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[Qualitative Research in Medicine & Healthcare 2021; 5:9686] [page 1]
In the course of unexpected and overwhelming events
such as the ongoing COVID-19 pandemic qualitative re-
search based on narrative inquiry may provide unique and
vital insights. It identifies individual survival parcourses
with universal valence. These parcourses are all but lost
in traditional medical, psychological, and social research
that overlooks individual experiences, classifying them as
background noises. From these very noises qualitative re-
search extracts the sound of coping mechanisms that
allow a person to come to term with his or her own per-
sonal tragedy even if death appears all but unavoidable.
An example of such itineraries is provided in the
memoir of Primo Levi.1 Levi faced death every minute of
the two years he spent as a prisoner in Auschwitz. He suc-
ceeded in dissipating his own fears and in encouraging his
prison mates by rehearsing and quoting Dante’s poem1 La
Divina Commedia (The Divine Comedy) where Ulysses
reminds his shipmates that no one can rob them of their
dignity. This anecdote that inspired victims of wars, per-
secutions, and natural disasters around the world would
have been lost in the official accounts of the Holocaust.
The articles that follow emphasize that it is always possi-
ble to find a pathway to heal one’s illness even when
scarcity of resources withstand medical management.
The other fundamental role of qualitative research
consists in a more complete analysis of the response to
the crisis. The scope of the analysis includes individual
impressions and experiences that highlight unsuspected
strengths of the system as well as unknown weaknesses.
Some of the articles that follow highlighted the sense of
solidarity and mutual responsibility among health care
workers. Under managers who lead by example this soli-
darity may become the main resource at a time when con-
fusion prevails and individual roles are muddied.
At the mean time an emergency of long duration pres-
ents new challenges that involve the burnout of the care-
givers, the rationing of limited resources, the economical
and emotional impact on the general population. While it
may not provide a response to each dilemma, qualitative
research puts a human face on each challenge and com-
forts the practitioner. Some quandaries, such as the ra-
tioning of care, may be insoluble. In this circumstance any
decision guided by compassion is the best decision.
This issue of Qualitative Research in Medicine and
Healthcare is dedicated to COVID-19. We collected the
testimony of health professionals who have been both pa-
tients and caregivers. Based on their embodied experiences,
the authors illustrate the healing trajectories available to
victims and caregivers of the victims, not only during a pan-
demic but throughout catastrophes of any type.
The pandemic has caught us unprepared at a medical,
social, and emotional level. The Western culture held out-
breaks of this size all but impossible in the so-called devel-
oped world. Widespread hygienic norms should be able to
prevent contagion by infectious agents, and a science able
to dissect the human genome may certainly find a remedy
against new organisms. These expectations might be legit-
imate, but they need to be placed in a realistic context de-
fined by human reactions and practical conditions. Let’s
start with precautional measures. Social isolation proved
out of reach for overcrowded residences,2 for retirement
homes,3 and for most work related activities that could not
be conducted from a distance. Face masks and vaccines are
only as good as the willingness to adopt them4 and as long
as the demand does not overwhelm availability. The devel-
opment of vaccines and therapies requires time, and during
this time the availability of hospital beds, life-supporting
devices, and health care providers5 may become overtaxed.
And it is currently overtaxed in some areas of the country
such as Southern California.
The economic duress caused by the pandemic may
delay the treatment of coronavirus as well as of other dis-
eases and may even cause food uncertainty.6 The emo-
tional cost of COVID-197 has not been fully evaluated yet,
Editor’s introduction: Qualitative research in the course of a pandemic
Lodovico Balducci
Senior Member Emeritus, Moffitt Cancer Center, Tampa, FL, USA
Correspondence: Lodovico Balducci, Senior Member Emeritus,
Moffitt Cancer Center, 4128 Carrollwood Village Dr, 33618
Tampa, FL, USA.
Key words: COVID-19; pandemics; qualitative research; ethics;
solidarity, religion.
Conflict of interest: The author declares no conflict of interest.
Received for publication: 11 December 2020.
Accepted for publication: 29 December 2020.
