo. She studies health care, immi-
gration, and gender.
Jose Roberto Cabral has a Master’s in Public Policy from University
College London. He has experience as an economic and political analyst
in the private and public sectors, as well as in campaign advisory and
politics.
Lorena Núñez Carrasco is an interdisciplinary scholar who holds a PhD
in Medical Anthropology from Leiden University. She is an associate pro-
fessor in the Department of Sociology, University of the Witwatersrand.
Her broader academic interest is on topics that intersect with culture and
health in diverse socio-economic and political contexts. In her research
and publications, both in Latin America and in Southern Africa, she
explores the linkages between migration and health. She is interested in
dying and death in the context of migration and displacement in Southern
Africa, a topic she is researching in the context of the COVID-19
pandemic.
Mora Del Pilar Castro holds a PhD in Social Anthropology. She is an
associate professor at the School of Health Sciences, Universidad Nacional
Arturo Jauretche (UNAJ). She is a researcher in Consejo Nacional de
Investigaciones Científicas y Técnicas (CONICET). Her work focuses on
the Medical Anthropology, Health Systems, Translational Health Sciences,
Applied Anthropology, Social Network Analysis, and Mixed Methods
Approach.
 Notes on Contributors  xi

Vera Schattan Coelho is a senior researcher and team coordinator at the

Brazilian Center of Analysis and Planning (Cebrap) where she leads the
Citizenship, Health and Development Group and associate researcher at
the Center for Metropolitan Studies (CEM, University of São Paulo). She
teaches at the Public Policy Program, Federal University of ABC (UFABC),
São Paulo, Brazil. Her areas of interest are social policies, health systems,
and citizen involvement in public policies and development. She works
with both qualitative and quantitative research methods and has extensive
experience in evaluating policies and coordinating comparative research
projects at the local, national, and international level.
Silvie Cooper is a Health Sociologist and Lecturer (Teaching) of Applied
Health Research at University College London, UK, and visiting research
scholar at WITS University in South Africa. Her research interests include
capacity building for health research, management of chronic pain, digital
health and patient education, using qualitative, mixed methods and trans-
lational research approaches. Alongside her research, she designs and
teaches on a variety of health and social science courses for undergradu-
ates, postgraduates and professionals. Topics include research and evalua-
tion methods, the social aspects of health and illness, and the impact of
context, practice and policy on healthcare experiences.
Megan Davies is a PhD student at the University of Basel, Switzerland.
Marème Diallo is a postdoc fellow of health system in the Medical
Research Council Unit The Gambia (MRC-G) at the London School of
Hygiene & Tropical Medicine. With the West African Global Health
Alliance (WAGHA), she is based in Senegal at the Institut de Recherche
en Santé de Surveillance Epidémiologique et de formation (IRESSEF). In
2018, Diallo defended a doctoral thesis of sociology of health on the
determinants of unmet need on family planning in Senegal. Since then,
she is a postdoc fellow at MRC-G where she mainly works on health sys-
tems in West Africa through maternal and neonatal health and sometimes
transnational health care uses. With Covid pandemic, she started working
on Human Resources on Health with a qualitative approach.
Nehla Djellouli is a social scientist based at University College London
Institute for Global Health. Her work focuses on policy/programme
implementation and evaluation drawing on social science and qualitative
and participatory methodologies. She has experience working on multidis-
ciplinary projects in the areas of maternal and new-born health; HIV/
xii Notes on Contributors

AIDS and epidemics; patient and public involvement; gender and health
inequalities in several countries (Bangladesh, Burkina Faso, Colombia,
India, Kenya, Malawi, Mozambique, Uganda, and the UK).
Cassandra Dorasamy is an MA student in the Development Studies
Programme at the University of the Witwatersrand (WITS University),
where she is also a tutor for the Critical Thinking and Sociology of Health
and Illness courses. She completed undergraduate studies from the
University of KwaZulu Natal in Community Development and Legal
Studies. Her MA research focuses on the governance of Muslim marriages
in South Africa and looks at issues of legal pluralism, law reform and gen-
der and multiculturalism through the personal experiences of women and
practitioners.
Itzel Eguiluz holds a PhD in International Migrations from UCM and
an MSc from the National Institute of Public Health of Mexico (INSP).
She works with qualitative methods researching issues about migration
and global health. As a consultant, she worked for the UNHCR, UNFPA,
and Partners in Health, among others. Also, she is a professor at the TEC
CCM, UNAM and the Instituto Mora and an invited professor at
Washington University.
Sarah Fitzgerald earned her Bachelor of Physiotherapy with Dean’s
Honours (2009) from La Trobe University, Bendigo, Australia. She prac-
ticed as a physiotherapist for over ten years in Australia, the United
Kingdom and New Zealand with a keen interest in intensive care rehabili-
tation and cardiorespiratory physiotherapy. She is now enrolled in the
Doctor of Medicine and Surgery (MChD) degree at the Australian
National University, Canberra, Australia, as a second-year student.
Andrea Freidus is Assistant Professor of Anthropology at University of
North Carolina Charlotte in the Department of Anthropology. She is an
applied medical anthropologist who has worked on a variety of research
topics including orphan care in Malawi, volunteer tourism, and health
disparities and food insecurity in Charlotte, North Carolina.
Paola Galbany-Estragués is a nurse and anthropologist with a PhD in
nursing science. She is Professor at Universitat de Vic-Universitat Central
de Catalunya. She is a member of AFIN at Universitat Autonoma de
Barcelona and the group Methodologies, Methods, Models and Health
and Social Outcomes, UVic-UCC.
 Notes on Contributors  xiii

Valentina Giunchiglia is a master student of Health Humanities at the

University College London Centre for Multidisciplinary and Intercultural
Inquiry (CMII). She got her bachelor in Molecular Biotechnology, spe-
cialization Bioinformatics, from Heidelberg University, and did research
at the German Cancer Research Center (DKFZ) in Heidelberg, Janssen
Pharmaceutica (J&J), the University of Edinburgh and the Centre of
Integrative Biology (CIBIO) at the University of Trento. Her research
interests are mainly focused on the study of the relationship between men-
tal and physical health through computational models.
Marcela González-Agüero is a nurse and medical anthropologist inter-
ested in the relationship between health, illness and care and how health
systems attend to the experiences and needs of individuals. In doing so,
she has worked with diverse populations and focused on different types of
health conditions (acute and chronic), contributing to the understanding
of healthcare as a social process. She is an assistant professor at the School
of Nursing, Pontificia Universidad Católica de Chile.
Ana González-Guerra is a general practitioner who graduated from the
Tecnologico de Monterrey School of Medicine in Mexico. She has worked
as a consultant for the Global Fund on issues related to tuberculosis. Also,
she has been trained in global health and in quality of care and patient safety.
Katarina Hoernke is a student at Norwich Medical School at the
University of East Anglia (UEA). Before her final year of the Bachelor of
Medicine, Bachelor of Surgery (MBBS) degree she intercalated in a
Masters of Global Health and Development at University College
London (UCL).
Victoria Cavero Huapaya is studying the Global Mental Health MSc at
KCL & LSHTM. She has experience working in mental health projects
related to the comorbidity of physical and mental health, common mental
disorders, and health providers’ mental health. She is doing her disserta-
tion as a policy document analysis regarding the excess mortality of people
with mental disorders in Peru.
Eleonora Iob is a PhD researcher in Psychobiology and Teaching Fellow
in Quantitative Research Methods at University College London (UCL).
Her PhD focuses on the neuroendocrine, inflammatory, and genetic
mechanisms involved in the link between adverse childhood experiences
and depression and is funded by the Soc-B Centre for Doctoral Training
xiv NOTES ON CONTRIBUTORS

in Biosocial Research (ESRC-BBSRC). Before joining UCL, Eleonora

graduated with a BSc (Hons) in Psychology from The University of
Manchester in 2016. After her BSc, she was awarded a full-tuition scholar-
ship for an MSc in Social Statistics and Research Methods at The University
of Manchester.
Ginger A. Johnson is a medical anthropologist who has conducted
research in East, West, and Southern Africa, North and Southeast Asia,
and in the Middle East and North Africa on behalf of the World Food
Programme (WFP), United Nations Children’s Fund (UNICEF), the
World Health Organization (WHO), the International Federation of Red
Cross and Red Crescent Societies (IFRC), United Nations Population
Fund (UNFPA), Population Services International (PSI) and United
Nations High Commissioner for Refugees (UNHCR). She was embedded
in West Africa with the IFRC during the 2014–2016 Ebola outbreak and
is a member of the Humanitarian Health Research Initiative at Australian
National University. Cecilia and Ginger co-direct the Rapid Research
Evaluation and Appraisal Lab (RREAL). The purpose of RREAL is to
improve the quality and impact of rapid research used to study and evalu-
ate clinical and health service models and interventions for time-sensitive
contexts. RREAL focuses on the development of rapid research in the
following areas: (1) health services research, (2) clinical trials, and (3)
global health and complex health emergencies.
Norha Vera San Juan is a social epidemiologist focused on mental health
policy and service development, particularly applying research methods
that promote stakeholder involvement. As part of her PhD, she developed
a measure of recovery as understood by Latin American mental health
service users. This work challenged the traditional focus on clinical views
and rather advocated for co-construction of knowledge to promote the
sustainable development of health services. She works as a postdoctoral
research associate at the NIHR Mental Health Policy Research Unit, a
commission of the Department of Health that provides timely evidence to
policymakers.
Chad Kaye is from New South Wales, Australia, and graduated with a
Bachelor of Medical Science (Physiology and Immunology) (2017) from
The University of Sydney. He is currently enrolled in the Doctor of
Medicine and Surgery (MChD) degree at the Australian National
University, Canberra, Australia, as a second-year student, and holds an
interest in Trauma and International Humanitarian Aid.
 NOTES ON CONTRIBUTORS xv

Liz Kingston is a member of the Health Research Institute at University

of Limerick and Infection Prevention Society, UK. Her teaching and
research interests are in the field of infection prevention and control and
hand hygiene with many publications in the field.
Kezia Lewins is a medical sociologist based at the University of the
Witwatersrand in Johannesburg, South Africa. She has an interest in health
disparities, acts of power and agency within health care and the health
system; she is an advocate of patient-centred care and is interested in the
way COVID-19 brings much of this to the fore.
Sasha Lewis-Jackson is a medical anthropologist interested in applied
health research and policy. She has previously conducted undergraduate
research into the 2014–2016 Ebola outbreak in West Africa. Her most
recent work undertaken as a postgraduate student at University College
London is an analysis of the clinical decision making of healthcare work-
ers, as they provide rehabilitation care for recovered COVID-19 patients.
Julia Lohmann is an assistant professor at the London School of Hygiene
& Tropical Medicine. She works on Human Resources for Health in low-
and middle-income countries, specifically on questions of motivation, sat-
isfaction, well-being, and mental health, as well as on health systems and
interventions to strengthen them more generally.
Gabriela Lotta is Professor of Public Administration at Fundação Getulio
Vargas (FGV). She coordinates the Bureaucracy Studies Center (NEB).
She is a professor at the National School of Public Administration, ENAP,
a researcher at the Center for Metropolitan Studies (CEM) and at the
Brazil Lab from Princeton University. She was a visiting professor at the
University of Aalborg (Denmark) in 2019 and a visiting professor at
Oxford University in 2021. She works mainly in the areas of public policy,
bureaucracy, health policy, and policy implementation. Lotta received her
BSc in public administration and PhD in Political Science at the University
of São Paulo.
Laura Maio has a background in Oriental Studies and Anthropology,
with an MSc in Development Studies and has spent the past ten years
working as evaluator and researcher in the UK healthcare sector. Her pre-
vious work includes qualitative research on palliative care for people with
dementia and evaluating specialist dementia nursing services using mixed
methods.She’s interested in applied research and how qualitative findings
can be used to improve healthcare provision and influence policy.
xvi NOTES ON CONTRIBUTORS

