Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 30 (3) April 2020
www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2020 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

Contents

page

Editorial: Bioethics and COVID19 Darryl Macer
65
Bioethics gone viral: How to protect ourselves from any
virus - Mihaela Serbulea
66
Ethics of care and Philippine politics during the
COVID-19 outbreak - Rogelio P. Bayod69
Commentary on Bayod- Leandro S. Estadilla
76
Globalization and consumer culture: social costs andpolitical implications of the COVID-19 pandemic77- Christopher Ryan Maboloc
Commentary on Maboloc - Aldrin F. Quintero
80
A brief historical review of the great pandemic of
1918: the Spanish Tlu - Leonard H. Le Blanc
81
Ethical and social challenges of COVID-19 in Iran
84
- - Mahta Baratipour
Commentary on Baratipour- Marites V. Fontanilla
85
Commentary on Baratipour- Leonard H. Le Blanc
86
Return to ourselves: psychological reTlections
over compulsory physical distancing during the
COVID-19 outbreak - Zehra Edisan86
Commentary on Edisan- Dennis Alfaro
90
Health care in India in the prevailing COVID-19
pandemic scenario - Dhastagir Sultan Sheriff
91Spiritual universal ethical values for a global
health system using change theory: results of adisintegrated approach in the 2020 pandemic
93- Suma Parahakaran
Bioethics at the time of coronavirus crisis; an ethicalreTlection on good public policies and a better future 97- Mireille D’Astous
Pandemics from the lens of former peace keeper: COVID-19 response - Purusottam KC
100
Evaluation of public health and clinical care ethicalpractices during the COVID-19 outbreak days frommedia reports in Turkey - Sukran Sevimli
103
Impacts of COVID19 Pandemic on Care of the Patientswith Cancer
Esra Bilir
111
Equality, Positive Health and Global Inequality in the
midst of the COVID-19 pandemic. Gerry F. Arambala 114
Tribal Communities and Nations in a time of COVID-19- Carmela M. Roybal
118
COVID19: Social Stigma and Public Health Dilemma 122- Shahanaz Chowdhury
Maintenance of Physical Distance to Prevent COVID-19:
A Glimpse at Bangladesh124- Wardatul Akmam and Md. Fakrul Islam

Editorial: COVID-19 must Push
Bioethics Journals to Open Access
For the Tirst time in the 30 year history of Eubios
Journal of Asian International Bioethics (EJAIB) we areissuing extra issues in 2020 concurrent with thedeclaration of the pandemic of COVID-19 which has
affected citizens in every country of the world, and thecontrol measures that have been forcefully implemented
in most countries. As a consequence we will see the entryof our world into an economic recession that may wellcause even more deaths from poverty, depression andother diseases.
In this collection of the Tirst 20 of the papers thatwere presented at the First International Public HealthAmbassador conference organised by Eubios Ethics
Institute and AUSN on 26 March 2020, we Tind scholars
from all around the world who approach the issue as oneof bioethics, social justice, discrimination, virology,
philosophy, homeopathy, history, psychology, spirituality,
environmental impact, resource allocation, indigenous
rights, and policy. This is both a great challenge but also
an opportunity. We need to pay much more attention to
every ethics of infectious disease, physical distancing,quarantine, and approved diet and physical and mental
health, then we have in the past century. Many papers in
EJAIB in the past 30 years have explored these issues, but
we need more scholarship on these issues.
I also continue my ongoing call for all journals of
Bioethics to be open access so the scholars andpolicymakers all around the world, can read about how
they can affect more ethical policy and review the impactsof the decisions that they make on the public. Surely one
message of this pandemic, is that no more can we ethicallytolerate bioethics journals that do not provide all thepapers openly to effect better policymaking. Some arequick to criticize others for their ethical failures but how
can they sit back and criticize when it is the barriers thatthey have placed on open access to ethics literature thathave led to insufTicient attention being paid to the ethicalissues that all policy makers around the world and all
governments need to pay great attention to.
There will be a further issue of this journal
published with more papers on this topic in the coming
weeks. I encourage more dialogue and more contributions
from around the world.
- Darryl Macer

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Bioethics gone viral: How toprotect ourselves from any virus- Mihaela Serbulea, MD, PhD
AUSN Visiting Professor of Traditional, Complementary andIntegrative Medicine; Yokohama, Japan; Romania
Email: traditional@hotmail.co.jp
Abstract
The fast pace in modern society has obliterated a lot of
our senses and “gut feelings”; However, the solution
comes with time and hopefully a change in perspectivefrom the human-centered to acknowledging that we are apart of the ecosystem, just like others including viruses.
Showing some respect by restraining our liberties maylead to deeper understanding of our own needs, inconjunction with the planet. Bioethics is about choices wemake. Depending on the options around us and on thevalues we base our decisions on. This may be a huge
opportunity to reevaluate the world in and around us.
Introduction
The Tive sources of energy for humans are, in my opinion,
communication, the Sun, air, water and lastly solid food.
Research on the longest and healthiest living people on
Earth have shown that some common rules apply. One ofthem is social interaction, community ties, family
involvement. In contrast to traditional societies, the fast
pace in modern society has much obliterated senses and“gut feelings”, as well as the perception of nature andseasonal changes.
This might be one of the macro-causes producing the
global crisis we are traversing. The solution could comewith recognition and reconnection, which might need aradical change in perspective. From the human-centeredperspective to acknowledging that humans are a part ofthe ecosystem as much as any other, including myriads ofviruses. Showing them respect by restraining our liberties
may lead to deeper understanding of our own needs, inconjunction with the planet.
The dreaded disease now affects the lungs, at thesame time as the lungs of the Earth are burning in
rainforests or are cut for proTit. This may be a chance forevery individual as well as for humankind as a whole toreconsider priorities and taking a deep breath to slow
down the race.
People seem to need an emergency to stop and think.
Much of mainstream education is focused on imparting
information more than on stimulating thinking. The
foundations on which decisions are made are based lesson a solid value system and more on Tluctuating trends.
In my understanding, bioethics includes topics andsituations which everyone will be faced with at somepoint in their lives. However, usually those moments ofcrisis offer little space of calm to conTidently make adecision unless scenarios have been thought throughbeforehand. Therefore such opportunities are necessary
and this might be a good occasion to ponder some of our
choices, past, present and future.
Health is always a priority, at least in theory. In
practice, the attitude is often different. “Prevention isbetter than cure” is universally known, however it usuallytakes a severe crisis or diagnosis to eventually consider
some lifestyle changes. If one is not talked into trying thelatest drugs or procedures Tirst. What if there is not a
speciTic treatment (yet) – the panic which underscores the“new coronavirus pandemic”.
Haven’t we learned in medical school decades agothat viruses mutate at least every season? How theimmune system works is still not entirely understood but
evidence is mounting on the interconnection between thegut, the brain, the immune and endocrine systems –“neuro-immuno-psycho-endocrinology” is the word that I
scribbled on my notes as a student. Wholistic thinking is
the way natural medicine works. Starting with the Tlow ofseasons, the recognition of celestial inTluences in our lives,
ancient wisdom reTlected in Ayurveda, Traditional
Chinese Medicine as well as in probably every folk systemof healing.
The recent developments in life science andtechnology have sequenced genomes, at the same time
recognizing that genes are switched on or off byenvironmental factors. This is tremendously empowering
as “fate” takes a new form. However, it needs courage tolisten to nature, especially when we are used to quick
Tixes. Nature is healing – others and itself.
There are modalities of healing, according to laws ofnature. One of these is “like cures like”, upon which
homeopathy is based. Another step in healing is removing
the obstacles to cure, creating the conditions for positivechange to take place. Whether it is beneTicial gut Tlora or
favorable business environment. And Tinally recognizingthat everything is interconnected.
Every long journey starts with a few steps. It seems
that this temporary halt, whether forced or deliberate,
will remind our conscious minds of the forgotten lifestyleand connection. Bioethics is about choices we make.
Depending on the options around us and on the values webase our decisions on. This may be a huge opportunity toreevaluate the world in and around us.
Pandemic 2020
Although the news blare about the dangers of the newcoronavirus, according to WHO data
https://apps.who.int/iris/bitstream/handle/
10665/326242/WER9432-en-fr.pdf?ua=1
and the current COVID-19 stats https://epidemicstats.com/ this virus seems to be at most of similar
virulence to those emerging in previous years. As it is a“new” virus, the fear comes from the unknown effects.
Advice on hygiene to prevent the spread is totally
appropriate, however unprecedented measures – fromschool closures irrespective of the contamination status to
deploying military of the streets for preventing“unnecessary” walks are raising question marks.
“Social distancing” has become the “in vogue” notion.
While reducing redundant activities and spending morequality time with family is seen as positive, the downsideof lockdowns around the globe (will) start to emerge. We
need to acknowledge that healthy individuals are often
asymptomatic carriers of the virus to people who are athigher risk due to advanced age or preexisting conditions.
Therefore measures of protection are needed. However,Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
enforcing laws which allow only eight people to attend afuneral (as it happens in Romania now) are infringing on
the liberty of choice, decision power and can cause lasting
psychological damage.
While the weather is gearing towards spring in the
Northern hemisphere, there is hope that the temperatureand humidity conditions which favorize the virus will
decrease as it is usual for seasonal outbreaks (Sajadi M.
Mohammad et al: Temperature, humidity and latitude
analysis to predict potential spread and seasonality for
COVID-19).
Do we need to be reminded that the cold season juststarts in the Southern hemisphere and that it will comeagain in several months in the Northern too? Isn’t it clearthat we need to build a strong immune system which canhandle whichever new non-self-entity comes its way?
How to build an efficient immune system
Maintaining “social distance” should by no means equal
deprivation from communication. While face-to-facemeetings and playground interaction might decrease,making efTicient use of technology can deepen
relationships.
The connection between nutrition and immunity has
long been established and reTlected not only in scientiTic
research over decades but also in proverbs from many
cultures (“you are what you eat”, “an apple a day keeps thedoctor away”, etc, etc). In short, whole foods, mainly
plants, lots of spices, colorful produce are part of the key
to vibrant health. The anti-inTlammatory, immune
boosting properties of innumerable compounds found in
fruits and vegetables are too complex to outline here. To
mention just a few: vitamin C, beta-glucan (found inmushrooms), Zinc, Selenium (whole grains, yeast,
sunTlower seeds, nuts), good old garlic, celery, ginger,
turmeric, oregano, fermented foods… Are you alreadyhungry?!
Changing culinary habits can be a daunting
experience in “normal” times. Why not take theopportunity of challenging times to undertake some steps
towards a healthier diet. We all know what it
encompasses, including “sacriTices” such as staying awayfrom sugar.
If space and time permits, working with the seasons
and with earth, literally, gardening might add uncountable
beneTits. From getting more exercise and sunshine toconnecting to nature and producing some of yournourishment, gardening is recognized as one of the mostsatisfying and rewarding activities.
This leads to two of the most important sources ofnutrition – sunshine and air. Do everything in your power
to inhale them, under any circumstances! In scientiTicterms this translates into improving vitamin D levels, ahormone produced in the skin, which affects EVERY cell inthe body and deserves utmost consideration !
Water, as the next in my hierarchy, can be seen as thepristine liquid coming from mountain sources, as hot
springs for bathing or as herbal tisanes. All of these are
powerful medicines and their healing properties havebeen recognized in every community and time. Try to get
the local knowledge on medicinal plants used in yourneighborhood/region.