This work is licensed under a Creative Commons Attribution Non-
Commercial 4.0 License (CC BY-NC 4.0).
©Copyright: the Author(s), 2021
Licensee PAGEPress, Italy
Qualitative Research in Medicine & Healthcare 2021; 5:9686
doi:10.4081/qrmh.2021.9686
Qualitative Research in Medicine & Healthcare 2021; volume 5:9686
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but we know it includes anxiety, depression, post-trau-
matic stress disorder and may lead to outbursts of domes-
tic and community violence. Naturally medical,
economical, and emotional issues have influenced each
other creating a multidimensional self-aggrandizing crisis.
Our overreliance on science to prevent a pandemic
proved misguided and now scientists foresee that even
worse pandemics may be on the horizon. The exploration
of human reactions and individual pathways to survival
and healing through narrative could not be more timely.
Germane to narrative based research on COVID-19
are previous literary descriptions of pandemics. Literature
and arts have dealt with pandemics of the past and in some
cases they have used pandemics as background of novels.8
It is important to ask what the present articles may add to
the existing material. We will mention the works that ap-
pear more relevant to the current situation.
The so called “black plague” that ravaged Europe be-
tween the fourteenth and the seventeenth century repre-
sented the most quoted literary model of a pandemic and
has inspired two major Italian novelists, Giovanni Boc-
caccio and Alessandro Manzoni. The Decameron (from
the Greek Ten Days) by Boccaccio is a collection of a hun-
dred short novels narrated over ten days by ten youths in
the outskirts of Florence, where they had fled the plague
in the fourteenth century. I Promessi Sposi (The Be-
trothed) is a long novel that takes place in the seventeenth
century in Northern Italy and contains a description of the
17th century plague in Milan, Italy. One is surprised of
finding many similarities between events occurring cen-
turies ago and the current epidemic of COVID-19. In both
reports the initial signs of the contagion had been disre-
garded and so were the precautionary measures (the face
mask of our time) and the impact of the epidemic had
been underestimated. In both cases the plague brought so-
cial havoc and economic disruption. In both cases people
unable to find a solution on their own recurred to God.
But in Manzoni’s account the religious ceremonies led to
increased spreading of the plague (does it sound famil-
iar?). Manzoni also describes the procession of carts car-
rying the dead to common tombs, (something we saw
today in Italy and in Brazil and something comparable to
the makeshift morgues of New York) and the conspiracy
theories that led to the death on the pyre of innocent indi-
viduals (the so called untori, ‘greasers’) accused to spread
the contagion by greasing the pews of churches and the
doors of buildings with infectious material.
Manzoni’s account includes several vignettes, of
which the most heart wrenching is the description of a
mother consigning to the monatto (undertaker) the corps
of her 7-years-old daughter Cecilia, dressed in her feast
dress and perfectly combed. The mother bribed the
monatto to take particular care of her precious child, that
she greeted with arrivederci (to see you soon). Though
they may be literary masterpieces none of these vignettes
describe personal trajectories toward coping with the
plague. The accounts of Boccaccio and Manzoni describe
the medical and social landscape in terms that appear rel-
evant to the COVID-19 pandemic but do not include the
personal attitudes that are the object of the present issue
of the journal.
The Algerian Nobel Prize winner Albert Camus wrote
La pest (The plague) in 1947. In this novel the author
imagines that an epidemics of plague causes the cloture
of Oran, a middle sized Algerian town. The characters of
the story are multifaceted and realistic, but the main focus
of the author is to express his philosophy through them.
Camus was an atheist existentialist, longing for a religious
faith. He regretted of being unable to believe in God. In
the novel the character of Mr. Tarrou reflects the person-
ality of Camus himself. Mr. Tarrou is an atheist who as-
pires to become a saint even in the absence of a deity. To
this end he succeeds in inspiring a sense of solidarity in
the population of Oran. A common goal allows the popu-
lace to overcome the desperation brought on by the epi-
demics and to discover a sense of personal closeness. It
also leads to the mobilization of unsuspected social re-
sources for the management of the plague. As we will see
this experience is germane to the experience of health pro-
fessionals caring for COVID-19 patients.