Diana Marre is Associate Professor of Anthropology and Director of the

AFIN Research Group and Outreach Centre at the Autonomous University
of Barcelona. She is the co-editor of International Adoption: Global
Inequalities and the Circulation of Children (New York University Press,
2009), La adopción y el acogimiento: presente y perspectivas (Ediciones
de la Universidad de Barcelona, 2004) y Maternidades, Procreación y
Crianza en Transformación (Bellaterra, 2013).
Sam Martin is a digital sociologist and social data scientist who has con-
ducted research on the digital discourse of vaccine hesitancy, digital health,
and chronic illness. She works with the Oxford Vaccine Group and was
previously Digital Analytics Lead at the Vaccine Confidence Project
(London School of Hygiene & Tropical Medicine) and has publications
on digital health, vaccine hesitancy, and data science methodology.
Trésor Zola Matuvanga is an MD and PhD student. He works as site
coordinator in an Ebola vaccine trial at Boende in DR Congo within a
collaboration between University of Kinshasa (UNIKIN) and University
of Antwerp. He is completing his specialization in tropical medicine at the
UNIKIN. He has great interest in medical anthropology.
Paulina Pérez-Duarte Mendiola is a paediatrician from Mexico, who is
passionate about the social and cultural aspects of child-rearing and chil-
dren’s healthcare. She is studying a Master’s in Medical Anthropology and
writing her dissertation about how ‘Play Therapy’ and ‘Imaginal Coping’
is used to support children with chronic illnesses.
Lucy Mitchinson is a PhD candidate at UCL researching the impact of
complementary therapies in palliative care. With a Bachelor of Science in
Psychology and a Master of Research in Psychological Research Methods,
Lucy has published work on nurses and midwives’ experiences of harass-
ment and bullying, barriers to career progression, and the experiences of
healthcare workers during the COVID-19 pandemic. Her background in
mixed methodologies and experience working as a research assistant at the
Bradford Institute for Health Research has inspired her interest in under-
standing the perspectives and experiences of patients and healthcare staff.
Brenda Moglia has a degree in Anthropology from Universidad Nacional
de La Plata. She has a master in Epidemiology, Management and Health
Policies and is a PhD candidate in Collective Health (Instituto de Salud
Colectiva, Universidad Nacional de Lanús). She serves as a doctoral fellow
 NOTES ON CONTRIBUTORS xvii

of the National Council for Scientific and Technical Research (CONICET,

Argentina). Her research topic is about the health care processes in public
hospitals from an ethnographic and ethno-­epidemiological approach.
Cristian R. Montenegro is a health sociologist interested in global men-
tal health policy. He holds a PhD in Social Research Methods from the
London School of Economics. His work broadly concentrates on the
exchanges between health and democracy, at the micro (service-user expe-
rience and engagement) and macro levels (health-related social move-
ments, democratic transitions, human rights, and health care policy),
specifically in the global south. He is a Research Fellow at the Wellcome
Center for Cultures and Environments of Health, University of Exeter.
Ann-Marie Morrissey Health Research Institute, Ageing Research
Centre, School of Allied Health, University of Limerick. Ann-Marie is a
Lecturer in Occupational Therapy at the University of Limerick (UL).
Her research background is neurorehabilitation. She is a member of the
Health Research Institute and the Ageing Research Centre in UL. She is
also a member of the research committee for the Association of
Occupational Therapists of Ireland.
Hypolite Muhindo Mavoko is specialized in tropical medicine, with a
main interest in neglected tropical diseases and ethics aspects. He holds a
PhD degree in medical sciences. He has experience in implementing and
conducting multidisciplinary research projects in remote (and challeng-
ing) areas in the Democratic Republic of the Congo.
Patrick Mitashi Mulopo is a medical doctor, specialist in Tropical
Medicine with PhD in medical sciences from the University of Antwerp
with the control of infectious diseases as the anchor point. He is working
in the control of infectious and re-emerging diseases. He is a teacher of
parasitic pathologies at the Faculty of Medicine, University of Kinshasa,
where he also exercises the functions of the Head of Department of
Tropical Medicine. He is author/co-author of some publications in the
field of infectious diseases, health policy, and synthesis of evidence.
Matthew Ncube holds an MSc degree in International Development
Studies from Wageningen University & Research, Netherlands (2021). In
his master’s degree, he specialised in ‘Politics and Governance of
Development’: a program that focuses on public policies, social transfor-
mation processes, contested power and political dynamics of development
xviii NOTES ON CONTRIBUTORS

in both local and international levels. Matthew joined the RREAL

COVID-19 project as a research intern, in partial fulfilment of his MSc
program requirements. He also holds a BA honours degree in Development
Studies from the University of the Witwatersrand and a Bachelor of Social
Sciences degree in International Relations from Monash University.
Vikram Niranjan is a public health specialist with his research focus on
public patient involvement, cancer research, quality of life, health promo-
tion programmes, and oral health. He’s working as postdoctoral researcher
at University of Limerick. He has been international speaker at interna-
tional conferences and has several paper presentations at conferences.
Maria Noonan is a lecturer in the Department of Nursing and Midwifery,
University of Limerick, Ireland. Maria’s research interests include imple-
mentation science, experience-based co-design, and systematic review
methodology and she is a fellow of evidence synthesis Ireland.
Oyepeju Ogundipe is a senior clinical research associate with 54gene.
Oyepeju is contributing to tackle disparities in healthcare research by sup-
porting clinical research capacity development in Africa. She earned a
bachelor’s degree in Pharmacy from University of Lagos and a master’s
degree in Global Health and Development from University College
London. She has interests in infectious diseases and medications outcome
and has gained experience in clinical research, quantitative, and qualitative
research involving data collection and statistical analysis. Due to her pas-
sion for social change, she volunteers with the ONE campaign as a ONE
Champion.
Anna Olsen is Associate Professor of the Social Foundations of Medicine
at the Australian National University Medical School. She is an experi-
enced qualitative researcher in the field of public health. Employing
empirical data and theory to practice and policy, she facilitates effective
collaborative efforts between researchers, communities and government.
Transformation and social justice lie at the heart of her research, with the
intent of creating a better understanding of health inequalities and, in
turn, influence policy responses and health care systems that respond to
people in the real world.
María Laura Palermo holds a Degree in Anthropology. She is a PhD
student at Facultad de Ciencias Naturales y Museo (FCNyM), Universidad
Nacional de La Plata (UNLP). She holds a PhD Scholarship 2016–2021
 NOTES ON CONTRIBUTORS xix

granted by Consejo Nacional de Investigaciones Científicas y Técnicas

(CONICET). She is a researcher in Laboratorio de Investigaciones en
Etnografía Aplicada (LINEA) at Universidad Nacional de La Plata and a
teaching assistant in Ethnography I Course (FCNyM-UNLP).
Lorena Pasarin holds a PhD in Natural Sciences and a degree in
Anthropology from the Universidad Nacional de La Plata, Argentina
(UNLP). She is teaching assistance in a graduate-level course on anthro-
pological theory. She is a researcher in Laboratorio de Investigaciones en
Etnografía Aplicada (LINEA) at Universidad Nacional de La Plata. She
holds a Postdoctoral Fellowship granted by Consejo Nacional de
Investigaciones Científicas y Técnicas (CONICET). Her work focuses on
Medical Anthropology, Environmental Anthropology, Applied
Anthropology, Social Network Analysis, and Mixed Methods Approach.
Christine Phillips is a general practitioner whose clinical work is in refu-
gee health care, and patients who live in deep urban poverty. Her research
addresses health services and systems, including workforce, to deliver
quality and equity in health care. She is Professor of Social Foundations of
Medicine at the Australian National University Medical School.
Nina Regenold is a master’s student at University College London
studying Medical Anthropology. She is interested in qualitative health
research, especially relating to health inequalities. She is examining the
gendered impacts of COVID-19 on healthcare workers in the UK in col-
laboration with the RREAL COVID-19 study.
Carolina Remorini holds a PhD in Natural Sciences and a degree in
Anthropology from the Universidad Nacional de La Plata, Argentina
(UNLP). She is a tenured professor at Universidad Nacional de La Plata
(UNLP) (School of Natural Sciences, University of La Plata). She is an
associate researcher in Consejo Nacional de Investigaciones Científicas y
Técnicas (CONICET) and a member of Laboratorio de Investigaciones
en Etnografía Aplicada (LINEA) at Universidad Nacional de La Plata. She
conducts ethnographic research on child development and health, in rural
and indigenous communities of Argentina. Her work focuses on Child
Development, Medical Anthropology, Qualitative Methods, and Applied
Ethnography.
xx NOTES ON CONTRIBUTORS

Priscila Rivera is a social anthropologist interested in applied research in

gender, reproductive technologies, health policy, and bioethics. Her
research is focused on egg donors in Spain: how their experiences and
motivations are shaped by gender, medical and clinical practices, laws, and
markets. She is an associate professor on Ecuador, Universidad Tecnica
Luis Vargas Torres.
Maria Romeu-Labayen is researcher at the AFIN Research Group at
Autonomous University of Barcelona. She is a mental health nurse and has
a PhD in Nursing from the University of Lleida. She is also associate pro-
fessor in the Department of Public Health, Mental Health and Mother-­
Infant Nursing, University of Barcelona.
Dotun Sangoleye is a seasoned medical doctor and public health enthu-
siast, with five years of experience in clinical medicine and nonprofits,
designing and managing programmes using social and behavioural change
communication for environmental sustainability. He is presently deploy-
ing behavioural change models to solve risk communication challenges in
public health. His interests are in designing and implementing policies and
reforms that provide social and financial risk protection for the most vul-
nerable communities.
Dena Shenk is former Director of the Gerontology Program at the
University of North Carolina at Charlotte, a position she held for 23 years,
and is Emerita Professor of Anthropology. Her research interests are diver-
sity within the older population based on gender, culture, and environ-
ment with an emphasis on individual expectations and experiences of
ageing. Recent research focuses on person-centred care for people with
dementia and the people who care for them and the use of photographic
methods.
Georgina Singleton is taking time out of her clinical training programme
in anaesthesia to complete a fellowship with the Health Services Research
Centre (HSRC). Her interests include perioperative medicine and qualita-
tive research methods; much of her recent work has combined the two.
During the COVID-19 pandemic, Georgina has also spent some time
working as an intensive care doctor in a regional cancer hub.
Alexia S-Rivera is a medical doctor from Anahuac University and a stu-
dent of the Master’s Degree in Health Sciences and Speciality in Health
Research at the Anahuac University. She works as project coordinator at
 NOTES ON CONTRIBUTORS xxi

the Instituto Mexicano del Seguro Social. She is Director of the Technical
Section of Mental Health of the Mexican Society of Public Health and has
been an expert consultant for international organizations on various health
issues. Her areas of interest in qualitative research are mental health and
public health policies.
Sandra Staudacher is a medical anthropologist and lawyer with expertise
in social and cultural aspects of ageing, health and care. Since 2018 she
holds a postdoctoral position at the Institute of Nursing Science (INS),
Department of Public Health at the Faculty of Medicine, University of
Basel. She is interested in analysing person-centred care, quality of life,
and interprofessionality in nursing homes.
Martí Subías is Registered Mental Health Nurse at Sant James of God
Hospital in Sant Boi, Barcelona. He is working as a case manager in men-
tal health. He is a PhD candidate, holds a master’s degree in Personality,
Eating and Emotional disorders by the University of Valencia, and is
Associate Professor on the Public, Mental and Pediatric Health Department
at the University of Barcelona.
Ashwin Swaminathan is a physician and infectious diseases specialist. In
addition to his clinical work, he has an interest in environmental epidemi-
ology and health care facility systems. He is also Clinical Director of
General Medicine at Canberra Hospital and senior lecturer at Australian
National University Medical School.
Anahi Sy has a degree in Anthropology, PhD, Natural Sciences from
Universidad Nacional de La Plata. She is a senior researcher from National
Council for Scientific and Technical Research (CONICET, Argentina)
and a graduate and postgraduate lecturer at the Instituto de Salud
Colectiva, Universidad Nacional de Lanús. She is an associate editor of the
scientific journal Salud Colectiva and has worked on issues of anthropol-
ogy and intercultural health, mental health and hospital institutions, from
an ethnographic and ethno-epidemiological perspective. She has pub-
lished several scientific works with national and international refereeing,
among the most outstanding ones: Socio/Ethno-­epidemiologies: propos-
als and possibilities from the Latin American production. Health Sociology
Review, 26:3, 2017 and the book Historias Locas, Ed. Teseo, Buenos
Aires, Argentina (2020).
xxii Notes on Contributors