67

Phyto therapy
Some suggestions of plants useful in immunity building
are Elder (Sambucus niger) – Tlowers and berries, St John’swort (Hypericum perfolatum), Chinese skullcap(Scutellaria baicalensis) (NOT Scutellaria lateriTlora)
among others.
Generally, medicinal plants act through a multitudeof pathways and mechanisms, unlike pharmaceuticals
which have a more speciTic action. Therefore natural
products can be used in a variety of situations, they havethe ability to tune the body’s self-defense mechanisms tohigher gear and act non-speciTically, towards any virus,
new or old.
Evidence showing effects in laboratory experiments
might not always be translatable in clinical efTicacy. Even if
an isolated herb extract has tested positively as an antiviral in vitro, there are a lot of reasons that the herb might
not have the desired effect in vivo. The required dosage ofthe active substance might be difTicult to concentrate in
the human body due to rapid metabolic processing,potential toxicity of high doses, etc. Therefore, traditional
knowledge of medicinal plants plays a crucial role inprevention and treatment of respiratory infections as wellas supporting the body in its recovery after illness.
To reiterate: prevention through herbs modulates
and strengthens the immune system, thus shortening theduration of the illness or preventing it entirely. Thisshould be the baseline of our health. However, if
symptoms appear, we should regard them as the
manifestation of the body’s Tight with the microscopic
invaders. The body’s response to the (viral) pathogen
should be supported, not inhibited. Fever, as should becommon knowledge by now, is the mechanisms throughwhich the innate alarm system raises temperature inorder to make the environment inhospitable to invaders.
If we lower the fever artiTicially, we create exactly theconditions for the pathogen to thrive. Herbs which are
known to reduce the duration of such illnesses, if
employed adequately, support a healthy resolution of thefever process. If during the fever one feels hot andrestless, some herbs help to relax, promote circulation,
have sweat promoting action (diaphoretic) and diuretic
effects, thus releasing heat. On the contrary, when you feelcold and chilly, you can take herbs that warm the body,resolving the discomfort.
Introduction to Homeopathy
Another law of nature, in contrast to the law of the
opposites, is the law of similarity. This is one of thefundamental principles of homeopathy, a medical science
founded around 220 years ago by German Dr Samuel
Hahnemann (1755 – 1843). The principle of “like cureslike” had been known since antiquity and practiced allover the world in various forms. Paracelsus (1493 – 1541)
described the doctrine of signatures where associations
between the shape of an organ and of some natural
product would indicate its use (walnuts for the brain,beans for the kidneys, etc). Hahnemann, having studied
medicine at the best universities of his time, wasdiscouraged by the appalling methods of healing andstopped practicing. In order to support his family, hetranslated medical texts from various languages he was68

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

master of. In one of these articles, he found the assertion
that the Peruvian bark tree (Chinchona ofTinalis) was
effective in treating malaria because it was bitter.
Hahnemann’s perceptive and inquisitive mind observedthat there are many other bitter substances, some muchstronger, which do not have anti-malarial properties. He
undertook a self-experiment, taking Chinchona barkdecoct, only to notice that he developed recurrent fever,headache and other malaria-like symptoms!
The Tirst principle of homeopathy can be formulated
as “the substance producing symptoms in a healthy
person will cure similar symptoms in a dis-eased person”.
Countless provings have been and continue to be
conducted worldwide to learn more about the symptoms
produced by various substances. A “proving” is a carefully
controlled (self)observation study of the effects produced
by any substance in nature in a variety of individuals.
Extremely detailed observations are done about thephysical, mental, emotional symptoms that theparticipants in the proving experience. These symptoms
are collected and compiled in themes which form the“remedy picture”. The totality of these symptoms will bematched to the totality of the symptoms presented by apatient. Please note the importance of the totality ofsymptoms and individualization. For example, if a numberof people would “prove” coffee, there will be people
experiencing restlessness, insomnia, palpitations, nausea,
various dreams, etc. The totality of these symptoms,
described in much more details, such as time ofoccurrence, exact description of the symptom, eg “as if…”,
concomitants with other symptoms, etc, forms the remedy
picture of Coffeea cruda. Hahnemann tested around 100
substances during his lifetime. To this day there are morethan 3000 proved remedies. Because some of thesubstances were (potentially) dangerous (depending on
the dose and the susceptibility of the prover), Hahnemanndevised a method of dilution and succusion (oscillatory,
strong movements) through which substances become“potentized”. This involves successive dilutions andsuccusions by which, it is now becoming evident throughnano-measurements, information passes on into thesolution thus explaining the stronger, more profound andlonger lasting effect of higher potencies compared tolower potencies, even though chemically there isn’t any
more molecule of the original substance left in thesolution. Initially one drop of the original substance(mother tincture) will be diluted with 99 drops of distilledwater and succussed, obtaining a dilution 1 to 100 (C 1
potency). From this solution one drop is taken and mixed
with 99 drops distilled water, succussed, obtaining C2, ahundredth dilution of C1, or 10-4. Some of the mostcommonly used potencies in homeopathy are C 30 and C
200. Above C 12, due to the Avogadro number, there is(theoretically) not a single molecule left from the original
solution. The inTinitesimal dilution only increases thepotency of the remedy, through mechanisms which areabout to be revealed through modern technologies such
as Transmission Electron Microscopy, electron diffraction
and chemical analysis by Inductively Coupled PlasmaAtomic Emission Spectroscopy (ICP-AES).

Use of homeopathy in epidemics
Homeopathy has proven its efTicacy initially during thegreat epidemics of the 19th century and the Spanish Tlu(1918 – 19). Treatment with homeopathy has achieved
signiTicantly lower mortality rates in pneumonia,
diphtheria, typhoid fever, scarlet fever, yellow fever,cholera, inTluenza among others. Homeopathy is being
used prophylactically in dengue fever also, a RCT is
published in peer-reviewed literature.
Although in homeopathy the treatment addresses
the person in its totality, physical, mental, emotional andsocial aspects, in case of epidemics where symptoms tend
to be similar across the population, the patient is not one
person, but “the people”. By analyzing physical symptoms(what kind of fever, what kind of mucus or muscular pain,etc) the emotional state and mental reactions to thesituation, several remedy pictures have come across andare being used by homeopaths in different countries(India, Italy, the Netherlands, Germany).
The Liga Medicorum Homeopatica Internationalis
has compiled the genus epidemicus remedies for the
COVID-19 as follows:
Early stage: Gelsemium, Bryonia alba, Ferrum phos,
Eupatorium perfolatum, Belladona
Later stage: Arsenicum album, Phosphorus, Ant-tart,
Stannum metallicum
Each person will be given one remedy at a time,chosen be differentiating the characteristic and peculiar
symptoms. As homeopathic remedies address thesymptoms in their totality, mental and emotional states
which are particularly prevalent during this epidemic canbe effectively addressed. Anxiety, fear of contagion, fear ofdeath, fear of poverty and other non-speciTic symptoms
can be alleviated. Depending on the status of recognition
and integration in the public health system, applicabilityof homeopathy varies from region to region.
Contemporary homeopaths have developed systemsof looking at families of remedies. Jan Scholten has
described the mineral remedies according to the periodic
system of elements, Michal Yakir applies a similar way of
thinking to botanical families, Drs Joshi are developing a
map for remedies from the animal kingdom according to
the same principle that life evolves from one stage to thenext and symptoms appear when Tlow is impeded. Whenthe smooth progression to the next stage in life is blocked
and symptoms appear, we call it a “disease”. Disease ismeant to help you evolve. Sometimes an individual dies,or a species goes extinct. This pandemic might be seen as
an expression of our planet’s suffering. Epidemics arealways acute diseases. In contrast to chronic diseases,
they end in cure or death. As remedies are energy from aparticular source, they regulate the energy Tlow of theindividual (in the case of a pandemic, a group at planetarylevel).
Conclusion
For the suffering planet, this event might be a way to let
off steam. Air travel has been reduced, pollution levels
seem to decrease, overcrowded cities are having a respite.
There is plenty of evidence that laughter is the best
medicine. Watch comedies and get creative. And sleep.
Recovery after an acute illness is as important asEubios Journal of Asian and International Bioethics 30 (3) (April 2020)
prevention. The fatigued body should be supported withnutritious food and demulcent herbs to sooth irritation in
the respiratory system. By listening carefully to thesymptoms through which our body speaks to us, we canregain control over our health. There is a lot of research
indicating that fear and worry weakens the immune
system. Although the economical and societal implicationsof this situation may be far worse than the impact of thevirus itself, the unprecedented measures taken globally
might offer an opportunity to consider one’s options for
improved health.
Bibliography:
L e a r n i n g H e r b s . c o m h t t p : / / w w w. h o m e o p a t h y. c a /debates_2013-03-22_SummaryResponseFromAndreSaine.shtml
https://homeopathychoice.org/app/uploads/2019/02/
E p i d e m i c - I n fe c t i o u s - D i s e a s e s - P u b l i c - H e a l t h - a n d Homeopathy-AFHC-Re-Citizen-Petition-from-Americans-forHomeopathy-Choice.pdf
http://www.homeopathycenter.org/news/homeoprophylaxishuman-records-studies-and-trials
Recent interviews with Jeremy Sherr, Michal Yakir, Andre Saine,
Massimo Mangialavori, Jan Scholen, Drs Joshi, Paul Herscu,
etc http://www.lmhi.org/Home/Coronah t t p s : / / w w w. n c b i . n l m . n i h . g o v / p u b m e d / 2 9 7 5 3 2 9 9Homeopathic Prevention and Management of Epidemic
Diseases (Jacobs J, 2018) https://www.ncbi.nlm.nih.gov/
pubmed/17227744

Ethics of care and Philippine
politics during the COVID-19
outbreak- Rogelio P. BayodCor Jesu College, the Philippines
Email: roger.bayod@gmail.com
Abstract
The outbreak of COVID-19 pandemic in the Philippines
reveals three things: Firstly, it reveals the government’s
lack of preparation to Tight a pandemic because of the illstate of the healthcare system in the country as evidenced
in its lack of budget, healthcare personnel and poor
healthcare facilities. Secondly, it also reveals the centurylong moral antagonism that had polarized the country
into the “moral we” who project themselves in good moral
standing by following laws and policies and the “immoral
them” who are judged to be hard headed, deTiant topolicies and guidelines imposed by the government andtherefore, a threat to the security of the public. Thirdly,
there is a movement toward agonism, a kind of space thatbrings the different voices and sentiments together in an
atmosphere of respect and openness regardless of classstanding, ideologies and morality in order to respond tothe challenge of COVID-19. This paper will argue that the
ethics of care as shown by President Duterte in his latest
address to the nation rather than moral politics advancedby the elite members of the society can provide a solidbase for social solidarity as the country struggles to Tight
the imminent threats of COVID-19.