A relatively small number of American novels have
the Spanish Influenza as background. Of these may be
worth mentioning John O’Hara: The doctor’s son (1936).
The author was indeed the son of a physician who took
care of influenza patients during the pandemic in a small
mining town. He highlights that the more likely victims
of the pandemic were the underprivileged living in
poverty, a finding germane to the current pandemic. The
author did not have the opportunity to appreciate the re-
lation of advanced age and mortality, because at that time
the general population was much younger and the per-
centage of individuals over 60 was minuscule.
Perhaps the document more relevant to our issue of
the journal is American Life Stories: Manuscripts from the
Federal Writers Project 1936-1940 that contains 2847
stories related to the Great Depression. Many of them re-
port personal accounts of the flu epidemics. The narratives
were collected by a number of writers and were organized
by John A. Lomax, Benjamin A. Botkin and Morton
Royce, and may be accessed online. The account of nurse
Alice Duffield from Arkansas, narrated by Lisa Taylor
with the title A woman on duty, is particularly compelling.
It talks of corpses spilling out of overcrowded morgues.
It talks about black and white workers walking together
in then segregated Arkansas. And she describes how her
nurse manager scolded her for crying in private. Given
the emergencies there was no time to waste in the expres-
sion of private distress.
This collection of snapshots of the Spanish Influenza
epidemic may indeed be an invaluable mine of informa-
tion for qualitative students and may to some extent com-
plement our findings. Yet I believe our contribution to the
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literature is unique in two respects. It represents an ac-
count of recent experiences rather than of decade old
memories. It follows the established rule of narrative
based qualitative research.
Two of the articles report the experience of health pro-
fessionals who caught the disease themselves. Leo
Begazo9 is a nurse manager in a major USA cancer center.
He disregarded the initial symptoms of COVID-19 as if
they represented a common viral infection and only when
he had developed significant respiratory distress sought
admission to the hospital that led to mechanical ventila-
tion, requiring medically-induced coma. Most likely his
disease was cured by the experimental drug tocilizumab
that Leo received as part of a clinical trial. He learned
three major lessons that will inspire his practice from now
on. He experienced healing when two nurses agreed to
pray with him prior to intubation. He realized that even if
he had not survived he was at peace with himself and
death did not scare him anymore. In other words he
learned that healing is a personal experience and is always
achievable even in the absence of a cure. From now on
healing will be the ultimate goal of the care he is going to
provide to cancer patients. He realized that the love of his
family and friends who insisted that he fight the disease
to the end has been the key to his cure. Without this sup-
port he probably would have forfeited mechanical venti-
lation when his situation deteriorated and without
ventilation he would have not been able to live long
enough to receive the drug that saved his life. He wishes
to emphasize how important it was in this respect the at-
titude of the hospital staff. They treated him with respect,
acknowledged him as a colleague, and obliged his request
to pray with him. They facilitated the interaction with his
family via video, and they surrounded him with affection
as well. In his own words they “treated him as a person
with COVID-19 and not as a case of COVID-19.” From
now on he will make sure that each patient finds the most
favourable conditions to a good outcome. He will treat all
patients with the same respect he received, will not shy
away from praying with them and will encourage family
and friends to express their affection in the most convinc-
ing way.
As an oncology nurse he knew a lot about death. Yet
he was surprised that his reaction toward the threat of
death was fear rather than anger, as he had expected. He
realized that the reaction to death may vary with the situ-
ation. A cancer patient who learns to have a limited time
to live but his/her death is not imminent has the time to
go through all the stages of death described by Kubler
Ross.10 The situation is quite different for a person facing
imminent and unexpected death.11 In this situation a num-
ber of different feelings compete with each other, includ-
ing fear of death, apprehension for the survivors, worry
for unfinished tasks, sorrow for missing a promising fu-
ture. And of course death may come unexpected also to
cancer patients due to an intercurrent disease or accident
or to treatment complications. In these situations the most
appropriate action of the provider may include listening,
allowing the patient to unravel the different emotions and
addressing the prominent ones.