Sophie Mulcahy Symmons is a PhD student at University College

Dublin conducting research to improve cervical cancer screening aware-
ness funded by the Irish Cancer Society. She has an MSc from University
College London in Population Health and BSc in Genetics from Trinity
College Dublin. She has an interest in health promotion, health commu-
nication and health equity and ethics in genetics and health.
Laura Teves holds a PhD in Natural Sciences and a degree in Anthropology
from the Universidad Nacional de La Plata, Argentina (UNLP). She is a
tenured professor and a researcher at UNLP. She teaches a course on
anthropological theory and conducts research using social network analy-
sis (SNA) applied to the study of economy and health in rural and indig-
enous communities in Argentina. Her work focuses on Applied
Anthropology, Social Network Analysis, and Mixed Methods Approach.
She is the Director of Laboratorio de Investigaciones en Etnografía
Aplicada (LINEA) at Universidad Nacional de La Plata.
Sagana Thayaparan is a medicine graduate from King’s College London
and is completing her MSc in Public Health at LSHTM. She is working on
a project exploring the experiences of BAME patients and relatives with
COVID in intensive care units in the UK. She is passionate about tackling
health inequities and medical education.
Emmanuella Togun is a Global Health and Development professional
focused on strengthening health systems in resource constrained settings.
She has proven experience garnered across public, private, non-profit, and
research institutions in Africa and Europe, where she has been working
across programmes, policy, advocacy, and research. She is also the co-­
founder of Afro Health Initiative, a platform that leverages the African
diaspora for health system strengthening on the continent. She holds a
Bachelor’s degree in Genetics from the University of Lagos and a Master’s
degree in Global Health from King’s College London. Outside of work,
she enjoys travelling, writing, and public speaking.
Glòria Tort-Nasarre is a nurse, anthropologist, and has a PhD in
Pedagogy. With more than 20 years of experience in the field of university
nursing teaching, she is a professor at the Faculty of Nursing and
Physiotherapy University of Lleida. She has led proposals for improving
university education through innovative teaching methodologies such as
problem-based learning, clinical simulation, and flipped classroom. At the
 Notes on Contributors  xxiii

same time, she is a primary care nurse. She is trained in qualitative research
and her topics of interest are good clinical practice in primary care and in
teaching in higher education. She belongs to the Greps (Health Education
Group) of the University of Lleida and collaborates with the AFIN group
of the Autonomous University of Barcelona.
Inayah Uddin has completed a BSc in Psychology and an MSc in Health
Psychology at UCL. Her research interests include research in healthcare
organizations and delivery of medical services in LMICs using qualitative
approaches.
Echezona Udokanma is a global health researcher with an interest in
health promotion, development, policy analysis, health system strengthen-
ing, and management. He has a background in Health Education and as
an African Graduate Scholar; he obtained an MSc in Global Health and
Development at the University College London. He has gained experi-
ence in research, policy analysis, and business management. He is a pub-
lished researcher with skills in data analysis, systemic, and analytical
reasoning, programme design, implementation and evaluation, and busi-
ness management. He hopes to synergize his research and management
skills in strengthening Nigeria’s health system.
Sam Vanderslott is a health sociologist at the Oxford Martin School and
Oxford Vaccine Group at the University of Oxford working on health,
society, and policy topics. She draws on perspectives from sociology, his-
tory, global public health, and science and technology studies (STS) and
has published in journals including Social Science and Medicine, Clinical
Infectious Diseases, Nature and Culture, and Human Development and
Capabilities.
Eva Vázquez-Segura (she) is a nursing graduate and a specialist in
Obstetric and Gynecological Nursing (Midwife). She’s been working as a
community midwife for the last 23 years, the last 18 years at Institut Català
de la Salut where she also works at Trànsit (a transgender healthcare ser-
vice). She’s got an MA in Women’s, Gender and Citizenship Studies and
is a PhD student of Gender Studies at Universitat Autònoma de Barcelona
doing her research on reproduction and non-binary people. She’s also
Assistant Professor of Sexual and Reproductive Health Nursing at
Universitat de Barcelona.
xxiv Notes on Contributors

Cecilia Vindrola-Padros is a medical anthropologist interested in applied

health research and the development of rapid approaches to research. She
works across four interdisciplinary teams, applying anthropological theo-
ries and methods to study and improve healthcare delivery in the UK and
abroad. She is a researcher on the NIHR-funded Rapid Service Evaluation
Team (RSET), a collaboration between UCL and the Nuffield Trust. She
has written extensively on the use of rapid qualitative research and co-
directs the Rapid Research, Evaluation and Appraisal Lab (RREAL) with
Dr. Ginger Johnson. She is the past Director and current training lead for
the Qualitative Health Research Network (QHRN). Cecilia works as a
Senior Research Fellow in the Department of Targeted Intervention,
University College London, and Social Scientist at the NIAA Health
Services Research Centre (HSRC), Royal College of Anaesthetists (RCoA).
Timothy Walter is from New South Wales, Australia, and graduated with
a Bachelor of Medical Science (2019) from the University of Technology,
Sydney. He is currently enrolled in the Doctor of Medicine and Surgery
(MChD) degree at the Australian National University, Canberra, Australia,
in the second year of the degree.
Christin Wolf is a graduate student at the University of North Carolina
at Charlotte in the departments of anthropology and public health with a
concentration in medical anthropology and community health. Her
research interests include the impact of COVID-19 on caregivers and per-
sons living with dementia as well as issues of food insecurity on college
campuses.
Shirley Yan is the Qualitative Research Lead at Noora Health. She has
experience in social and behavioural interventions and application of
human-centred design across public health interventions in malaria, sexual
and reproductive health, and patient education. She has an MSPH in
Social and Behavioral Interventions.
 List of Figures

Fig. 3.1 Epidemiological pathway of the virus according to the chapter

structure. The numbers on the map correspond with the case
study countries 42
Fig. 3.2 Number of policies per key finding for Spain and Italy 46
Fig. 3.3 Number of policies and new daily COVID-19 cases in Italy
and Spain 48
Fig. 4.1 Volunteers making handmade protective gowns at home in
Spain73
Fig. 4.2 Protective gown made of garbage bags 74
Fig. 6.1 Top keywords in Pakistan 121
Fig. 6.2 Discussion of COVID-19 antibody tests amongst HCWs
mixed with colloquial prayers for protection 122
Fig. 6.3 Discussion by one HCW regarding COVID-19 positivity
testing rates among local health providers 123
Fig. 6.4 Discussion of HCW challenges wearing PPE and increased
workloads during Ramadan 124
Fig. 6.5 Most frequently used channels among HCWs for sourcing
information on COVID-19 129
Fig. 10.1 New COVID-19 cases reported per day (weekly average)
and Healthcare Worker Hospitalisations per week during
South Africa’s first and second waves of COVID-19. (Derived
from: Our world in Data 2020/2021; Johns Hopkins
University CSSE 2020; NICD 2020; National Institute for
Occupational Health 2021) 204
Fig. 11.1 Mexican hospitalization COVID-19 area Medical Doctor
COVID-19 with PPE 233

xxv
xxvi List of Figures

Fig. 11.2 Mexican hospitalization COVID-19 area Medical Doctor

COVID-19 with PPE trying to rest in the middle of long
shifts234
Fig. 11.3 Nursing assistant in a hospital in the US 235
 List of Tables

Table 2.1 Existing guidelines for rapid REC set up during health
emergencies21
Table 2.2 Challenges and suggested solutions by researchers for
overcoming REC barriers 26
Table 2.3 Recommendations for researchers in navigating REC review
processes for rapid qualitative research 31
Table 9.1 Characteristics of study participants 184

xxvii
 CHAPTER 1

Caring on the Frontline: An Introduction

Cecilia Vindrola-Padros and Ginger A. Johnson

In December 2019, the first COVID-19 case was confirmed in Wuhan,

China. This would be followed by weeks of uncertainty and reports that
the virus had spread to other countries. As cases started to rise around the
world, we all became witnesses to the palpable strain the increase in hospi-
tal admissions created on healthcare systems around the world. Photos of
exhausted healthcare workers (HCWs), with bruises produced by masks
and visors, flooded the media. In many countries, the general public made
an effort to recognise the work of hospital workers by clapping and post-
ing thank you messages.
As the virus spread to more countries and the pandemic evolved to
include multiple epidemiological waves, frontline staff continued to bear
the brunt of the uncontrolled spread of the disease. Not all healthcare
workers were valued and cheered and many reported difficult encounters

C. Vindrola-Padros (*)
Department of Targeted Intervention, University College London, London, UK
e-mail: c.vindrola@ucl.ac.uk
G. A. Johnson
UNICEF, New York, NY, USA
e-mail: gijohnson@unicef.org

© The Author(s), under exclusive license to Springer Nature 1

Singapore Pte Ltd. 2022
C. Vindrola-Padros, G. A. Johnson (eds.), Caring on the Frontline
during COVID-19,
https://doi.org/10.1007/978-981-16-6486-1_1
2 C. VINDROLA-PADROS AND G. A. JOHNSON

with the general public (e.g. heated arguments and physical aggression)
due to fears that they would be ‘carriers of the virus.’ Many were physically
removed from public areas and even evicted from their homes. As personal
protective equipment (PPE) shortages were denounced around the globe,
HCWs feared they had become disposable and many called on their gov-
ernments to change the course of action, improving preventive measures
and investing in healthcare systems’ most precious resource—its workforce.
In many ways, the COVID-19 pandemic illuminated fractures of
healthcare systems around the world, perhaps especially those located in
the global North once considered to be among the best examples of func-
tioning healthcare. As governments scrambled to contain and deal with
the impact of this rapidly spreading virus, the effects of decades of budget
cuts, understaffing, fragmentation and inequalities in access to care could
no longer be denied.
This book is a testament to the experiences of frontline healthcare
workers delivering care during the COVID-19 pandemic. It paints a
global picture of the uncertainty, struggle, fears and hopes of the millions
of doctors, nurses, community health workers, therapists, cleaners, porters
and managers who worked tirelessly to respond to the demands created by
the virus. These experiences are understood and analysed in relation to
global trends, epidemiological ‘waves’ and local contextual factors. The
book maps these experiences across different stages of the pandemic,
including the anticipation and preparation for the impact of the virus while
looking afar at the damage it had produced in other countries, to planning
for the long-term consequences the pandemic had on populations and
healthcare systems—and the stark realisation that COVID-19 ‘is not
going away.’
The book is an unusual edited volume in the sense that the content was
created by a global network of research teams composed mainly of social
scientists who worked collaboratively since the early stages of the pan-
demic to share study protocols, materials, problems and solutions. The
network was developed by the Rapid Research Evaluation and Appraisal
Lab (RREAL), with headquarters in University College London in the
United Kingdom (UK). The UK team was the first team to design and
implement a rapid appraisal on the experiences of healthcare workers
delivering care during the COVID-19 pandemic in March 2020. This
team then began to contact research teams in other areas of the world,
asking them if they wanted to ‘replicate’ the study (with modifications
required for the local context) and join a global network of teams carrying
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 3

out a series of ‘mirror studies.’ The network grew rapidly and, at one
point, teams from 22 countries were replicating at least one aspect of the
study. The network met regularly to discuss emerging findings from the
study and paint a global picture of the experiences of healthcare workers.
This book is an attempt to bring this extensive knowledge base together,
reflecting on the similarities and differences of the experiences of health-
care workers at a global scale.
The authors represented within this book felt that the challenges posed
by a pandemic which affected HCWs and systems of care in every country
in the world, demanded a cross-cultural representation of shared vulnera-
bility and responsibilities. The book can be seen as a journey into the lives
of healthcare workers that were shaped by their governments’ response to
the pandemic through the development of public policies and guidelines,
changes in their clinical roles and care delivery practices, and the emo-
tional and psychological impact of working long hours and encountering
death on a daily basis. The journey is shaped by the exacerbation of pre-­
existing inequalities in access to care in the case of patients, but also in
relation to the working conditions of staff, where gender, social class and
ethnicity interlaced to increase the risk of infection and death in HCW
populations of lower socio-economic status and from minority eth-
nic groups.
The book is also a journey into the lives of the research teams that made
this global network possible, as it reflects on the challenges of carrying out
qualitative research in the context of a pandemic. These research teams
adopted approaches from the field of rapid qualitative research that allowed
them to quickly set up studies, analyse data during successive waves of data
collection and share emerging findings with relevant stakeholders (so that
findings could be used to inform response efforts). These journeys were
shaped by delays generated by ethics review committees, restrictions that
prevented access to medical facilities and staff, limited budgets for research
and the pressures researchers were facing in their own lives (uncertainty,
fears, childcare issues, illness and bereavement).
In the following pages, this introductory chapter sets the scene that
framed the development of this book. It provides a close look at the global
context of care delivery during the COVID-19 pandemic, drawing lessons
from previous epidemics. It then describes how our research sought to
document these experiences, teasing out the key messages for public
health authorities, UN and non-governmental organisations, think tanks
and other research teams we collaborated with to make sure the research
4 C. VINDROLA-PADROS AND G. A. JOHNSON

findings were actively used. The chapter ends with an overview of the
book by describing the content of chapters that cover public policy, men-
tal health and wellbeing, feeling protected and protecting others, resource
scarcity, end of life, clinical uncertainty, inequalities, religious interpreta-
tions of illness and care, the knock-on effects on other conditions and
areas of healthcare systems, and the long-term consequences of the
pandemic.

