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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
© The Editor(s) (if applicable) and The Author(s), under exclusive licence to Springer
Nature Singapore Pte Ltd. 2022
This work is subject to copyright. All rights are solely and exclusively licensed by the
Publisher, whether the whole or part of the material is concerned, specifically the rights of
translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on
microfilms or in any other physical way, and transmission or information storage and retrieval,
electronic adaptation, computer software, or by similar or dissimilar methodology now
known or hereafter developed.
The use of general descriptive names, registered names, trademarks, service marks, etc. in this
publication does not imply, even in the absence of a specific statement, that such names are
exempt from the relevant protective laws and regulations and therefore free for general use.
The publisher, the authors and the editors are safe to assume that the advice and information
in this book are believed to be true and accurate at the date of publication. Neither the
publisher nor the authors or the editors give a warranty, expressed or implied, with respect to
the material contained herein or for any errors or omissions that may have been made. The
publisher remains neutral with regard to jurisdictional claims in published maps and
institutional affiliations.
This Palgrave Macmillan imprint is published by the registered company Springer Nature
Singapore Pte Ltd.
The registered company address is: 152 Beach Road, #21-01/04 Gateway East, Singapore
189721, Singapore
Contents
v
vi Contents
Index307
Notes on Contributors
ix
x 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
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
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
xxv
xxvi List of Figures
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
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
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.
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:
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.
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
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.
References
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Organization 54 (1): 42–51.
Chima, Sylvester C. 2013. Global Medicine: Is It Ethically or Morally Justifiable
for Doctors and Other Healthcare Workers to Go on Strike? BMC Medical
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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.
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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
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nih.gov/pmc/articles/PMC5006982/.
Rennie, Stuart. 2009. An Epidemic of Healthcare Worker Strikes. Global Bioethics
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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.
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1 CARING ON THE FRONTLINE: AN INTRODUCTION 15
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
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.
Kulya mapunda.
Lied anhören
MusicXML-Datei herunterladen
Die ansprechenden Töne haben auch jetzt wieder ihren Zauber
auf den weißen Mann ausgeübt; hoch aufgerichtet sitzt er da, und
kräftig singt er mit, zum nicht geringen Vergnügen der Herren
Schwarzen. Ein Tanzlied ist es, dieses „Hasimpo“, wie es bei uns der
Einfachheit halber kurz genannt wird. Bei dem Arbeitslied passen
Melodie und Text, soweit ich diesen überhaupt habe übersetzen
können, wenigstens noch einigermaßen zusammen; was mir Pesa
mbili heute nachmittag jedoch als Grundlage dieses Hasimpo-Liedes
in die Feder diktiert hat, will mir noch nicht so recht in den Kopf. Der
Vollständigkeit halber hier zunächst der Versuch der Hilala-
Übersetzung:
„Arbeit, Arbeit. Der Jumbe wird weinen über seinen Sohn. Wir
lieben den weißen Ombascha, der ist stark. Danke. Der Sohn, er hat
wahrgesagt. O ich Dummer, meine Mutter geht weg, die Kinder
weinen. Weinet nicht, weinet nicht, weinet nicht.“
Also kraus wie immer, aber doch wenigstens in einzelnen Teilen
Zusammenhang und Sinn; das sílilo, sílilo, sílilo, weinet nicht, weinet
nicht, weinet nicht, klingt direkt ergreifend; weniger will mir der
Ombascha, der weiße Gefreite, in den Rahmen des Liedes passen;
doch wer vermag die Tiefen einer Negerseele zu ergründen! Und
noch dazu die eines Poeten.
Das Tanzlied heißt:
„Es essen Gemüse die Wairamba, sage ich, sie essen Gemüse,
sage ich, am Brunnen. Wenn ihr heim kommt, so grüßt sie, meine
Mutter, und sagt: Wir kommen. So sagte ich, und die Polizei hat den
Satanas gefaßt. Wir ließen nieder unsere Lasten von Zeug und
Perlen und nochmals Perlen. Die Sonne, die geht unter; unsere
Tanzerlaubnis ist zu Ende.“
Rührend ist auch hier wieder das Hereinziehen der Mutter,
rätselhaft die Polizei und ihre Beschäftigung mit dem Höllenfürsten.
Und nun kommt das Standardlied:
Lied anhören
MusicXML-Datei herunterladen
Neunzehntes Kapitel.
Zur Küste zurück.
Lindi, ausgangs November 1906.