69

Introduction
In this paper, I try to highlight the importance of strong
leadership in terms of handling a crisis such as the
COVID-19 Pandemic. To be able to achieve this goal, I will
picture the moral conTlicts in Philippine society that arerooted in colonial history as well as the social andeconomic divide that is gripping the country. The same
moral divide results in imbalances in the allocation of
resources, especially in the area of healthcare. The unfair
practices in the bureaucracy requires the government tobe steadfast in handling difTicult issues. It is argued thatPresident Duterte’s radical approach to governance shows
his commitment to social reform that is crucial in
improving healthcare in the country.
Countries around the world (whether rich and poor,
developed, developing and underdeveloped) are Tighting
in the outbreak of Corona Virus or COVID-19 pandemic
which started in Wuhan, China. Its spread to othercountries proved that this virus knows no boundaries.
Since the mobility of people is a global phenomenon, so is
the imminent threat of COVID-19. Hence, the World
Health Organizations (WHO) declared it a global
pandemic on March 11, 2020.
The Philippines, as a developing country, is not safe
from the reach of this virus because of open policy to theentry of foreigners, including Chinese workers into its
territories. Despite many calls from the “civic sphere”, theelite, the professionals and the upper middle class mostly
from the capital, that government should close its borders
and should not accept the entry of the Chinese, ourgovernment leaders continue to accept them and othertourists because Tirstly, they see it as part of the daily livesof people, and therefore, mobility is a human right.
Secondly, entry of Chinese and other tourists in the
country can help boost the economy of the country
through investments. Since the start of the presidency of
Duterte, China has helped the Philippines a lot in terms ofTinancial and other forms of aids. Thus, the government
sees the need to welcome Chinese people in the country
despite the many protests of those who are notnecessarily racist when it comes to Europeans andWesterners, but are racist when it comes to China.
Now, COVID-19 is in the country and it appears that
it is controllable because of the low number of cases. The
truth of the matter, however, is that, it is low in terms ofcount since the country lacks enough testing kits andfacilities and therefore, country has to wait for the resultin a matter of days. Patients under investigations havedied before the result of the test arrived.
People’s initial reaction to COVID-19 onset in thePhilippines
When the Tirst case of COVID-19 in the country wasrecorded, a jittery public mostly in the civic sphere
erupted in anger after it was revealed that the patient was
a 44-year-old Chinese together with his femalecompanion, who visited three cities in the Philippines
before they were both tested positive of the virus in
Manila (Santos, 2020a). During a Senate hearing following
the Tirst conTirmed death linked to the virus, legislators
questioned the Health Secretary Francisco Duque III overthe government's system of identifying and contact

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

tracing who may have come in contact with the infected
couple. An opposition senator, Francis Pangilinan, trying
to show his moral standing lambasted the DOH secretary,
saying "I think it's not just a failure of communication. I
think it's also a failure of leadership on the part of thehealth department”.
But the truth of the matter is that, no matter how goodyour leadership and management skills are, you will face
tremendous difTiculties because of limited budget forhuman and material resources. Even among the membersof the medical staff, some complained about the poor
healthcare system in the Philippines. At an infectious
disease hospital where the infected couple from Wuhan
was admitted, what the medical staff told Al Jazeera about
the lack of transparency from health authorities,
understafTing, and shortage of protective medical
equipment exposed the country's public health system that it is not prepared to manage the outbreak. A lot of
medical staff grew anxious and those who took care of thepatient had to quarantine themselves after the Chinese
man's condition turned for the worse and eventually diedof the infection. This resulted in some of them breaking
down in tears due to exhaustion and anxiety over the
spread of the virus.
Wanting to justify their department, Alethea De Guzman
from the Department of Health's Epidemiology Bureau
said that their department is prepared. But they are notexpecting the virus would infect people faster. Such astatement is reckless and bereft of basis. However, shesaid that despite the challenges, the overstretchedworkforce of health workers and limited resources, they
have contained the infections and prevented any cases of
local transmissions (Santos, 2020a). But the truth of thematter is the opposite because from day 1 March 5, 2020,
there were only conTirmed cases but as of this writing(March 26, 2020), there are already 707 cases distributedin Luzon, Visayas and Mindanao. This clearly suggests that
there were plenty of local transmission of the virus. The
mortality rate is also rather high with 48 persons whodied compared with only 28 patients who have recovered(Santos, 2020b).
The Philippine healthcare system
Let us have a glimpse of the sad state of the Philippine
Public Healthcare System. The level of per-person
healthcare spending in the country is one of the lowest
among Southeast Asia’s major economies while thenation’s healthcare spending is projected to increase
annually (Folger, 2020). In terms of doctor-to-patient
ratio, the Philippines has one doctor per 33,000 patients,and one hospital bed is available to every 1,121 Filipino
patients. The question now is where to accommodate
those who need to be isolated because of contagious
diseases such as COVID-19 not including others who need
to be quarantined. This data tells us that the Philippines
is not really ready to Tight a global pandemic. Our medical
front liners have felt anxious, especially medical doctors,
nurses and lab technicians in the last few days and weeks
with the exponential increase of COVID-19 cases in the
country.
Table 1 gives a glimpse of the distribution of
hospitals and hospital beds throughout the country in theyear 2016. According to Lim (2020), as of 2017, there
were 1,236 hospitals in the country 65% of which wereprivately owned. WHO recommends 20 beds per 10,000
population but the Philippines had 14.4 beds per 10,0000
in 1990 and only 9.9 beds per 10,0000 population in
2014. Since the virus was not contained within Manila
where ii started and reached to other regions, chances are
there will be more people who will be admitted to thehospitals all over the country and there will be more
people who should be quarantined and isolated, where
will these people be accommodated?
Table 2 shows the number of health facilities bygroup of islands in the Philippines during the last 2016
census. There are more private hospitals than public
hospitals in the country. However, the majority of thecountry’s population is poor and cannot really afford to
the higher fees of these private hospitals. If more people
are affected by COVID-19 in the coming days or weeks
many of whom still go out to work in order to have foodon their tables, chances are many of these people will die.
For most of these people, their lives have already been
endangered before COVID-19 came to the country. Thus,
they are not afraid to die of this virus anymore. What they
are afraid of is to let their families die in hunger if they
will not be allowed to go out and work. Unless thegovernment’s subsidy for their food and other basic
necessities which are being channeled by President
Duterte to the Local Government Units (LGUs) arrive, they
will continue to work, defying government’s order to stayin their houses. These measures are considered as
draconian by pundits, but in the Philippines, the lack of
discipline on the part of the people may need such strong
kind of means in order to ensure public safety. As may beobserved from news reports, similar measures are also
being employed in countries such as Italy, Peru and India.
As mentioned above, medical staff have been
complaining already about the sad state of the Philippine
Public Healthcare System. Jocelyn Santos-Andamo, thesecretary-general of Filipino Nurses United (FNU), anational union of nurses, said that the government does
not treat health as a priority and the already low healthbudget was further cut which resulted to less medical
supplies, poorly maintained medical equipment andunderstafTing even before COVID-19. Even before
COVID-19, the public health systems was alreadydeteriorating (Lim, 2020).
To provide a comparative picture of the number ofnurses and midwives working in the country vis-à-vis theASEAN countries, Table 3 provides a picture of thePhilippine’s standing. The Philippines belongs to thebottom along with Vietnam, Myanmar, Lao and Cambodia
in terms of number of nurses per 10,000 population as of2015 survey of the WHO. The public health nurses ratio in
the Philippines right now is 1 to 50,000 patients. Nurses
in the country prefer to work abroad because of higher
salary. In spite of this scenario, the overall health budget
share in the national budget decreased from 4.9% in 2019
to 4.5% in 2020 (Lim, 2020).
A study conducted by “The Borgen Project”, a non-proTit
organization that aims to address poverty and hunger in
the Philippines, reveals the following facts about thehealthcare system in the Philippines:

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

71

Table 1: Distribution of Hospital Beds by Ownership and Group of Islands as of 2016
Group ofIslands

Population

Government

PrivateHospitals

Beds

Hospitals

Beds

Total
Total
Hospitals beds

Average
Beds perbeds/Island 10,000Group
population

NCR

12,877,253

48

17,221

115

12502

163

29,723

182.3

23.1

The rest ofLuzon

44,592,844

217

15,573

410

21,103627

36,67658.5

8.2

Visayas

19,373,300

80

6757

87

8,439

167

15,19691.0

7.8

Mindanao

24,135,775

89

7,280

178

12,273267

20,093

75.3

8.3

Philippines

100,979,172

432

47,371790

54,317

1,224

101,688

83.1

10.1

Source: Department of Health, 2016; Department of Health-HFSRB, 201

Table 2: Number of Health Facilities by Group of Islands as of 2016
Group of Islands

Barangay Health
Stations

Rural Health Units

Government
Hospitals

Private Hospitals

N

%

N

%

N

%

N

%

NCR

20

0.10%

492

19%

48

11%

115

15%

The Rest of Luzon

9,936

49%

1,077

42%

217

50%

410

52%

Visayas

4,815

24%

471

18%

80

18%

87

11%

Mindanao

5,445

27%

547

21%

89

21%

178

23%

Philippines

20,216

100%

2,587

100%

434

100%

790

100%

Source: Department of Health, 2016; Department of Health-HFSRB, 2016

Table 3: Density of Nurses and Midwives in ASEAN Countries (Source: World Health Organization, 2015)
Countries