Working During an Infectious Epidemic:

A Global Look
The current global pandemic may feel like an unprecedent series of events
for which HCWs and the systems they work for could not have predicted
nor prevented. However, we do have many examples, both historic (e.g.
influenza pandemic in 1918) and more contemporary (e.g. SARS-CoV in
2002–2003, H1N1 in 2009, MERS-CoV in 2012, Ebola in 2014, Zika in
2016) of sudden outbreaks of infectious disease and their impact on local
health systems and human resources.
In this way, HCWs have a history of being at risk, and oftentimes the
‘canary in the coalmine,’ for infectious diseases. Surveilling infections
among HCWs is in fact a key component of event-based surveillance
(EBS) during the ‘alert’ phase of a pandemic. Data from two global viral
infectious disease outbreaks on the spectrum of Coronaviruses which have
occurred within the last two decades—SARS and MERS—is telling. For
the SARS outbreak which began in November 2002 in Southern China,
the number of HCW infections globally was over 21%. The largest num-
bers of SARS-infected HCWs were in China, with a significant minority of
infections reported in health staff in Canada, France, Germany, the
Philippines, Singapore, Thailand and Vietnam (Xiao et al. 2020). For the
MERS outbreak which began in June 2012 in Western Saudi Arabia (and
in which new cases have arisen periodically since), the number of HCW
infections reported from 2013 to 2020 has fluctuated depending on sea-
son, but with the highest reported peak comprising 32% of total infections
(peaking in 2014 and again in 2015). The largest numbers of MERS-­
infected HCWs have been from Saudi Arabia and, to a lesser extent, South
Korea (WHO 2020a; Xiao et al. 2020).
A meta-analysis of HCW occupational acquired infections from the
novel influenza A outbreak (H1N1) of 2009, as first reported in Mexico
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 5

and the US, revealed a pooled prevalence rate of 6.3% which the authors
characterised as placing HCWs “particularly at risk” (Lietz et al. 2016).
For all recorded cases of Ebola Virus Disease (EVD) since the virus was
first identified in 1976 near the Ebola River in what is now known as the
Democratic Republic of the Congo (DRC), HCW infections have com-
prised between 2 and 100% of EVD cases (Selvaraj et al. 2018). Up to
two-thirds of reported EVD infections among an ‘already scarce health
workforce’ in West Africa during the 2014–2016 outbreak were fatal. The
World Health Organisation’s (WHO) analysis of the West African out-
break concluded that “health workers are between 21 and 32 times more
likely to be infected with Ebola than people in the general adult popula-
tion” (WHO 2015).
What we can discern from these past experiences is that the challenges
posed to HCWs providing care during an infectious epidemic increase
significantly under certain social and biological conditions:

• When a disease is ‘novel’ and therefore limited scientific information

is known (e.g. HIV/AIDS pandemic recognised to have begun in
the US in the late 1970s and early 1980s), thereby increasing the
likelihood of rumours and misinformation;
• When severe symptoms/consequences of a previously known
(milder) disease are newly discovered (e.g. microcephaly in new-
borns as a result of the 2015–2016 Zika outbreak in Latin America),
usually as a result of ‘superspreading’ events and/or an increased
transmissibility of a virus leading to a wider population of
exposed persons;
• During outbreaks which are rapidly introduced to a new geographic
area (e.g. 2014–2016 Ebola outbreak in West Africa), especially
when a virus is previously understood as having a more limited envi-
ronmental scope;
• In under-resourced healthcare settings where HCWs are ill-paid, ill-­
trained or otherwise ill-prepared with the proper supplies to follow
standard infection prevention and control procedures (e.g. the 2009
‘summer of strikes’ in South Africa, Zambia, Nigeria and DRC by
HCWs who were protesting meagre pay and terrible working condi-
tions) especially when these conditions are exacerbated by inequali-
ties related to gender, social class and ethnicity (Rennie 2009; Chima
2013); and
6 C. VINDROLA-PADROS AND G. A. JOHNSON

• When disease symptoms first appear in marginalised populations who

are often excluded from mainstream social, economic or political
affairs (e.g. LGBTQ, immigrants, persons considered ‘foreign’ or
‘outsiders’), thereby leading to xenophobic rather than biomedical
interpretations of risk.

The COVID-19 pandemic is extraordinary in that it exemplified all of

the above conditions, especially in the early months of 2020 when the
world was grappling with the size and scale of the crisis. These conditions
created the uncertain circumstances where some political leaders could
downplay the severity of the crisis (thereby slowing response times), mis-
information could rapidly spread via social media (thereby eroding public
trust), faith-based interpretations of illness could prevail over public health
advice (thereby increasing the number of cases), and hospitals and health
systems could become overwhelmed (thereby requiring rationing of
needed supplies such as oxygen and PPE). These issues are universal signs
of health systems in crisis and significantly impacted the context where
HCWs provided care during the COVID-19 pandemic.
As stated above, surveilling infections among HCWs is a key compo-
nent of EBS, yet data on COVID-19-related infections among HCWs is
still hard to discern over a year after the pandemic began. Not all nations
have made their HCW SARS-CoV-2 infection and death rates available,
and the WHO does not currently post this information on their COVID
dashboard—despite the many other options available for ‘exploring’ data
(Erdem and Lucey 2021; WHO 2021). Reported numbers are sporadic
and often spread across multiple platforms. For example, as of April 2020,
a WHO situation report indicated that 22,073 HCWs from 52 countries
were infected (WHO 2020). In July 2020, the WHO African Regional
Office in Brazzaville reported over 10,000 HCW infections in African
nations. By September 2020, the WHO Pan American Regional Office in
Washington, DC were reporting 570,000 HCW infections and 2500
deaths (Erdem and Lucey 2021). In performing an independent analysis
from 37 countries where HCWs “have lost their lives in substantial num-
bers,” Erdem and Lucey (2021) estimated the median of HCW deaths per
100,000 population, at 0.05. Of the 37 countries surveilled, those with
the four highest reported numbers of total HCW infections were the US
(n = 114,529), Mexico (n = 78,200), France (n = 30,032) and Italy
(n = 28,896). Countries with the three highest reported numbers of HCW
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 7

deaths were Mexico (n = 1162), the US (n = 574), Italy (n = 214) and

Iran (n = 164).
A health system, no matter where it is located in the world, cannot
effectively address a crisis without the skilled and effective assistance of its
frontline workers. As the numbers reported here indicate, global health
systems often failed our HCWs by not appropriately predicting and pre-
venting the impact of COVID-19 on local health systems.

COVID-19 Mirror Studies

During the early stages of the pandemic, the Rapid Research Evaluation
and Appraisal Lab (RREAL) started having conversations with teams in
Pakistan and Australia to make decisions in relation to the scope of a study
on COVID-19. The team made the decision to focus on documenting the
perceptions and experiences of HCWs, tracking how these changed over
the course of the pandemic, but at the same time, using an agile research
design where emerging findings could be shared at different time-points
to inform response efforts.
The team based in the UK implemented the first study in March 2020.
It was designed as a rapid appraisal with the aim of answering the follow-
ing research questions: (1) What are HCWs’ perceptions of COVID-19-­
infected patients and potentially infected patients? (2) What are their
experiences delivering care in the context of this epidemic? (3) Do they
feel like they have the proper training and supplies to work with patients
potentially affected by COVID-19? If not, what additional resources
would help them—both mentally and physically—do their work more
effectively? and (4) Do HCWs experience any concerns delivering care in
this context? What are the underlying causes of these concerns with regard
to the new virus and how can we address those concerns?
The rapid appraisal combined three main research methods: (1) a
review of national healthcare policies, (2) mass media and social media
analysis of frontline staff experiences and perceptions during the pandemic
and (3) in-depth (telephone) interviews with front-line staff. Rapid
appraisals are commonly developed to collect and analyse data in a tar-
geted and iterative way within limited timeframes, often to ‘diagnose’ a
situation (Beebe 1995). A rapid appraisal design often combines two or
more methods of data collection and then uses triangulation from differ-
ent sources as a form of data validation (Green and Thorogood 2013;
Harris et al. 1997). The study was therefore designed to rapidly
8 C. VINDROLA-PADROS AND G. A. JOHNSON

triangulate data from multiple sources, so emerging findings could be

shared on an ongoing basis throughout data collection. The UK team
initially liaised with organisations who were informing response efforts to
make sure findings on the experiences of healthcare workers could be
shared with them in a timely way. Subsequently added research teams fol-
lowed this model of dissemination.
Conversations then began with teams in other countries to see if they
would be interested in replicating the study. A team in Pakistan was the
first to carry out a parallel study, later expanding it to include India,
Nigeria and the Democratic Republic of Congo (DRC). The Pakistan
team also expanded the original protocol to include data collection with
suspected patients (living in quarantine facilities), their families and mem-
bers of the general public living in areas of high transmission. A team in
Australia was also interested in replicating the study with healthcare work-
ers but delays with the study set-up meant they were not able to collect
and analyse data at the same pace as other countries. Several Latin American
countries then joined the network, bringing in new energy and speed, and
allowing us to document the experiences of HCWs working in Mexico,
Argentina, Chile and Brazil. The teams from Chile and Mexico, similar to
the Pakistan team, expanded the original protocol to include data collec-
tion with patients and members of the public. Spain also joined the study
around this time, led by researchers from nursing and rapidly covering the
experiences of nursing staff who had delivered care during both waves of
the pandemic.
A team from the US was contacted early on in the pandemic and
decided to venture into a different setting, documenting the experiences
of staff working in long-term residential care centres, after having heard
about the work of researchers from Switzerland. The Swiss team was car-
rying out research in a care home before the COVID-19 outbreak and
pivoted to study staff experiences during the pandemic. South Africa
joined the network thanks to pre-existing links with RREAL and rapidly
began the process of adapting the protocol to study localised healthcare
responses. This team had to overcome severe delays imposed by local eth-
ics review committees but was eventually able to secure approvals and
funding to explore the psycho-social and long-term effects of COVID-19.
Researchers from India, Italy, Nigeria, France, China, Poland, DRC, Peru
and Ecuador joined the network on a temporary basis, engaging with
some aspects of the study (i.e. the policy reviews) or becoming active
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 9

participants during early stages of the pandemic and then leaving the net-
work due to competing priorities, lack of funding and limited capacity.
All of these teams became important components of the RREAL
COVID-19 Global Network. The network met on a regular basis, discuss-
ing issues with study set-up and implementation as well as sharing emerg-
ing findings as these became available. The network facilitated the rapid
sharing of learning as strategies that had been effective for rapid studies in
some areas of the world could be adapted and implemented in others. The
network also generated a sense of community as, despite the regional dif-
ferences, we all had a shared purpose. The last aim of the network was to
paint a global picture of the experiences of HCWs delivering care during
the COVID-19 pandemic, an aim that has materialised with the publica-
tion of this book.