Stefano Leccardi12 is a specialist in pulmonary dis-
eases who currently works as a hospitalist in a general
hospital in Northern Italy. He lived the epidemic as a
provider and as a patient: after taking care day and night
of COVID-19 patients he caught the infection himself and
like Begazo he had been threatened by imminent risk of
death from respiratory failure.
The outburst of the epidemic led to an unexpected and
most welcome outpouring of human solidarity among the
hospital staff that inspired each person to work to the best
of his/her ability, out of a sense of service. One may say
that the epidemic allowed them to discover the satisfac-
tion and the pride to care for other human beings. When
asked to be part of the COVID management team Stefano
had no second thought, despite the risks and the incon-
venience involved. He realized to be endowed with
unique expertise to manage these patients and lived his
service as a privilege. The time had come for him to pay
back a world that had been most gracious and welcoming
to him. Perhaps Lucia, the nurse manager of his ward had
the most important influence in promoting solidarity. To-
gether with her spouse and her children she decided to
table the beloved family outings and instead to make a
family project of the management of COVID. Without
extra compensation Lucia was working fourteen daily
hours every day of the week, always with a smile. She did
not ask the staff to provide extra work, but her example
elicited what Leccardi calls “a joyful competition” among
the staff members to provide extra service. And perhaps
to talk about solidarity is limitative in scope. When the
mother of a physician died all her colleagues offered to
cover her work shifts. When she came back to work, she
stated she felt surrounded by love. It may be impossible
to define love in words, but it is something one recognizes
when he/she sees it.
When the ward became overwhelmed the health de-
partment mandated that the ICU be reserved for individ-
uals younger than 75. It was a legitimate decision that
contrasted however with the principle of justice, one of
the four pillars of medical ethics. Leccardi does not try to
afford this vexing dilemma. Instead, he acknowledges that
the practice of medicine in the presence of an emergency
may involve insoluble predicaments. It would have been
inappropriate for a provider to decide on his/her own to
prioritize which life to save. But a society has the right to
manage limited resources and providers may obey gov-
ernmental directions, without compromising their ethical
principles.
Like Begazo, Leccardi faced imminent death. Like it
was the case with Begazo, the threat of death allowed him
to widen his scope of healing, to learn that healing is an
always reachable personal settlement even when cure is
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out of reach.13 Perhaps inspired by the psychiatrists in his
family (his mother and his late brother) he introduced the
concept of the wounded healer14 originally formulated by
Carl Jung. Leccardi felt that his flirtation with death gave
to him a special credibility to bring healing to incurable
patients. Finally, like Begazo, Leccardi credited his recov-
ery as much to the love and care he was surrounded with
as he does to his medical treatment.
The article by Hernandez et al.15 illustrates an ethical
dilemma that might have been unknown during previous
pandemics. An ethical consult was requested concerning
a 42-year-old woman who had developed COVID-19
after a bone marrow transplant for the management of
acute leukemia. It is important to highlight that the patient
belonged to an ethnic minority, that appeared more sus-
ceptible to the infection. At the meantime minority indi-
viduals are more likely to suspect that providers may
shortchange them of their best care. Indeed, the patient
had refused in multiple occasions to provide advanced di-
rectives about her health care. On admission she was un-
able to express her wishes because of encephalopathy and
her husband was by default her health care surrogate.
Since her admission, the situation appeared hopeless,
because she had bilateral pneumonia and was neutropenic
as a result of her recent transplant. Nonetheless, she re-
ceived all available treatment including Tocilizumab,
Remdesivir, convalescent plasm and steroids. The situa-
tion became more complicated because of a pneumoperi-
cardium that would have required a surgically placed
drainage, but the procedure was judged too risky, and the
development of disseminated herpes infection. The spouse
and the father were originally reluctant to discontinue life
supporting care. Rather than making the decision to dis-
continue all treatments because of futility, as it would
have been his prerogative, the ethic consultant recom-
mended a family reunion involving the children and the
parents of the patient. During that reunion it was ex-
plained to the family that the life supporting treatment was
prolonging the patient’s death and the family unanimously
agreed that the most compassionate course of action in-
cluded trusting the patient to comfort care.