Midwives and Nurses per 10,000 Population

Brunei

80.5

Singapore

57.6

Malaysia

32.8

Thailand

20.8

Indonesia

13.8

Philippines

12.7

Vietnam

12.4

Myanmar10

Lao PDR

8.8

Cambodia

7.9

72

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

1) The WHO refers to the Filipino Healthcare System as“fragmented.” There is a history of unfair and unequal
access to health services that signiTicantly affects the poor.
The government spends little money on the program
which causes high out of pocket spending and further
widens the gap between rich and poor.
2) Out of the 90 million people living in the Philippines,
many do not get access to basic care. The country has ahigh maternal and newborn mortality rate, and a highfertility rate. This creates problems for those who haveespecially limited access to this basic care or for thoseliving in generally poor health conditions.
3) Many Filipinos face diseases such as Tuberculosis,
Dengue, Malaria and HIV/AIDS. These diseases pair withprotein-energy malnutrition and micronutrient
deTiciencies that are becoming increasingly common.
4) Healthcare in the Philippines suffers from a shortage ofhuman medical resources, especially doctors. This makes
the system run slower and less efTiciently.
5) Filipino families who can afford private health facilities
usually choose these as their primary option. Private
facilities provide a better quality of care than the public
facilities that lower income families usually go to. The
public facilities tend to be in rural areas that are more run
down. These facilities have less medical staff and inferior
supplies.
6) Only 30 percent of health professionals employed by
the government address the health needs of the
majority. Healthcare in the Philippines suffers because theremaining 70 percent of health professionals work in the
more expensive privately run sectors. [from https://borgenproject.org/about-us/]
As the number of COVID-19 cases increases day afterday, the strain on health resources and personnel has
revealed how weak the country’s healthcare system reallyis (Lim, 2020). Private hospitals that have been attending
to most of the COVID-19 patients appealed to thegovernment to establish COVID-19 designated hospitals
because they lack manpower since many of their staff
have been put on 14-day quarantine (Lim, 2020). Indeed,such a dire situation may be traced to years of neglect on
the part of previous administrations who were controlled
by the oligarchy or business elite in the capital.
Understandably, the lack of access of the people to quality
healthcare will require a strong moral resolve on the partof the government.
Government’s response to this pandemic
To respond to the call of having designated COVID-19
hospitals, the government designated the Lung Center of
the Philippines and Dr. Jose N. Rodriguez Hospital as
COVID-19 exclusive hospitals. The University of thePhilippines (UP), Philippine General Hospital alsosigniTied its willingness to exclusively handle COVID-19
cases (Lim, 2020). However, public hospitals are also
running on limited resources. The Philippine General
Hospital (PGH) appealed to the public for PPEs like masks,
70% alcohol, and surgical gowns. While some public
hospitals have received PPE donations and free shuttle
rides for frontline responders, other hospitals are still
struggling with shortages in medical supplies andpersonnel (Lim, 2020).

To intensify the state’s Tight against the spread of
COVID-19, President Rodrigo Duterte declared a state of
public health emergency in the Philippines on March 9
due to the conTirmation of local transmission of the virus.
Then, on March 12, 2020, the President decided to put theentire Manila on Enhanced Community Quarantine and on
March 15, 2020, he expanded it to the entire country andclosed its borders to foreigners. The spokesperson of thepresident clariTied that "strict home quarantine shall be
implemented in all households, transportation shall besuspended, provision of food and essential services shallbe regulated, and heightened presence of uniformed
personnel to enforce quarantine procedures will be
implemented” (Santos, 2020c). However, as expected, notall establishments want to follow the “work from home
scheme”. Some establishments (especially in the private
sector) still asked their employees to report to work by
imposing a ‘no work, no pay policy’. In a society where a
lot of people are really in need of work, private
establishments can even pride themselves of being
generous to the poor by giving them work despite
government’s mandate not to require their employees toreport to work and instead to devise a ‘work from home’scheme. The government did not also impose sanction to
the establishments for continuously requiring theiremployees to work by imposing a ‘no work, no pay’ policy.
Thus, for the poor and those who are solely dependent on
their daily work for survival, they did not have a choice
but to work and brave the challenge of COVID-19 virus
just to let their family have food to eat (Santos, 2020c).
Mixed reactions from citizens
Robert Mendoza, president of the Alliance of HealthWorkers, lambasted the government's response of
putting the entire country into enhanced community
quarantine and sending its military and police to penalize
those who won’t follow, saying “what we need is mass
testing, more trained healthcare workers, and anincreased health budget” (Santos, 2020c). In addition,
Renato Reyes of BAYAN said that "social distancing andwork from home is impossible for the poor and daily wage
earners because of the “no work, no pay” policy of someestablishments. Thus, they will rather risk getting
COVID-19 to keep their jobs” (Santos, 2020c).
In a poor country such as the Philippines withlimited budget for welfare and safety nets, the community
quarantine is forced to die of hunger rather than the virus.
In fact, for some of them, the virus is only an issue for therich who most often travel to other countries and socialize
with rich people (interview with street vendor in Digos
City, March 17, 2020). Thus, many of them continue to sellin the streets and they just are careful not to get infectedby the virus. The same sentiment is shared by tricycle
drivers, a popular public transport in Digos City. Many ofthem asked if they are forbidden to go out and pick up
passengers what will they feed to their families. They will
not let their families die or see them dying out of hunger
because they are not doing their job to feed them. Besides,
they cannot rely on help from the government who, forthem, only cares for rich people (interview with tricycle
drivers, March 17, 2020). These are also the sameEubios Journal of Asian and International Bioethics 30 (3) (April 2020)
reactions from the agency-based janitors whom I
interviewed on March 17, 2020.
Thus, in Digos City where I live, a lot of poor people
and those who are daily wage earners continue to workand defy the home quarantine directives of thegovernment. Many of them received negative criticismsand even scorn from the people in the “civic
sphere” (those who are upper middle class, the rich andthe professionals in the city) for being hard headed,uncivilized and a threat to the people’s safety because
they might cause the spread of virus in the whole city. A
lot of rich people called these people who continue to defy
government’s order to stay home as “irresponsible, stupid
and trouble-makers”. While some of them understandtheir plight – that they need to work to feed their families,
some even accuse them of being lax and lacking inforesight and preparation. “They should have saved asmall portion of their income to be used for emergency
situation such as this so that they help in the solution of
the problem rather than becoming part of the problem”.
Hence, a clear divide emerges between the educated andobedient “we” among the elite and the upper middle classagainst the deTiant, hard headed and trouble-maker“them” among the poor and the daily wage earners whoneed to work in order to survive, defying government’s
order to just stay at home.
Morality versus poverty issues in COVID-19
For many of the rich and the elite in this country who
belong to the “civic sphere”, they have a good moral
standing in dictating the poor and those who belong to the“mass sphere” what to do in this time of crisis because
they are knowledgeable enough as to the long term
implication of following or defying government’s
guidelines on community quarantine to the entire
population (the rich and poor alike). While the poor, even
before COVID-19, have already been facing death due totheir poverty and that, they must continue to work
despite government’s warning to stay at home because
they need to Tind food for their family in order to survive.
For those in the civic sphere, this behavior of the poor issomewhat selTish because they are only concerned of
their own families disregarding other families. But for thepoor, the rich are selTish because they are imposing
something to them without really helping them. In fact,
one tricycle driver said that “this COVID-19 only came tous here in the region because of the rich. They are thecarriers of this disease and not the poor; so why are theytelling us to stop our daily work so that we might notcarry this virus and infect the whole community? They are
the ones who carried it here in our region” (interview
with tricycle driver, March 17, 2020).
Clearly, moral antagonism between the moral “we” inthe civic sphere versus the immoral “them” in the masssphere is becoming more evident with the coming of
COVID-19 in the country. But when you trace the roots ofthis moral conTlict, this moral antagonism has long existed
in this country since the colonization period until now.
This is apparent in how the elite in the country governedusing the machinery of the state and subjecting local
leaders to their rule (Maboloc, 2019). The elite andpowerful had been imposing their notion of morality, right73

and good to the poor people without really listening totheir daily stories of struggle and survival. In its programs
and policies, the ruling elites in collusion with rich people,
are imposing a kind of morality to the poor. For example,
in the implementation of their supposed “pro-poor”
program, the “Conditional Cash Transfer (CCT)”, thegovernment has strict criteria on who will receive andcontinue to receive the small amount of money that is
granted to the families such as: they have to attainmonthly meetings, they have to send their kids to school
every day as their kid’s attendance will be monitored by
the teacher, and etc. The CCT became an apparatus ofcontrol to discipline the poor to become “good” citizens
based on their deTinition of what is a good citizen (Kusaka,
2017). The same Tinding is shared by Seki (2015) when hesaid that conditional cash transfers are not effective interms of directly reducing poverty because the real
purpose is to empower the poor through disciplining
them to become good and responsible citizens. Thus, for
Seki as well as for Kusaka, this is a form of neoliberal
governance that aspired to mold people’s desires, hopes
and beliefs by subjecting them to different mechanisms ofcontrol and surveillance (Maboloc, 2019; Kusaka, 2017).
What is the real reason why the previous
administration and even the present administration
continue to implement the CCT? If they really want todiscipline the poor, they can just deploy the military (asthey had been doing in the past) to threaten the poor towork hard or else they will be killed; as simple as that. But
why did the government spend billions for this program
and why is it the current administration of Duterte evenincreased the beneTits of the recipients if its purpose isjust to control and discipline the poor? Duterte, projectedby the mainstream media to be a “killer” would have justkilled all of these poor who are deTiant of his orders.
Kusaka (2017: 232) also said that, “conditional cashtransfer may also be understood as a policy that attempts
to break through the impasse imposed by moral
antagonism between the civic and the mass spheres”. In
short, this can be seen as an attempt by the government tosatisfy the two conTlicting parties without necessarily
forcing them to come into unity. Kusaka (2017:232) also
found that in the Philippines, handouts by politicians to
the poor are desired as poverty assistance in the masssphere but viewed as morally repugnant in the civic
sphere but “it was possible to provide aid to the poor
without incurring a major backlash from the civic sphere,
if it were done on the condition that it would impart
discipline to the poor by turning them into good,
responsible citizens.”
However, Kusaka (2017) also found that thesuspicion that cash transfers are a waste of money that
only worsens the dependence of the poor is deeply
ingrained in the “morally upright and responsible citizens
in the civic sphere”. It must also be noted that discomfort
and resentment as to the process of selection andimplementation of the CCT also exist in the mass spherebecause in exchange of a small amount of cash, they will
be scrutinized and subjected to both criticism of theirlifestyle as being immoral and the pressure to correct it(Seki, 2010). This is also afTirmed in my own interviews
with the CCT recipients of Davao del Sur. A lot of them