Challenges and Benefits of Carrying Out Rapid

Qualitative Studies During a Pandemic
As stated above, there is precedent for understanding how infectious epi-
demics can and will impact HCWs. Our study is not unique in looking at
these impacts. The uniqueness of our study lies in the fact that we exam-
ined the experiences of frontline healthcare workers delivering care during
the COVID-19 pandemic simultaneously, in multiple countries and with
multiple global partners, using shared rapid research study protocols as a
baseline for data collection (i.e. ‘mirror studies’). We do this as scientists
for cross-cultural comparison purposes, but we also do this as humans who
believe the COVID-19 pandemic should serve as an important reminder
that shared vulnerability equals shared responsibility.
Our frontline workers were considerably more vulnerable than others
due to the impacts of this pandemic, not just from the risk of transmission,
but also the sheer mental and physical exhaustion produced by their work.
This vulnerability demanded we try and capture their experiences, in real-­
time, so that evidence-based recommendations could be made to improve
their ability to provide care and achieve better patient outcomes. While
the numbers of HCW-related infections (as reported above) tell an impor-
tant story, they only tell part of the story. Digging deeper into these num-
bers reveal emerging trends in inequalities in terms of who is most likely
to be infected (and severely so) by gender, ethnicity and seniority (e.g.
junior vs senior staff); mental health and well-being needs; impacts on
10 C. VINDROLA-PADROS AND G. A. JOHNSON

HCWs’ families and communities—to name just a few. We believe the

experiences of delivering care during a pandemic are best captured through
qualitative research to provide crucial context to the ‘big data’ numbers
that have been (and continue to be) frequently reported regarding the
COVID-19 pandemic.
The responsibility our global team of researchers felt in capturing these
experiences could not be neglected or avoided because of the very real
challenges that the pandemic placed on traditional face-to-face methods of
data collection—they demanded we innovate. For our team, this meant
innovation in sharing resources and creating new and productive (global)
linkages and platforms for engagement so that methodological innova-
tions developed in one context could be replicated elsewhere. And finally,
through the process of creating the chapters represented in this book, we
innovated by creating writing teams of researchers who could reflect upon
important local findings from a cross-cultural perspective. The chapters in
this book reinforce both past and contemporary lessons learned that
should not be forgotten in the wake of a still raging pandemic. We need
our HCWs and our health systems to be better prepared to deal with
whatever ‘wave’ of COVID may be coming next, and for the next infec-
tious outbreak of pandemic potential that is around the corner. Although
the COVID-19 pandemic is an extraordinary example, we cannot be com-
placent in thinking it is a once in a lifetime event.

The Chapters in This Book

One of the early tasks of the global COVID-19 network was to identify
trends in the experiences of healthcare workers that could be mapped
around the world. This early mapping led to a list of topics that we felt
captured the essence of the lived experience of the HCWs who had shared
their stories with us, without losing sight of the wider social, economic
and political contexts where they worked. The book was, therefore,
designed to provide an overview of public policies, the infrastructures of
care delivery, the emotional impact of working during a pandemic and the
ways in which HCWs negotiated barriers on a daily basis. Chapter 1 is this
introduction to the book, covering experiences from other epidemics and
introducing the model of mirror studies that were replicated rapidly across
the globe.
Chapter 2 examines the design and implementation of rapid qualitative
research in the context of a pandemic, highlighting the barriers that still
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 11

remain in the timely set-up of studies. The chapter focuses on the experi-
ences of the researchers who tried to get these studies quickly off the
ground so the pandemic and its impact on the healthcare workforce could
be tracked on a real-time basis. This timeliness was key to ensure the
research findings could be used to inform changes in policy and practice.
The chapter reflects on the unsuitability of current processes for the review
and approval of qualitative studies and proposes changes that need to be
made for research carried out in the context of global pandemics.
Chapter 3 provides an analysis of how the political motives of individual
governments influenced the policy and guidance that shaped healthcare
organisation and delivery throughout the pandemic. The chapter includes
a comparison between countries’ political approaches and leadership, and
the levels of guidance provided to healthcare workers on the delivery of
care and use of resources. Alterations in laws and guidelines are discussed
in relation to the individual trajectories of the pandemic within the UK,
Italy, Spain, South Africa, Mexico and Switzerland. The accounts of
healthcare workers and their experiences delivering care under these new
guidelines and whether they helped or hindered their ability to provide
care are explored to analyse each country’s response and the practicalities
of the guidance they provided.
Chapter 4 explores one of the most contentious and politically charged
issues of the COVID-19 pandemic: the proper stock, distribution and use
of personal protective equipment (PPE) for healthcare workers and the
effects on the delivery of care. The chapter brings together findings from
research conducted in Spain, UK, India, Argentina, Ecuador, the US,
Senegal, Gambia and Burkina Faso, and examines how feelings of safety
and protection shaped HCWs’ experiences of delivering care during the
pandemic. The chapter engages with issues of PPE shortage, its manage-
ment at a national policy level and HCWs’ response to this at an individual
level (e.g. involving the improvisation of their own equipment, protest
and even refusal to deliver care).
Chapter 5 analyses the experiences of healthcare workers (HCWs)
when dealing with ‘the unknown’ during the COVID-19 pandemic in
Chile, Brazil and Argentina. The authors argue that, in these countries,
the uncertainties caused by the pandemic converged with previous social,
political and economic incertitude in the region. The authors describe the
ways in which uncertainty was exacerbated by constantly changing proto-
cols and norms, where HCWs had to assume different roles and responsi-
bilities in the workplace.
12 C. VINDROLA-PADROS AND G. A. JOHNSON

Given the impact of religious interpretations of illness, and religious

events and mass gatherings as contributing to the spread of COVID-19,
Chap. 6 explores the intersections between religion and the pandemic.
The chapter discusses religious perceptions on the cause and consequences
of infection with COVID-19, how intra- and inter-faith divisions contrib-
ute to risk perception, circulation of religious-based myths and rumours,
and to what extent religious leaders followed or rejected public health
guidelines for controlling the spread of infection. Data were generated
through interviews conducted with HCWs, analysis of social media con-
versations and policy reviews from Pakistan, Nigeria and DRC with a focus
on the beliefs and practices of Muslims and Christians, and the communi-
ties in which they reside. How religious perceptions of illness impacted the
context in which HCWs provided care is a crucial element of analysis of
data from these three populous nations.
Chapter 7 explores the short-term and long-term effects of COVID-19
on the wellbeing and mental health of HCWs in Mexico, Ireland, the UK
and India. The chapter is guided by the following questions: How does
the COVID-19 pandemic affect mental health and daily activities for
HCWs? What are the tools and strategies that they are creating and imple-
menting for this new and challenging reality? What are the programmes
put in place to support HCWs during and after the pandemic? What are
the most stressing issues they are confronting, personal shortages, fear
about contracting the SARS-CoV-2, shortage of medical and protection
supplies, or even the patient-practitioner-family relation?
Chapter 8 provides a comparative analysis of the experiences of care
workers in long-term residential care homes in the US and Switzerland
that have had to implement public health policies and provide adequate
care for older residents. A large proportion of COVID-19 infections and
deaths occurred in long-term residential care centres where caregivers had
to make important decisions in order to balance safety measures and pub-
lic interests with the preservation of the quality of life of a social group
considered as very ‘high risk.’ These experiences were largely shaped by
the models of care, with the U.S. relying heavily on a medical model and
the Swiss maintaining a more person-centred approach.
Chapter 9 is a slightly different chapter in the sense that it explores
HCWs’ experiences in a context where the healthcare system was not
heavily affected during the pandemic. Drawing from data collected in
Canberra, in the Australian Capital Territory (ACT), the authors describe
the experiences of HCWs from a range of settings and services who carried
 1 CARING ON THE FRONTLINE: AN INTRODUCTION 13

out changes to their workplaces as they prepared for a pandemic that did
not arrive. The authors explore the feelings of HCWs who remained in a
state of anticipation and waiting and use these experiences to discuss the
implications of a workforce that needs to be in a perpetual state of
readiness.
Chapter 10 provides a closer look at testing for COVID-19, using the
experience of South Africa as a case study. In this chapter, the authors
approach testing as a complex process shaped by socio-cultural, economic
and political factors and highlight the symbolic nature of testing at a
national scale (with a focus on the government’s approach to testing), and
at an individual level (making the virus visible). Notions of testing as neu-
tral are questioned through the use of empirical data which sheds light on
how tests during the pandemic were imbued with value and power.
Chapter 11 focuses on the role of HCWs at patients’ end of life. The
end of life for hospitalised patients, notifying families after a COVID-19
death, and management of the deceased patient are only some of the situ-
ations related to the end of life in this unknown new reality in the
COVID-19 era. The chapter engages with questions such as: How does
this new reality modify communication with patients and families? What
are the tools and strategies that healthcare workers are creating and imple-
menting for this new and challenging reality? The chapter draws from
experiences from HCWs and models for the delivery of end-of-life care in
Mexico, the UK, Ireland and the US.
Chapter 12 looks at how various countries have refocused their medical
systems to cope with the anticipated surge of COVID-19 cases. Using a
range of case study examples, from South Africa, Argentina and Ireland,
this chapter argues that access to and the provision of routine and essential
(non-COVID) services have ‘fallen like a stack of dominos’ as a result of
preparation for and treatment of COVID-19 patients. This has affected a
wide range of services such as primary and preventative care where mater-
nal, infant and childcare have been affected, as well as routine immunisa-
tion and screening for infectious and non-communicable diseases.
Furthermore, secondary and tertiary care has also been compromised with
both the provision of regular treatments suspended, and the quality of
clinic and hospital care compromised. Whilst healthcare has undoubtedly
been affected across the board, the significant inequities in healthcare
within the case study countries mean that much of the population that
needs and requires uninterrupted healthcare has indeed suffered the most.
14 C. VINDROLA-PADROS AND G. A. JOHNSON

The concluding chapter (Chap. 13) discusses the main themes from the
chapters in the book and uses these findings to develop a future research
and practice agenda. It outlines the areas that we need to develop to make
sure we can address the social, political and economic impacts of
COVID-19 in addition to informing preparedness strategies for future
pandemics.

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6/1472-­6939-­14-­S1-­S5.
Erdem, Hakan, and Daniel R. Lucey. 2021. Healthcare Worker Infections and
Deaths Due to COVID-19: A Survey from 37 Nations and a Call for WHO to
Post National Data on Their Website. International Journal of Infectious
Diseases 102: 239–241. https://www.ncbi.nlm.nih.gov/pmc/articles/
PMC7598357/.
Green, Judith, and Nicki Thorogood. 2013. Qualitative Methods for Health
Research. London: SAGE.
Harris, Kari Jo, Norge W. Jerome, and Stephen B. Fawcett. 1997. Rapid assess-
ment procedures: A review and critique. Human Organization 56 (3): 375–378.
Lietz, Janna, Claudia Westermann, Albert Nienhaus, and Anja Schablon. 2016.
The Occupational Risk of Influenza A (H1N1) Infection Among Healthcare
Personnel During the 2009 Pandemic: A Systematic Review and Meta-Analysis
of Observational Studies. PLoS One 11 (8): e0162061. https://www.ncbi.nlm.
nih.gov/pmc/articles/PMC5006982/.
Rennie, Stuart. 2009. An Epidemic of Healthcare Worker Strikes. Global Bioethics
Blog. http://globalbioethics.blogspot.com/2009/06/epidemic-­of-­health-­
care-­worker-­strikes.html.
Selvaraj, Saranya A., Karen E. Lee, Mason Harrell, Ivan Ivanov, and Benedetta
Allegranzi. 2018. Infection Rates and Risk Factors for Infection Among Health
Workers During Ebola and Marbug Virus Outbreaks: A Systematic Review. The
Journal of Infectious Diseases 218 (S5): S679–S689. https://academic.oup.
com/jid/article/218/suppl_5/S679/5091974.
WHO. 2015. Health Workers Ebola Infections in Guinea, Liberia and Sierra Leone.
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 1 CARING ON THE FRONTLINE: AN INTRODUCTION 15