This case is emblematic of our times for medical and
cultural reasons. This lady had received organ transplan-
tation, a procedure that might have cured her leukemia,
but had made her more susceptible to infections. Organ
transplantation is becoming every day more common and
so is the number of vulnerable patients. But even without
bone marrow transplantation modern medicine has al-
lowed the survival of more and more individuals likely to
succumb during an epidemic. Many cancer patients are
among them. This lady belonged to an ethnic minority that
had been underserved by medicine and she and her family
were afraid of being shortchanged as it had happened in
the past and may still happen. This situation is also likely
to become more and more common given the increased
diversity of the world population. Of particular concern
is the large number of undocumented immigrants that may
delay the quest of treatment out of fear of being incrimi-
nated. In the course of an epidemic they may become a
reservoir of infection.
The ethical team was culturally sensitive and led to
the solution of this case through compassion. This case
emphasizes the importance of cultural competence in the
management of a pandemic, especially since the minority
population is the most vulnerable.
All articles deal with religious beliefs that may also
lead to healing. Organized religion may provide social re-
sources in addition to the personal ones and it behooves
the practitioner to discover these resources that may in-
clude economical and emotional support, childcare and
help in the instrumental activities of daily living. In a pan-
demic these resources appear particularly relevant. No-
body would advocate exploiting the pandemic in order of
influencing people’s beliefs. Nobody nowadays would
support the situation described by the Italian director Vit-
torio De Sica in the movie Umberto D where an old retiree
agreed to recite the rosary daily to gain the benevolence
of the nurse manager, who was a nun. We are talking
about unearthing all existing resources to make most ef-
fective the treatment of the seriously ill.
What we have learned from these reports?
Two health care providers discovered the full scope of
healing and plan to make of healing the main focus of
their practices. This lesson is far from new, but it is worth
repeating, because healing is a personal experience
reached through a personal parcourse and each parcourse
is new to some extent. For Begazo prayers led to healing,
for Leccardi the discover of healing coincided with the
discovery of the ultimate sense of human life. Both of
them emphasize the importance of personal care, of the
respect of human dignity, and of spirituality for the
achievement of healing. Both conclude that it is necessary
to learn to coopt death as a human experience to be able
to heal. If death is the ultimate enemy the whole humanity
is doomed to failure.
By way of his personal experience Leccardi confirms
the literary hypothesis of Mr. Tarrou in Camus’ The
Plague that a major event like a pandemic may reveal un-
suspected reserves of human solidarity as well as of pro-
fessional energy. To unearth these reserves, leaders need
to lead by role modeling rather than commanding. Lecca-
rdi goes a step farther and recognizes that role modeling
is made possible by unconditional love, that is, love that
looks for no other remuneration but service itself. This
consideration expresses a challenge to a culture that con-
siders personal profit the primary motivation of any
human action and the satisfaction of personal feelings the
only worthwhile goal. A common tragedy reminds us “not
to ask for whom the bell tolls. It tolls for thee.” During
the pandemic we learned that if we can’t live together we
will have to die together.
The pandemic elicited a number of ethical questions,
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such as rationing of care and provision of futile treatment.
The answer to these questions needs to be based on ethical
principles but adapted to the practical circumstances. Ra-
tioning of care as a provider’s choice is unacceptable, but
at the same time it behooves the practitioner to heed the
directions expressed by governmental agencies that rep-
resent the will of society. The provision of futile care is
wrong, but the discontinuance of any care needs to be
planned through a compassionate decision involving the
patient’s family.
All the articles emphasized the role of religion as a
personal and social resource. While we certainly honor
these testimonies, I believe they should be generalized by
saying that healing is a spiritual experience and a practi-
tioner should learn how to utilize the existing spiritual re-
sources of which the CPT trained hospital chaplains are
the most reliable.
Without affording all the issues related to the manage-
ment of coronavirus I hope that this issue of the Journal
will become an incentive for other professionals to share
their experience and creating individual trajectories to
healing in the course of a pandemic.
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