74

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

said that there is so much party politicking in theselection, implementation and even monitoring of the
programs and activities related to CCT to the point thateven if they don’t want to, they will be forced to remain in
the lists of those who are to receive the cash grant(interviews with CCT recipients, October 2019, Davao delSur).
Another example of imposition of moral values by
the elite and “upright” citizens to the poor citizens in thePhilippines even before COVID-19 is the introduction andapproval of the Responsible Parenthood and Reproductive
Health Act of 2012 (RH Law) of the then Aquino
Administration. The RH law is viewed as part of thebroader poverty reduction effort of the government suchthat it targets poor women a priority in receiving
healthcare services, information, contraceptives andcapacity building and monitoring (Kusaka, 2017). Kusaka
further said that the RH Law also calls for “values
education” that will address issues such as teenage
pregnancy, the rights of women and children, responsible
parenthood, among others. Thus, despite the opposition
from the Catholic Church, the law was enacted with thesupport of the elite and “upright” citizens in the civic
sphere because of its “moral” and “values education”
components for the poor to become “responsible” citizens.
However, Kusaka (2017: 233) also points out that “thisunderlying civic-sphere discourse of rescuing the poor frompoverty through family planning is a tacit moral
assumption that the poor are irresponsibly producing too
many children.” This kind of assumption by Kusaka implies
neglect over the phenomenon of structural violence andinequalities that push the poor further and further at themargins of society. Thus, it is very clear that the social
policies of the Philippine government especially during
the previous administration exemplify a neo-liberal
governance that attempts to address poverty by educating
the poor to become moral citizens with a limited welfare
budget.
From moral antagonism to agonism through ethics ofcare
On March 23, 20120, President Duterte had anannouncement to the whole nation after the house ofrepresentatives and the senate granted him additional
power to Tight the threats of COVID-19. As I listened tohim, I feel a “caring father” in him. He reassured the publicthat the government will be on top of the situation. He
directed all local government units (LGUs) and agencies
like Department of Health (DOH), Department of Social
Welfare and Development (DSWD), Department of Tradeand Industry (DTI), The Armed Forces of the Philippines(AFP) and others to really see to it that all people
especially those who are in dire need of help in thismoment of total lockdown of the country due to COVID-19
threats receive the necessary aid from the government.
Like a caring but strict father, he also gave stern warning
to those who might take advantage from the situation tocollect money in their own pocket that he will go after
them and punish them. As a father, he wants fairness andhe is Tirm in his directive to not let party politicking
interfere with the distribution of economic aids. He ended

up his address with a call for unity and resiliency in the
midst of the COVID-19 threat.
The words of the president in his address to thenation can be summed up to a call for social solidarity. He
knew that there had been so much division already in the
country. In fact, his coming to the presidency has further
aggravated this moral division of the “upright we” citizensof the elite and rich and the “immoral and uncivilizedthem” of the poor and the masses. The so-called “moral”
and “upright” citizens of this country did not really likehim. They judged him to be “immoral” and not having
moral ascendancy to govern the country. As a result of
this, lots of his supporters from the mass sphere got angry
with plenty of people in the civic sphere. Many times, hehas projected himself as belonging to the mass spherethrough his manner of speaking and misdemeanor andthrough his radical and populist style of politics andgovernance even if plenty in the mass sphere suffered andeven died because of his kind of governance. For many ofthem, this is his way of disciplining his children as a father.
This is afTirmed in the study of Kusaka among the drug
addicts in the slums of Metro Manila. Kusaka found thateven some drug addicts supported Duterte andabandoned his vice when Duterte became president.
According to Christopher Ryan Maboloc, the claim that
Duterte is a father who cares for his constituents can betraced in Philippine history, from the time of Miguel
Malvar to Luciano San Miguel and Makario Sakay(Maboloc, 2019). Maboloc (2019) writes: “Solidarity isdeveloped through meaningful communal ties. Duterte has
shown the character of being a father-Yigure when he was amayor. He attends to the needs of the ordinary people andby speaking their own tongue, he secures their trust. Callinghim “Tatay Digong” meant that he is a leader who makes
himself readily available to the people, consults themwhenever he needs to, warns and issues threats to those
who might mean harm to his constituents. The concept of“Tatay” or father in the context of the Filipino’s communal
experience is not limited to blood relations or anything
biological for that matter. It is about being endeared to thewisdom of old. Someone is respected as such because one
cares about the good and shows compassion to the people.”
Indeed, if we make an analysis of the present society
Filipinos are amid this situation, treatment of Duterte as acaring but strict father is present even amongprofessionals. In my interview with teachers in the
Catholic schools of Davao del Sur and Davao Occidental, a
lot of them considered Duterte as a caring father but very
strict. I was so struck with one teacher who confessed in
front of his co-teachers in a Focus Group Discussion (FGD)
that he used to be a drug addict though he was employed
in a Catholic school. While the sermons of the bishops andpriests and the teachings of the nuns reminded him toabandon his vice and to return to God, he was not able to
do it. But when Duterte became president and he listened
to the man’s call to the young to abandon their vices
especially in taking and selling drugs, he was hit hardly tothe core of his heart and immediately, he abandoned his
vice. When asked further why he did it or was it because
he was afraid for his life, his answer also hit me to thecore. He was even teary eyed when he narrated the storyof his life “I changed not because I am afraid. I changed

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
because I can see in him the image of my father who diedmany years ago. He is like Tatay (Father) Digong who
sacriTiced a lot for his children. But we did not value his
sacriTice for us until he got sick, maybe he got frustrated
from us, and died….” (Interview with a male teacher in a
Catholic School, October 2019, Davao Occidental).
Despite the fact that he appears to belong to themass sphere, undoubtedly, President Duterte reallybelongs to the elite. He is not really poor as he said.
However, he is so grounded with the realities in the
ground and among the poor, he understands their
feelings, he listens to them and even speaks theirlanguage. That’s why for most of the Davao people, he isreally their “Tatay”. But since he is also an elite, he can alsoeasily enter into their world, dine and eat with them. In
fact, he is a president who can easily crisscross between
these two divided moralities and can generate high levelof acceptance and approval from both camps. Thus, he canuse this inTluence to unite the people in the country byacting as a compassionate but strict father always
motivated with an ethics of care. Since he can penetrate to
the different but most often opposing camps in thiscountry and receive high level of trust and acceptancefrom them, he really knows relationships anchored bygenuine care for the other. This is the essence of the ethics
of care. As Carol Gilligan writes in one of her interviews,“An ethic of care is grounded in voice and relationships, inthe importance of everyone having a voice, being listened
to carefully (in their own right and on their own terms)
and heard with respect. An ethics of care directs ourattention to the need for responsiveness in relationships(paying attention, listening, responding) and to the costsof losing connection with oneself or with others”. [https://ethicsofcare.org/carol-gilligan/]
Psychologically speaking, when people are given due
recognition and importance, they tend to cooperate andare willing to participate in collective action. We cannot
give genuine care , respect and recognition if we cannot
really enter in the shoes of other people. In counselingwords, this is called empathy and genuine care. What thecountry needs now is a father- a caring andcompassionate father who will listen and guide hischildren. In a brighter note, COVID-19 has brought a lotof good things to this country. For one, it let its ailingenvironment rest and recuperate. It also brought families
together. This is the right time when a father of one
nation, one family, Duterte should bring the Filipino
people together to Tight for this challenge. He has publicly
shown his soft side, his ethics of care during his night’s
address to the nation on March 23, 2020. He just needs tobe more concrete in his ethics of care through systematicand systemic programs, services and policies that will
beneTit all but with preferential option for the poor withthe help, support and understanding of the rich. The
nation this time does not need strong and moralistic
leaders. What we need in this trying time is a caring
father. After all, as Kusaka (2017: 234) pointed out“morality does not really rectify the unequal social
distribution per se, and moral intervention carries therisk of dividing the people into “good” and “bad”, thereby
creating a new form of exclusion”. This new form of75

exclusion will be another breeding ground for rebellion
that will pull our country back instead of moving forward.
However, let us accept the fact that we cannot reallyachieve perfect unity in society especially in a pluralistic
society such as ours with its rich histories of oppression
and subjugation by elite rulers even if we employ
normative deliberation or deliberative democracy to give
space for those at the margins of society to participate andhave a voice in important public and political discourses.
Deliberations are normative and deliberations based on
norms and morality cannot avoid the exclusion of people
for various reasons. Thus, there will always be “voices”
wanting to be heard. What is imperative at this point ofcrisis that the country is facing is the cultivation of what
Moufe (2000) calls “agonism”. For me agonism is apeaceful coexistence of interdependent but opposing
camps that have the capacity to respect for one anothereven if they continue to struggle to advance the legitimacyof their positions and this can happen if people continue
to nurture “conversations” instead of debates.
Conclusion
The President’s manner of leadership will be crucial inattaining social solidarity in this heavily divided country
by exemplifying it in his own word and deeds. This is thetime that he should engage the people, especially those
who are against him, in “crucial conversations” bydisplaying himself as a compassionate father waiting forthe comeback of his prodigal son while letting the “good”,
elder son understand why he needs to do such actions. He
should be a model of welcoming each one and listening tothe other’s narratives and allowing people from the “civic”
and “mass” spheres to also listen to each other’s stories
and narratives without the conscious desire to evaluate
and judge them based on their own standard of what isgood and right. He must be agent of dialogue to expand
the contact zones of multiple public spheres where
diverse “others” encounter one another to help suppress
the moralization of politics in this country (Kusaka, 2017).
After all, as in most families, a caring father or (mother) is
what is most needed to unite the family.
Lastly, Duterte must act as a good shepherd to his
Tlock this time. He must continue to engage the public in a
regular basis and inform them about the situations of thecountry and reassure them that his government is on topof every challenge that a country is facing. He needs to beat the forefront to lead his people in this Tight. Whileleading them, he also needs to discipline those who are
not following the right path towards the green pasture
like those who are not following protocols and he must do
this fairly but still compassionately. As a shepherd, heshould understand that a lot of people will do something
to save their families but this is his time to remind themthat we are a bigger family and that our lives areinterrelated.
What makes a shepherd good is not his power,
intelligence or techniques in shepherding (although they
are important) but his heart – a heart that cares and that
listens to all.