———. 2020a. MERS Situation Update. World Health Organization. https://

applications.emro.who.int/docs/WHOEMCSR326E-­eng.pdf?ua=1.
———. 2021. COVID-19 Explorer. World Health Organization. https://world-
healthorg.shinyapps.io/covid/.
Xiao, Jian, Min Fang, Qiong Chen, and Bixiu He. 2020. SARS, MERS and
COVID-19 Among Healthcare Workers: A Narrative Review. Journal of
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jiph.2020.05.019.
 CHAPTER 2

Reflecting and Learning from the Experiences

of Researchers on Gaining Ethics Approval
During the COVID-19 Pandemic

Silvie Cooper and Sophie Mulcahy Symmons

Introduction
During any public health emergency, ethics committees must be rigorous,
responsive, and timely for successful review of research proposals. This
chapter explores the guidance for rapid research in emergency contexts—
in this instance, the COVID-19 pandemic—and the scrutiny qualitative
researchers encountered when seeking ethics approval from a Research
Ethics Committee (REC). In order to frame our discussion about the
principles and purpose of RECs, we first review the literature and
guidelines for conducting ethical reviews during public health

S. Cooper (*)
Department of Applied Health Research, University College London, London, UK
e-mail: silvie.cooper@ucl.ac.uk
S. M. Symmons
Institute of Epidemiology and Healthcare, University College London,
London, UK
e-mail: sofia.symmons.19@alumni.ucl.ac.uk

© The Author(s), under exclusive license to Springer Nature 17

Singapore Pte Ltd. 2022
C. Vindrola-Padros, G. A. Johnson (eds.), Caring on the Frontline
during COVID-19,
https://doi.org/10.1007/978-981-16-6486-1_2
18 S. COOPER AND S. M. SYMMONS

emergencies. The overarching challenges faced by qualitative researchers

in getting approval for their research is presented generally, and in the
context of the COVID-19 pandemic, where guidance for qualitative
research is lacking. By taking a case study approach to researchers’ experi-
ences of gaining approval during the COVID-19 pandemic, we reflect on
the competency and capacity requirements for successfully seeking ethics
review for rapid qualitative research. We review what was expected of
RECs and approval process during the pandemic, what unfolded for
Global Network researchers in seeking to gain required study approvals, as
well as lessons to take forward in navigating REC processes for conducting
rapid qualitative research.

Principles of RECs
Ethics is an intrinsic part of research. The role of a REC is to review
research proposals to conform with national and international ethical
guidelines. Review of research by a REC is required for all research involv-
ing human participants (to varying extents) and must be approved before
key stages (data collection for instance) can commence. RECs hold
researchers accountable to protecting participants in research and to con-
sider the risks and benefits to the participants and community in question.
Ethical principles in health research are well known and date back to
the Nuremberg Code in the 1940s, which have been refined and built
upon over time. Beauchamp and Childress (1979) outline four main prin-
ciples in health research that researchers must strive to uphold: autonomy,
beneficence, non-maleficence, and justice. These principles are in place to
ensure research is conducted equitably. RECs have been established inter-
nationally to hold researchers accountable to these principles, which have
since been embedded in legislation and regulations for research. RECs
review all aspects of research proposals, from the aims, methodologies,
consent process, and dissemination of findings. They have a responsibility
to objectively ensure ethical principles for the management and conduct of
research are considered and upheld.

Ethics Review Challenges Faced by Qualitative Researchers

There are risks and potential harms involved in all research. For qualitative
research, this could include anxiety and distress experienced because of
participation in the research; exploitation; misrepresentation; and
 2 REFLECTING AND LEARNING FROM THE EXPERIENCES OF RESEARCHERS… 19

identification of participants, as outlined by Richards and Schwartz (2002).

These matters can be addressed through scientific soundness of the pro-
posed protocol, informed consent, providing follow-up care if needed,
and using reflexive practice to maintain confidentiality and uphold the
quality of the study. Mitigating challenges such as confidentiality, consent,
anonymity, situational and relational ethics have been addressed by
Goodwin et al. (2020) for qualitative health research generally, which are
well known and accounted for by qualitative researchers. Qualitative
researchers have noted that the ethical review process is often a barrier to
conducting their work as their methodologies are more regularly chal-
lenged by ethics or funding boards as an understanding of qualitative work
by these boards is limited (Ells 2011; McCormack et al. 2012). For exam-
ple, qualitative research can be hampered by stringent REC rules, such as
the use of hand-­signed consent forms where it may not be appropriate,
and requirements for risk and harms to be identified outright even when
research designs must evolve in response to the context (McCormack
et al. 2012; van den Hoonaard 2001). McCormack et al. (2012) call for
better collegiality between REC board members and qualitative research-
ers to remedy such challenges. It is suggested that reviewers with qualita-
tive expertise should review protocols based on “ethical soundness” not
methodologies used if they are not experts in the field (van den
Hoonaard 2001)

Guidelines for RECs in Health Emergencies to Facilitate

Rapid Research
During a health emergency, most researchers would expect to face unan-
ticipated ethical challenges while conducting research. As stated by the
World Health Organization (WHO); “Disasters in general and epidemics
or outbreaks in particular raise and magnify many ethical issues related to
the provision and standard of health care delivery, privacy and confidential-
ity, informed consent, community engagement, benefit sharing, and resource
allocation” (World Health Organization 2020b). Due to the many unpre-
dictable challenges the current COVID-19 pandemic presents, the WHO
set up a “Working Group on Ethics and COVID-19” in 2020 to engage
and consider how to mitigate unethical situations and priority setting for
resources, such as vaccine distribution, in response to the pandemic. The
key concepts the working group identify for application to the COVID-19
pandemic include solidarity, equity, trust, autonomy, equal moral respect,
20 S. COOPER AND S. M. SYMMONS

and vulnerability (Dawson et al. 2020). These concepts are intertwined

with REC principles. In the context of a health emergency, rapid facilita-
tion of research to generate knowledge that contributes to immediate
responses is required without diminishing the quality and ethical standards
researchers should follow. Therefore, REC guidelines exist to enable com-
mittees to approve emergency protocols for researchers to conduct
research in such circumstances without delay. A piece that summarised key
rapid review guideline documents for RECs during the COVID-19 pan-
demic states that RECs have a responsibility to act with “rigorousness,
responsiveness and timeliness” during public health emergencies (Reyes
2020). Hence, it is the REC’s role to ensure that research is reviewed
responsively in an emergency with openness to innovations in research
methodologies and without delay or oversight of ethical principles
(Reyes 2020).
Ethical guidelines for conducting rapid research during the COVID-19
pandemic are based on lessons from REC processes from previous epi-
demics, such as the 2003 SARS outbreak which emerged in China, the
2014-2016 Ebola outbreak in West Africa, and the 2015-16 Zika out-
break in Latin America (Aarons 2018; Saxena et al. 2019; Schopper et al.
2016; Tansey et al. 2010; World Health Organization 2020b). Ensuring
RECs have fast-track processes in place during health emergencies helps to
mitigate delays and missed opportunities for responsive research. A group
of ethics committee members in Canada reflected on their experiences of
RECs during the SARS outbreak in 2003, suggesting a framework for
RECs in health emergencies involving increased diligence and flexibility of
procedures (Tansey et al. 2010). These include reviewers to review proto-
cols that reflect their expertise, number of reviewers to review protocols
that match risk of the protocol, virtual meetings, and enhanced communi-
cation with researchers (Tansey et al. 2010). As a result of the Ebola out-
break, workshops were organised to plan how RECs could prepare and
facilitate ethical review during epidemics. These workshops were con-
ducted by the African Coalition for Epidemic Research, Response and
Training (ALERRT) and the WHO (Saxena et al. 2019). The findings
included the need for pre-decided Standard Operating Procedures (SOPs)
for health emergencies, pre-approval processes for generic studies and
clarification on terminology used, labelling research into high or minimal
risk categories to facilitate the level of scrutiny needed for each proposal as
well as a pre-review process. Template expedited review pathways were
highlighted as a key facilitator, exemplified by two Caribbean countries
Another random document with
no related content on Scribd:
 THE TWO GIRLS STEPPED OUT OF THE ELEVATOR AND
FOUND GARRY KNAPP WAITING FOR THEM.
Dorothy Dale’s Engagement Page 41

“First National Bank of Womankind,” she cried gaily. “I always

carry it there in case of accident—being run over, robbed, or an
earthquake. But that five dollars is all I own. Oh, dear! I wish I had
stuffed the whole roll into my stocking.”
“Don’t, Tavia! it’s not ladylike.”
“I don’t care. Pockets are out of style again,” pouted her friend.
“And, anyway, you must admit that this was a stroke of genius, for I
would otherwise be without a penny.”
However, Tavia was too kind-hearted, as well as light-hearted, to
allow her loss to cloud the day for Dorothy. She was just as
enthusiastic in the afternoon in helping her friend select the goods
she wished to buy as though all the “pretties” were for herself.
They came home toward dusk, tired enough, and lay down for an
hour—“relaxing as per instructions of Lovely Lucy Larriper, the
afternoon newspaper statistician,” Tavia said.
“Why ‘statistician’?” asked Dorothy, wonderingly.
“Why! isn’t she a ‘figger’ expert?” laughed Tavia. “Now relax!”
A brisk bath followed and then, at seven, the two girls stepped out
of the elevator into the lobby of the hotel and found Garry Knapp
waiting for them. He was likewise well tubbed and scrubbed, but he
did not conform to city custom and wear evening dress. Indeed,
Dorothy could not imagine him in the black and severe habiliments of
society.
“Not that his figure would not carry them well,” she thought. “But
he would somehow seem out of place. Some of his breeziness and
—and—yes!—his nice kind of ‘freshness’ would be gone. That gray
business suit becomes him and so does his hat.”
 But, of course, the hat was not in evidence at present. The captain
of the waiters had evidently expected this party, for he beckoned
them to a retired table the moment the trio entered the long dining-
room.
“How cozy!” exclaimed Dorothy. “You must have what they call a
‘pull’ with people in authority, Mr. Knapp.”
“How’s that?” he asked.
“Why, you can get the best table in the dining-room, and this
morning you rescued us from trouble through your acquaintanceship
with Mr. Schuman.”
“The influence of the Almighty Dollar,” said Garry Knapp, briefly.
“This morning I had just spent several hundred dollars of Bob
Douglass’ good money in that store. And here at this hotel Bob’s
name is as good as a gold certificate.”
“Oh, money! money!” groaned Tavia, “what crimes are committed
in thy name—and likewise, what benefits achieved! I wonder what
the person who stole it is doing with my money?”
“Perhaps it was somebody who needed it more than you do,” said
Dorothy, rather quizzically.
“Can’t be such a person. And needy people seldom find money.
Besides, needy folk are always honest—in the books. I’m honest
myself, and heaven knows I’m needy!”
“Was it truly all the money you had with you?” asked Garry Knapp,
commiseratingly.
“Honest and true, black and blue, lay me down and cut me in two!”
chanted Tavia.
“All but the five dollars in the bank,” Dorothy said demurely, but
with dancing eyes.
And for once Tavia actually blushed and was silenced—for a
moment. Garry drawled:
“I wonder who did get your bag, Miss Travers? Of course, there
are always light-fingered people hanging about a store like that.”
 “And the money will be put to no good use,” declared the loser,
dejectedly. “If the person finding it would only found a hospital—or
something—with it, I’d feel a lot better. But I know just what will
happen.”
“What?” asked Dorothy.
“The person who took my bag will go and blow themselves to a
fancy dinner—oh! better even than this one. I only hope he or she
will eat so much that they will be sick——”
“Don’t! don’t!” begged Dorothy, stopping her ears. “You are
dreadfully mixed in your grammar.”
“Do you wonder? After having been robbed so ruthlessly?”
“But, certainly, dear,” cooed Dorothy, “your knowledge of grammar
was not in your bag, too?”
Thus they joked over Tavia’s tragedy; but all the time Dorothy’s
agile mind was working hard to scheme out a way to help her chum
over this very, very hard place.
Just at this time, however, she had to give some thought to Garry
Knapp. He took out three slips of pasteboard toward the end of the
very pleasant meal and flipped them upon the cloth.
“I took a chance,” he said, in his boyish way. “There’s a good show
down the street—kill a little time. Vaudeville and pictures. Good
seats.”
“Oh, let’s!” cried Tavia, clasping her hands.
Dorothy knew that the theatre in question was respectable
enough, although the entertainment was not of the Broadway class.
But she knew, too, that this young man from the West probably could
not afford to pay two dollars or more for a seat for an evening’s
pleasure.
“Of course we’ll be delighted to go. And we’d better go at once,”
Dorothy said, without hesitation. “I’m ready. Are you, Tavia?”
“You dear!” whispered Tavia, squeezing her arm as they followed
Garry Knapp from the dining-room. “I never before knew you to be
so amenable where a young man was concerned.”
“Is that so?” drawled Dorothy, but hid her face from her friend’s
sharp eyes.
It was late, but a fine, bright, dry evening when the trio came out of
the theatre and walked slowly toward their hotel. On the block in the
middle of which the Fanuel was situated there were but few
pedestrians. As they approached the main entrance to the hotel a
girl came slowly toward them, peering, it seemed, sharply into their
faces.
She was rather shabbily dressed, but was not at all an unattractive
looking girl. Dorothy noticed that her passing glance was for Garry
Knapp, not for herself or for Tavia. The young man had half dropped
behind as they approached the hotel entrance and was saying:
“I think I’ll take a brisk walk for a bit, having seen you ladies home
after a very charming evening. I feel kind of shut in after that theatre,
and want to expand my lungs.”
“Good-night, then, Mr. Knapp,” Dorothy said lightly. “And thank you
for a pleasant evening.”
“Ditto!” Tavia said, hiding a little yawn behind her gloved fingers.
The girls stepped toward the open door of the hotel. Garry Knapp
wheeled and started back the way they had come. Tavia clutched
her chum’s arm with excitement.
“Did you see that girl?”
“Why—yes,” Dorothy said wonderingly.
“Look back! Quick!”
Impelled by her chum’s tone, Dorothy turned and looked up the
street. Garry Knapp had overtaken the girl. The girl looked sidewise
at him—they could see her turn her head—and then she evidently
spoke. Garry dropped into slow step with her, and they strolled
along, talking eagerly.
“Why, he must know her!” gasped Tavia.
 “Why didn’t he introduce her then?” Dorothy said shortly. “It serves
me right.”
“What serves you right?”
“For allowing you, as well as myself, to become so familiar with a
strange man.”
“Oh!” murmured Tavia, slowly. “It’s not so bad as all that. You’re
making a mountain out of a molehill.”
But Dorothy would not listen.
 CHAPTER VI
SOMETHING OF A MYSTERY

