In some cases, the people responsible for conducting the day-to-day work involved in a research study may be highly trained professionals, including doctors, nurses and other healthcare practitioners. In other cases, much of the direct contact with research participants will be maintained by field-workers and other front-line research staff with very variable levels of training or support. We use the term ‘front-line research staff’ to include all those directly interacting with research participants, whatever their professional background, and whether they are local or deployed from abroad.
A number of the features of a global health emergency, in particular its disruptive nature and the time pressure to act, combined with the nature and degree of the risks of harm, may exacerbate the ethical challenges such research staff face, compared with their work in more routine circumstances. The nature of their work may mean they are subject to stigma or other kinds of disadvantage, including, at times, risk of physical danger. Ethical dilemmas may arise in the context of their work that were not envisaged at the time of ethical review, and little, if any, support may be accessible in working out how to respond, particularly where channels of communications are disrupted or non-existent. The complex and changing situation on the ground, potentially involving many different organisations, can add to the risk of unclear lines of accountability, lack of support for both paid and volunteer staff alike, and scope for moral distress as a consequence of unresolved ethical issues in emergency contexts.
Clear guidance has been issued by bodies such as WHO and the UN’s Interagency Standing Committee on the responsibilities of governments and others with respect to both locally-engaged and expatriate front-line staff. These include obligations with respect to their safety, their access to necessary training and resources, and clarity about their terms of deployment and access to healthcare. However, there remain a number of ethically-contentious issues with respect to such responsibilities. These include how and whether differential treatment between expatriate and locally-engaged staff can be justified; and how workers can best be supported when they themselves are faced with difficult ethical questions in the field.
The WHO has advised that those working in emergencies on the front-line in the healthcare sector, which may include those undertaking research, have themselves obligations to the community, including duties to participate in public health surveillance (with due respect for patient confidentiality), and to provide accurate information to the public. Recently, attention has also been drawn to the existence of abusive behaviour by some staff working for international aid agencies, and to the associated responsibilities of organisations to undertake appropriate vetting and monitoring of staff.
18. Do the exigencies of global health emergencies (for example levels of risk, security requirements, extremity of humanitarian need, rapidity of response) change the obligations on, and expectations of, front-line research staff in any way?
19. What constitutes fair treatment of both local and expatriate front-line research staff, and who is responsible for ensuring that they receive such treatment? Can differential treatment ever be justified?
20. What mechanisms are there, or should there be, to help ensure that obligations to front-line research staff are honoured?
21. What ethical responsibilities do front-line research staff in emergencies themselves hold?