76

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

References
Folger, J. (2019). Can You Trust the Health Care System in thePhilippines? Retrieved last March 27, 2020 at https://www.investopedia.com/articles/personal-Tinance/111015/
can-you-trust-philippines-healthcare-system.asp
Kusaka, W. (2017). Moral Politics in the Philippines: Inequality,
Democracy and the Urban Poor. National University ofSingapore Press.
Lim, J.L. (2020). COVID-19 and the Philippine Health Care
System. Retrieved March 24, 2020 at https://www.ibon.org/
COVID-19-and-the-philippine-healthcare-system/
Maboloc, C.R.B. 2019. “The Predatory State and Radical Politics:
The Case of the Philippines.” In Journal of ASEAN Studies,
Volume 7, Number 2: 162-175.
Maboloc, C.R.B.. 2019. “Between Radical Politics and Dutertismo:
A Reply to Critics,” SES Journal of Applied Philosophy,
Volume 5, Number 1: 1-18.
Moufe, C. (2000). The Democratic Paradox. London: Verso
Santos, A. (2020c). Philippines 'ill-prepared' as it grapples withcoronavirus threat. Retrieved March 24, 2020 at https://www.aljazeera.com/news/2020/02/philippines-illp r e p a r e d - g r a p p l e s - c o r o n a v i r u s threat-200218004321154.html
Santos, A. (2020a). Coronavirus: Philippines quarantines islandof 57 million people. Retrieved March 24, 2020 at https://w w w. a l j a z e e ra . c o m / n e w s / 2 0 2 0 / 0 3 / c o ro n av i r u s philippines-quarantines-island-57-millionpeople-200316161225532.html
Santos, E. (2020b). Philippines COVID-19 death toll rises to 45,
cases now 707. Retrieved March 27, 2020 at https://www.cnnphilippines.com/news/2020/3/26/philippinesCOVID-19-cases-death-toll-recoveries.html
Seki, K. (2010). Governing Through Inclusion: The Un/Making ofthe ‘Citizen’ and ‘Community’ through Neoliberal Urban
Development in Metro Manila, Philippines”, Japanese Review
of Cultural Anthropology. https://ethicsofcare.org/carolgilligan/

Commentary on Bayod- Leandro S. Estadilla
St. Paul University Quezon City
Email: kurtlean@yahoo.com
Bayod’s paper about the experiences of the country intime of COVID-19 reTlects on the state of the nation, fromthe disappointment of the Filipinos to the learnings andappreciation of the “not so familiar sector” of the society.
This pandemic made me reTlect and give support to thepaper.
The Philippine government was caught
dumbfounded on how big this pandemic would become.
Though there had been lots of scenarios that should have
served as a warning for the country (the likes of Wuhan,
China, Italy, and Iran), still the government downplayed
the situation. In pronouncements around January thisyear, the government claimed that we were ready—facility, healthcare, and economic-wise. The government
even boasted at the early stages that the virus is just a
simple Tlu and will never reach the archipelago; thus,
banning the inbound and outbound Tlights from China was
not an option. Further, the government ensured the publicthat hospitals in the country were enough toaccommodate cases of COVID-19 (if the virus happened toreach the boundaries of the country), and lastly, theexecutive branch even bragged on the economic
standpoint and budgetary reserves of the nation that canbe used to combat the said scenario.
Now, the Philippines slowly succumbs to the drastic
effect of the pandemic. Thousands of Filipinos are now
infected by the virus, many are dying (unfortunately
mostly are senior citizens), hospitals are in full capacity
and are no longer capable of accepting additional
COVID-19 patients, the front liners (physicians andnurses) do not have enough PPE’s to do their job
effectively while keeping themselves healthy, supplies ofbasic necessities are gradually diminishing in the market,
and stock market has reached the record bottom in thelast eight years.
This incident reveals injustice and the insensitivityof some politicians and elites in the country. At the point
when testing kits for COVID-19 was limited, politicians
were the Tirst who underwent testing—regardless ofwhether they were asymptomatic or not. Worst, evenfamily members of these “VIP’s” (as the local social media
called them with sarcasm) also consumed most of theinadequate kits. Additionally, when the government
issued an executive order to Enhance Community
Quarantine (ECQ) and laid down the rules to be followed,
it was found that the lawmakers themselves were theones violating the laws. The president of the republic evenasserted that he would not do social distancing and would
continue to mingle, do handshakes and even do “besobeso” to his friends since this is what Filipinos knew him
for. Another is a senator, who is considered as PUM(person under monitoring) even accompanied his
pregnant wife to one of the premier hospitals in the
country without declaring that he is suspected to be a
carrier of the virus. This triggered outrage from thehealthcare professionals since it exposed them to thevirus (at the time when they are needed the most andtheir numbers are dwindling). It was later found that thissenator even attended a gathering hosted by anothersenator with the members of their political party in one ofhis mansions in an exclusive village of the capital at thetime when social gatherings were prohibited and one ofthe provisions of ECQ.
Nevertheless, this paved way for the different strataof the society and the local government units to join hands
in prayer and to Tind ways how to augment the
shortcomings of the government particularly in providing
the PPE’s, supporting the basic needs of the society, and inproviding food and support to healthcare workers. Tons of
donation drives were created by different nongovernmental organizations (NGO), artists, and evenordinary people of the community. This resulted inmillions of pesos pouring in to support the “frontline
workers” and those who are mostly in need of basic
necessities like food, shelter, and water. This also serves asa wake-up call for everyone to value the works andhardships of the people who continue to work andprovide services to the common good of the Filipinos.
The physicians, nurses, security guards, bank tellers,merchandisers, soldiers, policemen, farmers, media
personnel, food delivery personnel to name a few are now
regarded as the new and true heroes of the country.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Globalization and consumer
culture: social costs and political
implications of the COVID-19
pandemic- Christopher Ryan Maboloc, PhD
Ateneo de Davao University, the Philippines
Email: ryanmaboloc75@yahoo.com
Abstract
Using the available data and literature on pandemics, thisinvestigation looks into the COVID-19 crisis from an
economic as well as social aspect, and elaborates thepolitical and moral implications of the outbreak. The
paper argues that globalization and consumerism
contribute to the impact of the pandemic to the millions of
lives around the world. It counters the idea of property
rights to address issues related to the affordability of
future vaccines and access of the poor to modern
medicine and advanced treatments. While strong
leadership and draconian measures appear necessary toensure the safety of the public, the analysis indicates thathuman solidarity is crucial to overcome the existential
threat of this pandemic. Democracy, it will be argued,
remains important as opposed to measures that violate
the rights of people as societies try to contain the spreadof the virus.
Introduction
This study examines the COVID-19 pandemic using
available data and literature. It is an interpretative
analysis that focuses on the socioeconomic ramiTicationsof the pandemic. It attempts to explain why thecoronavirus spread rapidly. Globalization and consumer
culture are a part of the problem. In addition, the paper
examines the reaction of governments in terms of theenforcement of strict discipline and curfews, especially incountries such as the Philippines. It is important to makedistinctions and proper nuances about the value ofleadership and collective efforts. In terms of purpose, thepaper offers a radical critique of property rights andargues that governments around the world and global
institutions should consider multilateral agreements tomake future vaccines accessible and affordable indeveloping countries.
Pandemics: socioeconomic costs
In 1919, 40 to 50 million were killed by the Spanish Flu(Qiu et al., 4). The World Health Organization (WHO)reports that 11,299 died out of 28,581 conTirmed cases
during the 2016 Ebola scare (Nabarro and Wannous
2016). The Severe Acute Respiratory Syndrome (SARS)
outbreak in 2003 killed 774 people out of 8,098 reported
cases (Mackellar 2007, 429). Experts explain that apandemic is a disease “occurring worldwide, or over a
very wide area, crossing international boundaries andusually affecting a large number of people.” (Harris 2000).
In this sense, a pandemic is evaluated based on criteriasuch as disease movement , severity, level of
infectiousness, and mortality rate (Qiu et al. 2016, 5).

77

Early research published by the leading scientiTic journal
Nature points to bats as the source of the COVID-19
disease (Peng et al. 2020, 270-273). The US Center for
Disease Control (CDC) has revealed that the Tirst animal tohuman transmission happened at a wet market in the cityof Wuhan in Hubei Province, China (CDC 2020).
Half of Europe’s population was decimated during
the 14th century pandemic known as the Black Death (Qiu
et al. 2016). As of March 27, 2020, the Johns Hopkins
University has reported 595,952 conTirmed cases and27,341 deaths around the world for COVID-19 (JHU
2020). The United States has overtaken China in terms ofthe number of cases. The US has reported 103,729 cases
and 1,693 deaths. Italy has recorded the highest numberof deaths with 9,134 out of 86,498 cases, followed by
Spain with 5,138 deaths out of 65,719 cases. China hasreported 81,394 cases with 3,295 deaths while Iranreported 32,332 cases with 2,378 deaths. In thePhilippines, the Department of Health (DOH) reports 803
active cases with 54 deaths.
The COVID-19 pandemic has affected every
continent, except Antarctica. In 2006, it was estimatedthat an inTluenza outbreak in the US would cost 200
hundred billion dollars (Prager 2006). A decade
thereafter, that estimate appears as a miscalculation. In
response to the economic impact of COVID-19, President
Donald Trump signed a two-trillion dollar relief package
for the American people. European states like Germany
allocated 550 billion euro as an economic stimulus and
Italy will inject 150 billion euro into the economy to help
their citizens get back onto their feet. The United
Kingdom will spend 450 billion dollars from its treasury
to support British people and businesses. But it is still too
early to estimate the actual costs of this pandemic.
Developed economies expect a contraction of their Gross
Domestic Product.
As of the moment, major stock markets around theworld are down, with Wall Street losing two trillion
dollars after only a week of the pandemic. Countries that
rely on tourism bear the major impact. Popular tourist
spots are deserted and other places of interest likemuseums and parks are closed. The International Olympic
Committee and Japan have since agreed to postpone the2020 Tokyo Olympics. Major sports leagues including theNBA, the Premier League, and the NFL have all suspended
playing games for the current season, resulting in billionsof dollars in lost or foregone revenues. But above all, it isordinary folks who suffer the most due to lost income.
Strict curfews in countries such as India, Peru, and thePhilippines, and closed borders in North America andEurope prevent people from going to work.
In the Philippines, there have been major social andeconomic disruptions due to what the government calls
an Enhanced Community Quarantine. Thousands ofpeople are refused entry into the country’s capital.
Lockdowns in major cities mean very strict discipline
imposed by the military and the police. The absence ofsafety nets is causing anxieties and great discomfort to apeople majority of whom rely on a daily minimum wage inthis consumption-based and service-oriented economy. At
present, the Philippine president has signed into law a billpassed by Congress granting him stand-by powers that