Tavia slept her usually sweet, sound sleep that night, despite the
strange surroundings of the hotel and the happenings of a busy day;
but Dorothy lay for a long time, unable to close her eyes.
In the morning, however, she was as deep in slumber as ever her
chum was when a knock came on the door of their anteroom. Both
girls sat up and said in chorus:
“Who’s there?”
“It’s jes’ me, Missy,” said the soft voice of the colored maid. “Did
one o’ youse young ladies lost somethin’?”
“Oh, mercy me, yes!” shouted Tavia, jumping completely out of her
bed and running toward the door.
“Nonsense, Tavia!” admonished Dorothy, likewise hopping out of
bed. “She can’t have found your money.”
“Oh! what is it, please?” asked Tavia, opening the door just a trifle.
“Has you lost somethin’?” repeated the colored girl.
“I lost my handbag in a store yesterday,” said Tavia.
“Das it, Missy,” chuckled the maid. “De clark, he axed me to ax yo’
’bout it. It’s done come back.”
“What’s come back?” demanded Dorothy, likewise appearing at
the door and in the same dishabille as her friend.
“De bag. De clark tol’ me to tell yo’ ladies dat all de money is safe
in it, too. Now yo’ kin go back to sleep again. He’s done got de bag
in he’s safe;” and the girl went away chuckling.
Tavia fell up against the door and stared at Dorothy.
“Oh, Doro! Can it be?” she panted.
 “Oh, Tavia! What luck!”
“There’s the telephone! I’m going to call up the office,” and Tavia
darted for the instrument on the wall.
But there was something the matter with the wires; that was why
the clerk had sent the maid to the room.
“Then I’m going to dress and go right down and see about it,”
Tavia said.
“But it’s only six o’clock,” yawned Dorothy. “The maid was right.
We should go back to bed.”
Her friend scorned the suggestion and she fairly “hopped” into her
clothes.
“Be sure and powder your nose, dear,” laughed Dorothy. “But I am
glad for you, Tavia.”
“Bother my nose!” responded her friend, running out of her room
and into the corridor.
She whisked back again before Dorothy was more than half
dressed with the precious bag in her hands.
“Oh, it is! it is!” she cried, whirling about Dorothy’s room and her
own and the bath and anteroom, in a dervish dance of joy. “Doro!
Doro! I’m saved!”
“I don’t know whether you are saved or not, dear. But you plainly
are delighted.”
“Every penny safe.”
“Are you sure?”
“Oh, yes. I counted. I had to sign a receipt for the clerk, too. He is
the dearest man.”
“Well, dear, I hope this will be a lesson to you,” Dorothy said.
“It will be!” declared the excited Tavia. “Do you know what I am
going to do?”
 “Spend your money more recklessly than ever, I suppose,” sighed
her friend.
“Say! seems to me you’re awfully glum this morning. You’re not
nice about my good luck—not a bit,” and Tavia stared at her in
puzzlement.
“Of course I’m delighted that you should recover your bag,”
Dorothy hastened to say. “How did it come back?”
“Why, the clerk gave it to me, I tell you.”
“What clerk? The one at the silk counter?”
“Goodness! The hotel clerk downstairs.”
“But how did he come by it?”
Tavia slowly sat down and blinked. “Why—why,” she said, “I didn’t
even think to ask him.”
“Well, Tavia!” exclaimed Dorothy, rather aghast at this admission of
her flyaway friend.
“I do seem to have been awfully thoughtless again,” admitted
Tavia, slowly. “I thanked him—the clerk, I mean! Oh, I did! I could
have kissed him!”
“Tavia!”
“I could; but I didn’t,” said the wicked Tavia, her eyes sparkling
once more. “But I never thought to ask how he came by it. Maybe
some poor person found it and should be rewarded. Should I give a
tithe of it, Doro, as a reward, as we give a tithe to the church? Let’s
see! I had just eighty-nine dollars and thirty-seven cents, and an old
copper penny for a pocket-piece. One-tenth of that would be——”
“Do be sensible!” exclaimed Dorothy, rather tartly for her. “You
might at least have asked how the bag was sent here—whether by
the store itself, or by some employee, or brought by some outside
person.”
“Goodness! if it were your money would you have been so
curious?” demanded Tavia. “I don’t believe it. You would have been
just as excited as I was.”
“Perhaps,” admitted Dorothy, after a moment. “Anyway, I’m glad
you have it back, dear.”
“And do you know what I am going to do? I am going to take that
old man’s advice.”
“What old man, Tavia?”
“That Mr. Schuman—the head of the big store. I am going to go
out right after breakfast and buy me a dog chain and chain that bag
to my wrist.”
Dorothy laughed at this—yet she did not laugh happily. There was
something wrong with her, and as soon as Tavia began to quiet
down a bit she noticed it again.
“Doro,” she exclaimed, “I do believe something has happened to
you!”
“What something?”
“I don’t know. But you are not—not happy. What is it?”
“Hungry,” said Dorothy, shortly. “Do stop primping now and come
on down to breakfast.”
“Well, you must be savagely hungry then, if it makes you like this,”
grumbled Tavia. “And it is an hour before our usual breakfast time.”
They went down in the elevator to the lower floor, Tavia carrying
the precious bag. She would not trust it out of her sight again, she
said, as long as a penny was left in it.
She attempted to go over to the clerk’s desk at the far side of the
lobby to ask for the details of the recovery of her bag; but there were
several men at the desk and Dorothy stopped her.
“Wait until he is more at leisure,” she advised Tavia. “And until
there are not so many men about.”
“Oh, nonsense!” ejaculated Tavia, but she turned to follow Dorothy.
Then she added: “Ah, there is one you won’t mind speaking to——”
 “Where?” cried Dorothy, stopping instantly.
“Going into the dining-room,” said Tavia.
Dorothy then saw the gray back of Garford Knapp ahead of them.
She turned swiftly for the exit of the hotel.
“Come!” she said, “let’s get a breath of air before breakfast. It—it
will give us an appetite!” And she fairly dragged Tavia to the
sidewalk.
“Well, I declare to goodness!” volleyed Tavia, staring at her. “And
just now you were as hungry as a bear. And you still seem to have a
bear’s nature. How rough! Don’t you want to see that young man?”
“Never!” snapped Dorothy, and started straight along toward the
Hudson River.
Tavia was for the moment silenced. But after a bit she asked slyly:
“You’re not really going to walk clear home, are you, dear? North
Birchland is a long, long walk—and the river intervenes.”
Dorothy had to laugh. But her face almost immediately fell into
very serious lines. Tavia, for once, considered her chum’s feelings.
She said nothing regarding Garry Knapp.
“Well,” she murmured. “I need no appetite—no more than I have.
Aren’t you going to eat at all this morning, Dorothy?”
“Here is a restaurant; let us go in,” said her friend promptly.
They did so, and Dorothy lingered over the meal (which was
nowhere as good as that they would have secured at the Fanuel)
until she was positive that Mr. Knapp must have finished his own
breakfast and left the hotel.
In fact, they saw him run out and catch a car in front of the hotel
entrance while they were still some rods from the door. Dorothy at
once became brisker of movement, hurrying Tavia along.
“We must really shop to-day,” she said with decision. “Not merely
look and window-shop.”
“Surely,” agreed Tavia.
 “And we’ll not come back to luncheon—it takes too much time,”
Dorothy went on, as they hurried into the elevator. “Perhaps we can
get tickets for that nice play Ned and Nat saw when they were down
here last time. Then, if we do, we will stay uptown for dinner——”
“Mercy! All that time in the same clothes and without the
prescribed ‘relax’?” groaned Tavia. “We’ll look as though we had
been ground between the upper and the nether millstone.”
“Well——”
They had reached their rooms. Tavia turned upon her and
suddenly seized Dorothy by both shoulders, looking accusingly into
her friend’s eyes.
“I know what you are up to. You are running away from that man.”
“Oh! What——”
“Never mind trying to dodge the issue,” said Tavia, sternly. “That
Garry Knapp. And it seems he must be a pretty nappy sort, sure
enough. He probably knew that girl and was ashamed to have us
see him speaking to one so shabby. Now! what do you care what he
does?”
“I don’t,” denied Dorothy, hotly. “I’m only ashamed that we have
been seen with him. And it is my fault.”
“I’d like to know why?”
“It was unnecessary for us to have become so friendly with him
just because he did us a favor.”
“Yes—but——”
“It was I. I did it,” said Dorothy, almost in tears. “We should never
allow ourselves to become acquainted with strangers in any such
way. Now you see what it means, Tavia. It is not your fault—it is
mine. But it should teach you a lesson as well as me.”
“Goodness!” said the startled Tavia. “I don’t see that it is anything
very terrible. The fellow is really nothing to us.”
 “But people having seen us with him—and then seeing him with
that common-acting girl——”
“Pooh! what do we care?” repeated Tavia. “Garry Knapp is nothing
to us, and never would be.”
Dorothy said not another word, but turned quickly away from her
friend. She was very quiet while they made ready for their shopping
trip, and Tavia could not arouse her.
Careless and unobservant as Tavia was, anything seriously the
matter with her chum always influenced her. She gradually
“simmered down” herself, and when they started forth from their
rooms both girls were morose.
As they passed through the lobby a bellhop was called to the
desk, and then he charged after the two girls.
“Please, Miss! Which is Miss Dale?” he asked, looking at the letter
in his hand.
Dorothy held out her hand and took it. It was written on the hotel
stationery, and the handwriting was strange to her. She tore it open
at once. She read the line or two of the note, and then stopped,
stunned.
“What is it?” asked Tavia, wonderingly.
Dorothy handed her the note. It was signed “G. Knapp” and read
as follows:

“Dear Miss Dale:

“Did your friend get her bag and money all right?”
 CHAPTER VII
GARRY SEES A WALL AHEAD

“Why, what under the sun! How did he come to know about it?”
demanded Tavia. “Goodness!”
“He—he maybe—had something to do with recovering it for you,”
Dorothy said faintly. Yet in her heart she knew that it was hope that
suggested the idea, not reason.
“Well, I am going to find out right now,” declared Tavia Travers,
and she marched back to the clerk’s desk before Dorothy could
object, had she desired to.
“This note to my friend is from Mr. Knapp, who is stopping here,”
Tavia said to the young man behind the counter. “Did he have
anything to do with getting back my bag?”
“I know nothing about your bag, Miss,” said the clerk. “I was not on
duty, I presume, when it was handed in. You are Miss——”
“Travers.”
The clerk went to the safe and found a memorandum, which he
read and then returned to the desk.
“Your supposition is correct, Miss Travers. Mr. Knapp handed in
the handbag and took a receipt for it.”
“When did he do that?” asked Tavia, quickly, almost overpowered
with amazement.
“Some time during the night. Before I came on duty at seven
o’clock.”
“Well! isn’t that the strangest thing?” Tavia said to Dorothy, when
she rejoined her friend at the hotel entrance after thanking the clerk.
“How ever could he have got it in the night?” murmured Dorothy.
 “Say! he’s all right—Garry Knapp is!” Tavia cried, shaking the bag
to which she now clung so tightly, and almost on the verge of doing a
few “steps of delight” on the public thoroughfare. “I could hug him!”
“It—it is very strange,” murmured Dorothy, for she was still very
much disturbed in her mind.
“It’s particularly jolly,” said Tavia. “And I am going to—well, thank
him, at least,” as she saw her friend start and glance at her
admonishingly, “just the very first chance I get. But I ought to hug
him! He deserves some reward. You said yourself that perhaps I
should reward the finder.”
“Mr. Knapp could not possibly have been the finder. The bag was
merely returned through him.” Dorothy spoke positively.
“Don’t care. I must be grateful to somebody,” wailed Tavia. “Don’t
nip my finer feelings in the bud. Your name should be Frost—
Mademoiselle Jacquesette Frost! You’re always nipping me.”
Dorothy, however, remained grave. She plainly saw that this
incident foretold complications. She had made up her mind that she
and Tavia would have nothing more to do with the Westerner, Garry
Knapp; and now her friend would insist on thanking him—of course,
she must if only for politeness’ sake—and any further intercourse
with Mr. Knapp would make the situation all the more difficult.
She wished with all her heart that their shopping was over, and
then she could insist upon taking the train immediately out of New
York, even if she had to sink to the abhorred subterfuge of playing ill,
and so frightening Tavia.
She wished they might move to some other hotel; but if they did
that an explanation must be made to Aunt Winnie as well as to Tavia.
It seemed to Dorothy that she blushed all over—fairly burned—
whenever she thought of discussing her feelings regarding Garry
Knapp.
Never before in her experience had Dorothy Dale been so quickly
and so favorably impressed by a man. Tavia had joked about it, but
she by no means understood how deeply Dorothy felt. And Dorothy
would have been mortified to the quick had she been obliged to tell
even her dearest chum the truth.
Dorothy’s home training had been most delicate. Of course, in the
boarding school she and Tavia had attended there were many sorts
of girls; but all were from good families, and Mrs. Pangborn, the
preceptress of Glenwood, had had a strict oversight over her girls’
moral growth as well as over their education.
Dorothy’s own cousins, Ned and Nat White, though collegians,
and of what Tavia called “the harum-scarum type” like herself, were
clean, upright fellows and possessed no low ideas or tastes. It
seemed to Dorothy for a man to make the acquaintance of a strange
girl on the street and talk with her as Garry Knapp seemed to have
done, savored of a very coarse mind, indeed.
And all the more did she criticise his action because he had taken
advantage of the situation of herself and her friend and “picked
acquaintance” in somewhat the same fashion with them on their
entrance into New York.
He was “that kind.” He went about making the acquaintance of
every girl he saw who would give him a chance to speak to her! That
is the way it looked to Dorothy in her present mood.
She gave Garry Knapp credit for being a Westerner and being not
as conservative as Eastern folk. She knew that people in the West
were freer and more easily to become acquainted with than Eastern
people. But she had set that girl down as a common flirt, and she
believed no gentleman would so easily and naturally fall into
conversation with her as Garry Knapp had, unless he were quite
used to making such acquaintances.
It shamed Dorothy, too, to think that the young man should go
straight from her and Tavia to the girl.
That was the thought that made the keenest wound in Dorothy
Dale’s mind.
They shopped “furiously,” as Tavia declared, all the morning, only
resting while they ate a bite of luncheon in one of the big stores, and
then went at it again immediately afterward.
 “The boys talk about ‘bucking the line’ about this time of year—
football slang, you know,” sighed Tavia; “but believe me! this is some
‘bucking.’ I never shopped so fast and furiously in all my life.
Dorothy, you actually act as though you wanted to get it all over with
and go home. And we can stay a week if we like. We’re having no
fun at all.”
Dorothy would not answer. She wished they could go home. It
seemed to her as though New York City was not big enough in which
to hide away from Garry Knapp.
They could not secure seats—not those they wanted—for the play
Ned and Nat had told them to see, for that evening; and Tavia
insisted upon going back to the hotel.
“I am done up,” she announced. “I am a dish-rag. I am a disgrace
to look at, and I feel that if I do not follow Lovely Lucy Larriper’s
advice and relax, I may be injured for life. Come, Dorothy, we must
go back to our rooms and lie down, or I shall lie right down here in
the gutter and do my relaxing.”
They returned to the hotel, and Dorothy almost ran through the
lobby to the elevator, she was so afraid that Garry Knapp would be
waiting there. She felt that he would be watching for them. The note
he had written her that morning proved that he was determined to
keep up their acquaintanceship if she gave him the slightest
opening.
“And I’ll never let him—never!” she told herself angrily.
“Goodness! how can you hurry so?” plaintively panted Tavia, as
she sank into the cushioned seat in the elevator.
All the time they were resting, Dorothy was thinking of Garry. He
would surely be downstairs at dinner time, waiting his chance to
approach them. She had a dozen ideas as to how she would treat
him—and none of them seemed good ideas.
She was tempted to write him a note in answer to the line he had
left with the clerk for her that morning, warning him never to speak to
her friend or herself again. But then, how could she do so bold a
thing?
 Tavia got up at last and began to move about her room. “Aren’t
you going to get up ever again, Doro?” she asked. “Doesn’t the inner
man call for sustenance? Or even the outer man? I’m just crazy to
see Garry Knapp and ask him how he came by my bag.”
“Oh, Tavia! I wish you wouldn’t,” groaned Dorothy.
“Wish I wouldn’t what?” demanded her friend, coming to her open
door with a hairbrush in her hand and wielding it calmly.
Dorothy “bit off” what she had intended to say. She could not bring
herself to tell Tavia all that was in her mind. She fell back upon that
“white fib” that seems first in the feminine mind when trouble
portends:
“I’ve such a headache!”
“Poor dear!” cried Tavia. “I should think you had. You ate scarcely
any luncheon——”
“Oh, don’t mention eating!” begged Dorothy, and she really found
she did have a slight headache now that she had said so.
“Don’t you want your dinner?” cried Tavia, in horror.
“No, dear. Just let me lie here. You—you go down and eat.
Perhaps I’ll have something light by and by.”
“That’s what the Esquimau said when he ate the candle,” said
Tavia, but without smiling. It was a habit with Tavia, this saying
something funny when she was thinking of something entirely foreign
to her remark.
“You’re not going to be sick, are you, Doro?” she finally asked.
“No, indeed, my dear.”
“Well! you’ve acted funny all day.”
“I don’t feel a bit funny,” groaned Dorothy. “Don’t make me talk—
now.”
So Tavia, who could be sympathetic when she chose, stole away
and dressed quietly. She looked in at Dorothy when she was ready
to go downstairs, and as her chum lay with her eyes closed Tavia
went out without speaking.
Garry Knapp was fidgeting in the lobby when Tavia stepped out of
the car. His eye brightened—then clouded again. Tavia noticed it,
and her conclusion bore out the thought she had evolved about
Dorothy upstairs.
“Oh, Mr. Knapp!” she cried, meeting him with both hands
outstretched. “Tell me! How did you find my bag?”
And Garry Knapp was impolite enough to put her question aside
for the moment while he asked:
“Where’s Miss Dale?”
Two hours later Tavia returned to her chum. Garry walked out of
the hotel with his face heavily clouded.
“Just my luck! She’s a regular millionaire. Her folks have got more
money than I’ll ever even see if I beat out old Methuselah in age!
And Miss Tavia says Miss Dale will be rich in her own right. Ah,
Garry, old man! There’s a blank wall ahead of you. You can’t jump it
in a hurry. You haven’t got the spring. And this little mess of money I
may get for the old ranch won’t put me in Miss Dorothy Dale’s class
—not by a million miles!”
He walked away from the hotel, chewing on this thought as though
it had a very, very bitter taste.
 CHAPTER VIII
AND STILL DOROTHY IS NOT HAPPY

“But what did he say?” demanded Dorothy, almost wildly, sitting up

in bed at Tavia’s first announcement. “I want to know what he said!”
“We-ell, maybe he didn’t tell the truth,” said Tavia, slowly.
“We’ll find out about that later,” Dorothy declared. “Go on.”
“How?”
“Why, of course we must hunt up these girls and give them
something for returning your bag.”
“Oh! I s’pose so,” Tavia said. “Though I guess the little one,
Number Forty-seven, wanted to keep it.”
“Now, tell me all” breathed Dorothy, her eyes shining. “All he said
—every word.”
“Goodness! I guess your headache is better, Doro Dale,” laughed
Tavia, sitting down on the edge of the bed. Dorothy said not a word,
but her “listening face” put Tavia on her mettle.
“Well, the very first thing he said,” she told her chum, her eyes
dancing, “when I ran up to him and thanked him for getting my bag,
was:
“‘Where’s Miss Dale?’
“What do you know about that?” cried Tavia, in high glee. “You
have made a deep, wide, long, and high impression—a four-
dimension impression—on that young man from the ‘wild and
woolly.’ Oh yes, you have!”
The faint blush that washed up into Dorothy Dale’s face like a
gentle wave on the sea-strand made her look “ravishing,” so Tavia
declared. She simply had to stop to hug her friend before she went
on. Dorothy recovered her serenity almost at once.
 “Don’t tease, dear,” she said. “Go on with your story.”
“You see, the little cash-girl—or ‘check’, as they call them—picked
the bag up off the floor and hid it under her apron. Then she was
scared—especially when Mr. Schuman chanced to come upon us all
as we were quarreling. I suppose Mr. Schuman seems like a god to
little Forty-seven.
“Anyhow,” Tavia pursued, “whether the child meant to steal the
bag or not at first, she was afraid to say anything about it then. Her
sister—this girl who came to the hotel—works in the house
furnishing department. Before night Forty-seven told her sister. She
had heard Mr. Knapp’s name, and from the shipping clerk the big girl
obtained the name of the hotel at which Mr. Knapp was staying. Do
you see?”
“Yes,” breathed Dorothy. “Go on, dear.”
“Why, the girl just came here and asked for Mr. Knapp and found
he was out. She didn’t know any better than to linger about outside
and wait for him to appear—like Mary’s little lamb, you know! Little
Forty-seven had told her sister what Mr. Knapp looked like, of
course.”
“Of course!” cried Dorothy, agreeing again, but in such a tone that
Tavia frankly stared at her.
“I do wish I knew just what is the matter with you to-day, Doro,”
she murmured.
“And the rest of it?” demanded Dorothy, her eyes shining and her
cheeks still pink.
“Why, when little Forty-seven’s sister saw us with Mr. Knapp she
jumped to the correct conclusion that we were the girls who had lost
the money, and so she was afraid to speak right out before us——”
“Why?”
“Well, Dorothy,” said Tavia, with considerable gravity for her, “I
guess because of the old and well-established reason.”
“What’s that?”