78

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

will also send money to poor households. Around 300
billion pesos (six billion dollars) has been allocated toprovide some form of relief to more than four millionfamilies living below the poverty line.
When the COVID-19 outbreak was Tirst reported, it
took a while for global leaders to react. Somegovernments may have underestimated the impact of thedisease (RNZ 2020). The WHO did not immediately
declare COVID-19 a pandemic even though the signs wereclear. In fact, the outbreak happened at the height of theChinese Lunar New Year, with millions of people travelinginside and outside of China. Italy, for instance, had three
direct Tlights every week from Wuhan prior to theoutbreak. It is also important to consider the fact that
China did not immediately report the Tirst human tohuman transmission (BBC 2020), which has a severe
implication in terms of the spike of cases today, withcountries such as Italy and Spain struggling to contain the
disease. It was a Chinese doctor named Dr. Li Wenliang
who revealed the outbreak on social media; the same
doctor died from coronavirus (BBC 2020).
Globalization and consumer culture
In what way has globalization and consumer culture
contributed to where we are right now? Globalization has
brought great advantages to humankind. It has created somuch wealth and comfort. But it has also, as a necessaryconsequence, created a hegemonic divide among andbetween peoples. That hegemonic divide has caused wars
and hunger; in short, death for many. This pandemic is
one of the consequences of a globalized world. In the past,
people worried that a virus would infect computer
programs and destroy or steal data. Few people saw it
coming, that the bigger threat would be a virus of thisgeographic reach, one that threatens to ruin the lives of
millions. Researchers warn that a public healthemergency threatens national and regional security (Qiu
et al 2016).
Consumer culture has an impact because the way
people live has a direct link to the swift spread of thevirus. People have lifestyles anchored on materialism.
Modern technology and social media now dictate the ways
people live. Most of us consume goods without regard forthe environment. The environment, in this way, gets backat man for having neglected its intrinsic worth. Thispandemic, as a natural disaster, is attributable to manhimself. China, being at the heart of a globalized economicorder, is linked to every major country, if not all countries,
in terms of the goods it sells. With the wealth it is creating,comes the ill consequences of a world that is virtuallyinterconnected.
During the 1918 Spanish Flu, air travel was notpresent, transport hubs did not exist, and large malls
where people crowd were not around. According to Dr.
Anthony Fauci, the top US public health expert battling
this pandemic, the patterns and levels of infection direct
us to the points of convergence of people who travel (CNN
Interview 2020). Tourists coming to Europe from China
and Europeans coming into the US contributed to spikes
in the number of cases (CNN Interview 2020). Contact
tracing is about containment but in advanced economies,
we are talking of thousands of people at airports,

commercial centers, and parks, making it virtually
impossible to trace every single person. It is difTicult todetermine when the numbers would come down, withNew York still peaking, and the same fear for the UK as ofthe moment.
The spread of the virus is hastened by theinterconnected nature of global economies. In poor
countries such as the Philippines, the lack of government
resources means that it is very difTicult for the people towithstand the impact of COVID-19. Hospitals are
overwhelmed and the DOH appears to lack the basic
competency to conduct massive tests. A pandemic withthe potential to kill millions is not something that acountry like the Philippines is prepared for. The strong
leadership of the current president might help, but
overall, the situation is dire given the lack of social
infrastructure and safety nets for the population.
Assuming that the worst is still to come, the consequences
to the lives of the people will be unquestionably
unbearable. But it also matters to recognize the efforts ofhealthcare front-liners who are battling the disease andlocal ofTicials in the community who have exerted great
effort to keep the public safe. Reports say that in thePhilippines nine doctors have died Tighting thecoronavirus (CNN Philippines 2020).
Political implications of a pandemic
The WHO has recognized that China's bold approach hasradically improved the situation in Wuhan. From as highas 80,000 cases, only 13 new cases was reported in China
during the middle of March. This has prompted theChinese government to open parts of Hubei to air travel,
except the city of Wuhan. Reports say that more than
three thousand medical workers were infected in China as
they battled the disease, with 12 fatalities. Wuhan waspractically a ghost town during the lockdown, with thecommunist regime using every means to ensure thatpeople do not go out to the streets, a draconian measureusing state power and the police.
While some pundits in the West are blaming China's
controlocracy (a term coined by Stein Ringen), the world
can learn how cooperation and strong leadership can help
solve this crisis. Europe as a continent is the newepicentre of the disease because of the integrated
economies of landlocked states. The easy mobility ofpeople, including their consumer culture driven way oflife, caused the spread of the virus among European cities
and states. To halt this spread, borders have been orderedclosed, although countries such as Italy, which has since
surpassed China in terms of the number of deaths, was
too late to react in terms of measures to contain the
spread of the virus.
One key thing to look into, as expressed by stateauthorities in the United States, including New York,
which now has the highest number of infections in the US,
is the availability of emergency supplies, protective gears,
and medical equipment. New York, for instance, will need
15,000 ventilators but Governor Andrew Cuomo said that
the Federal Government has only delivered 400 (CNN
2020). In Wuhan, private individuals and couriers helpedin the distribution of medical supplies. Factories produced
35,000 to 300,000 masks a day. The government built two

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
hospitals with 1,000 and 1,600 bed capacity in just 10
days. But those were not enough so they converted
stadiums and government buildings into wards as well.
A lockdown causes great discomfort and economic
suffering. But this is a matter of life and death. Public
safety, in this regard, is paramount. In the Philippines,
ordinary folks need to but do not understand the problem.
That the archipelago is a natural barrier to the contagion
is not necessarily the case. While early discussions
focused on the right to mobility, closing major airports
was a correct decision on the part of the government.
Curfews are being imposed, with violators apprehended
by local authorities. The collective effort of the community
is important, but some of these draconian measures also
have severe implications to the lives of the people, say for
instance, in terms of ensuring the food supply for the
population.
Given the struggle of government ofTicials worldwide
to keep the people inside their homes, can we blame
democracy for the spread of the virus? The point is that it
is wrong to assume that human freedom or democracy
must be sacriTiced in order to protect public health. In the
Tirst place, the world is in this difTicult situation because
China is not a democracy. Since the Chinese regime
controls all aspects of life in the state, the world was toolate to react when in fact, the Tirst case might have
happened on December 1, 2020 (BBC 2020). China only
reported the Wuhan outbreak to the WHO in the middle ofJanuary. Precious time was already lost in terms of putting
measures to contain the virus. This scenario is
symptomatic of geopolitics and ideological wars that
actually endanger millions of lives around the world.
For now, it matters that people understand that
democracy is about choosing the right leaders who can
implement good programs to beneTit and protect the wellbeing of the people. Instead of harsh and cruel measures
such as what is happening in India that is shown on social
media, compassion and care for the wellbeing of others
would be preferable. We have to respect human rights andthe dignity of the people even in times of crisis. Decency
even in our death is not just a philosophical matter but
political as well. We have to preserve our humanity andefforts to make the lives of people digniTied and the basic
respect for others secured as we pursue a better future foreveryone after this pandemic.
Moral implications of the COVID-19 Pandemic
What is apparent in this outbreak is the effort of thescientiTic community to come up with a potential vaccine
for the virus. Dr. Fauci fears that the viral infection might
become cyclical, thus the vaccine is a necessity. For thisreason, hundreds of millions of dollars will be invested bypharmaceutical companies in the race to produce one.
However, since private companies will be investing a lot ofmoney, it is expected that the motive for proTit will exist.
Given the lack of resources in the Third World, poor
people will be at a great disadvantage considering that thevaccine will not come cheap.
The issue is rooted in the concept of patents. Poor
countries cannot just manufacture any drug due torestrictions for potential violations to property rights. Any
country that replicates a pill without the permission from79

the owner of the patent is inviting suits in international
courts. Pharmaceutical companies insist on their right torecover costs from research and development. Many ofthese drugs are patented in afTluent societies. As a result,the poor citizens in Third World countries die, notbecause diseases cannot be treated, but due to the lack ofmoney to procure medicines. From a moral end, it is hightime for global institutions to look into the problem inorder to make the access to lifesaving medicines fair.
Multilateral and bilateral agreements remain feasible
considering the humanitarian concern that is at stake.
This pandemic, in a way, reveals the unjust
structures in the world in the area of healthcare. While weunderstand that healthcare is a right that should beprioritized by governments, access to lifesaving
treatments is never a priority. With this, the impact to thelives of those who are affected will be huge and terribly
discomforting. Right now, the reported deaths in the
COVID-19 pandemic are high in wealthy states. But as theoutbreak threatens to reach depressed and overcrowded
places, the loss of human lives might be staggering if
community transmission is not controlled. In view of this,it matters that all governments must use every effort andmeans to prevent the spread of the virus.
Beyond state measures, rules and policies that focus
on the control of the population in order to protect publichealth, societies can begin to look into the importance ofindividual moral responsibility. For instance, a top senate
ofTicial in the Philippines who has been recently tested as
positive for COVID-19, while on home quarantine, went toa hospital during the prenatal check-up of his wife, thus
compromising the lives of the people he had contact with.
This is quite revealing since poor Filipinos are sufferingfrom the imposition of strict measures, whereas a top
ofTicial has shown insensitivity to the situation of thepeople, notwithstanding the potential of illness or deathfor someone that he might have infected.
A further moral implication with regard to thispandemic is the situation of children with disability. A
doctor in the Philippines died while serving as a front
liner in the Tight against the disease. The man left behind ason who has a cognitive disability. Such a situation should
open the consciousness of people in terms of the human
implications of the pandemic. While countries discuss andfocus on the economic impact of COVID-19, the moral
aspect of the crisis is beginning to unfold. It now becomesa question of moral concern and care for those who haveno means in life. The fact of the matter is that this is not
only about the wellbeing of the general population; there
are people who need special care whose lives are
irreparably compromised.
Conclusion
Resources are necessary in order to prepare a country
when it comes to a pandemic. Dr. Fauci has revealed thepotential of a second wave of the disease. Without any
vaccine or drug, the suffering of people right now can only
be magniTied. For this reason it is important that thescientiTic community work on a vaccine to avert that kindof situation. However, states can look into a solid form of
mutual cooperation that is considerate of the plight of thepoor in the Third World who do not have an access to80

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

lifesaving vaccines given the affordability issue and theunfair practices of pharmaceutical companies who insist
on their property rights. Global institutions, in this regard,
must enter into multilateral agreements with regard to
the accessibility of the poor to modern medicines.
While strict discipline and police power might help
in controlling a crowd, the concept of individual
responsibility based on the concern for others and asensitivity to the situation of the community as well as thewellbeing of the public in general remains important.
While state measures may be necessary, these will bemeaningless if the people do not embrace a responsible
behavior or attitude. A collective effort on the part of thecommunity is required in order to make rules that keep
the public safe. But all measures should be pursued withthe basic respect for the rights of people in mind. The
world is at risk because of the lack of free speech in China
in the Tirst place. If we are to pursue a better future after
this pandemic, governments must guarantee and secure
the democratic rights of people.
References
BBC News. 2020. “Li Wenliang: Coronavirus kills Chinese
whistleblower doctor.” https://www.bbc.com/news/worldasia-china-51403795.
Centers for Disease Control. 2020. “Coronavirus Disease 2019
(COVID-19).” https://www.cdc.gov/coronavirus/2019-ncov/
cases-updates/summary.html.
CNN Philippines. “Young Doctor dies due to COVID-19.” https://cnnphilippines.com/news/2020/3/18/young-doctor-diescoronavirus.html
Johns Hopkins University. 2020. Coronavirus Resource Center.
https://coronavirus.jhu.edu/.
Fauci, A. 2020. CNN News. “Primetime with Chris Cuomo”
Harris, S. S. 2000. A Dictionary of Epidemiology, Fourth Edition
MacKellar, L. 2007 ‘Pandemic inTluenza: A review’, Population
and Development Review, Vol. 33, No. 3, pp.429-451
Nabarro, D. and Wannous, C. 2016. “The Links between Publicand Ecosystem Health in Light of the Recent Ebola Outbreaks
and Pandemic Emergence.” In EcoHealth: 1-3.
Peng, Z, Xinglou, Y., and Wang, X. 2020. “A pneumonia outbreakassociated with a new coronavirus of probable bat origin.” In
Nature 579: 270-273.
Prager, F., Wei, D., & Rose, A. 2016. “Total Economic
Consequences of an InTluenza Outbreak in the United States.”
Risk Analysis.
Qiu, W., Rutherford, S., Mao, A., and Chu, C., 2016 and 2017. “The
Pandemic and its Impact.” In Health, Culture and Society,
Volume 9 and 10: 1-10.
RNZ News. 2020. “We’re underestimating COVID-19: Experts
debate government response.” https://www.rnz.co.nz/
news/COVID-19/412281/coronavirus-we-reunderestimating-COVID-19-experts-debate-govt-response

Commentary on Maboloc- Aldrin F. Quintero, MA
Notre Dame of Marbel University, the Philippines
Email: mengzi.khun@gmail.com
The paper is all about investigating the most recent
outbreak, the COVID-19 pandemic, from an economic aswell as a social point of view. The paper also argues that
globalization and consumerism are contributory to theimpact of the pandemic. The paper proposes possible
moral solutions to address the emerging issues related toaccessibility of lifesaving treatments, the availability of
medical supplies and protective equipment and future
vaccines especially in poor countries
It was mentioned in the paper that ‘globalization has
brought great advantages to humankind. It has created somuch wealth and comfort for people. But it has also, as anecessary consequence, created a hegemonic divide
among and between people. That hegemonic divide has
caused wars and hunger.’ I support this statement
presented by the speaker. In addition, the spread ofcoronavirus represents the downside of globalization. At
the same time, the impact of COVID-19, in such a shortperiod of time, reminds us all of the inter-relatedness of
our countries and peoples. My point here is not topromote anti-globalization sentiments; it’s a call torecognize one of the downsides of an ever-globalizing
world. COVID-19 is presenting the world with a unique
opportunity to prove just how far we have come from themedieval practices in the past. Implementation of rational,
ethical, and effective measures is the only way forward.
I totally agree with professor Maboloc that
“resources are necessary to prepare any country when it
comes to a pandemic”. While poorer communities who areexposed to it are affected more, at the end of the day webreathe the same air, draw water from the same resource,and so on. Inequality and poverty hurts the poor the most,but in the end, it affects us all — it stunts economic
growth, gives rise to crime and violence, creates unsafe
and unhealthy environments, leads to a collective sense offear and hopelessness, to name a few. I was reminded ofthis with the outbreak of the new coronavirus. Nothing
has emphasized our connectedness – locally, nationallyand globally – more than COVID-19, which continues torage around the world. Nothing will also emphasize thelink between poverty, income inequality, and health morethan the spread of this incredibly contagious disease.
This period requires critical visionary and peoplecentered leadership at all levels of society. While
recognizing our fundamental responsibility for selfprotection and guaranteeing our very lives, of equal
importance is the sovereign role of governments toprotect our people and societies. This is the chance to help
and trust our governments. They were formed to takecollective actions, to undertake important jobs which
need to be done for our collective survival; things which
we cannot do as individuals. As pointed out by professor
Maboloc “the concept of individual responsibility basedon concern for others and a sensitivity to the situation of
the community as well as the wellbeing of the public ingeneral remains important”. As in all public healthemergencies, poor children and poor families suffer the
most. An ethically defensible policy of school closuresneeds not just the bar of public health necessity;
government agencies and community organizations in
education, nutrition assistance and housing, as well as
public health, must also be planning to take active
measures to mitigate the disproportionate burden thatwill fall on our most vulnerable children. It is also
appropriate and accurate for the health sector to reassure
the public that most people who contract COVID-19 willEubios Journal of Asian and International Bioethics 30 (3) (April 2020)
recover fully on their own. At the same time, the public
needs to be prepared for the possibility of more dires c e n a r i o s . S o , wh i l e a c k n o wl e d g i n g o u r s o l oresponsibilities, our governments, must do, what we electthem to do, inter alia, the protection of the people, in all
forms, in this globalized world.

A brief historical review of thegreat pandemic of 1918: theSpanish flu- Leonard H. Le Blanc, III, PhD
Dean, American University of Soveiregn Nations, USA/
ThailandE-mail: leblancleonard@gmail.com
Abstract
The coronavirus pandemic of 2019 will have a major
negative impact on the world. Virtually no part of the
globe will remain unaffected except in the most isolated
locations. As at least one learned commentator has
already recently opined that world history will now be
divided into two major eras: B.C. (Before Coronavirus)
and A.C. (After Coronavirus). There will unquestionably
be many dramatic changes in all Tields of human endeavor.
None of the changes bodes well at face value, but there
might be some positive aspects once the pandemic is
Tinally over. There is also no question now that the virus ismoving much faster than the human effort being
frantically waged to contain it. This virus is not a newphenomenon. There have been almost annual virus
outbreaks from Asia, like the Hong Kong Tlu, Swine Tlu and
SARS over the decades. Also viral outbreaks haveoccasionally originated in Africa, like the Ebola virus.
However, there is no question that mankind was notprepared for this quickly spreading, highly contagious
viral infection.
Several commentators have immediately drawn
similar comparisons with the last major historical virus
outbreak that devastated the world over one hundredyears ago: The global “Spanish Flu” pandemic. It would be
helpful if a brief historical review was accomplished of theimportant events that led to the pandemic and what
efforts were taken at the time to contain it. Although
medical advances have been very impressive over the past
century, the public health tools and medical procedures
used to contain and control virus outbreaks has notadvanced with as much modern innovation. Isolation andquarantine, face masks and ventilators, social isolationand disinfectants are being used exactly as they were backin 1918.
Introduction
Since the Black Death pandemic swept Europe in the
Middle Ages, no pandemic has had a greater public healthimpact on humanity than the “Spanish Flu” or inTluenza
pandemic in 1918-1920 to date.
Although the Black
Death lasted much longer than the “Spanish Flu”, it killed amuch higher percentage of people in Europe.
The
inTluenza pandemic was the worst pandemic of the81

modern era. All human activities were set aside in aneffort to stem the wide-ranging ravages. Millions were left
as orphans. Medical scientists were desperate to Tind acure, or at least Tind the origins of the virus to better
understand it. There have been a number of scholarly
attempts to explain all aspects of the pandemic since it
was a multi-faceted calamity.
This particular Tlu outbreak that occurred over 100
years ago is one of the deadliest pandemics in humanhistory. It remains to be seen exactly how badly thecurrent coronavirus (COVID-19) will impact the world.
The 1918-1920 pandemic was the Tirst of two pandemics
that were caused by the H1N1 virus. The other being theswine Tlu global outbreak in 2009.
Influenza origins and contributing factors
Exactly where the Tlu originated is still a matter of intense
conjecture and great debate after a number of decades.
Even the name “Spanish Flu” is a misnomer as the Tlu did
not actually originate in Spain. Many more reports of thepandemic frequently appeared in Spanish news outlets aswartime censorship was not a factor there due to Spain
being a neutral country during World War I. So the
misconception arose that the Tlu virus originated in Spain.
This inTluenza was eventually, if erroneously, called the“Spanish Flu.”
Greatly accelerating the means of the virus
spreading is the fact that there are more than half amillion virus particles that can be passed to those nearby
when an infected person coughs or sneezes. One of the
major factors that contributed to the widespreadtransmission of the Tlu was global travel.
Moderntransportation systems made it much easier for civilians,
military troops and sailors to spread the virus, especiallyduring World War I as troops from many nations weretransported to France by the Allied nations and then later
repatriated.
According to some virologists and medical historians
there were three waves of the inTluenza strain. The Tirst
strain or wave was in March 1918. The second strain or
wave started in August 1918. The peak of the epidemic
was in October 1918. It appeared simultaneously in
Boston, Massachusetts, U.S.A., in Breast, France andFreetown, Liberia. The third strain or wave started in
1919.
Numbers of world fatalities
There have been various estimates on the total number ofpandemic deaths. It has been estimated that about 500
million people, perhaps one-quarter of the earth’s
population, was infected over a century ago. In one 1991
study, it was estimated that between 25 and 39 million
people had died. Some studies have said 30 million people
died in less than six months. In a 2005 estimate, it was
written that up to 50 million people died or less than
three percent of the world’s population at the time. Evenone estimate has stated the Tigure could be as high as 100
million people expired or about Tive percent of the world’s
population. However, in a recent 2018 reassessment, theestimate was stated that only 17 million people died. In
general, it is estimated that between one and six percent

82

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)of the world’s population died if the world’s population
was between 1.8-1.9 billion at the time of the pandemic.
These deaths included my paternal grandmother’s
youngest uncle and second youngest uncle and his wife in1918 in Maine, USA. They all died of bacterial pneumonia,
the most commonly-related cause of death due to the Tlu
virus, according to their death certiTicates. I only foundout about their deaths during a genealogical study I did
several years ago on my paternal grandmother’s family
members. They were all in their mid-20s, still very young.
They left a young son, named Donald, who was cared forby his paternal grandparents as an orphan according to
the 1920 U.S. census.
Worldwide spread
The pandemic killed many people all over the world.
However, some nations were not as affected. Several South
PaciTic islands, namely American Samoa and the Frenchcolony of New Caledonia, prevented all ships from landing
there and thus recorded no Tlu deaths. Japan’s death rate
was a minor fraction of other nation’s fatalities by also
greatly restricting ships from docking. It is estimated thatbetween 12-17 million deaths occurred in India or
approximately Tive percent of the population.
The pandemic was easily New Zealand's worst
public health crisis. It was also its worst natural disaster.
Over 8,500 New Zealanders succumbed to the inTluenza
virus and the attendant pneumonia in just six weeks. It is
recorded that nearly a quarter of the victims were Maori.
The native New Zealand population there died at seventimes the death rate of European New Zealanders.
Some epidemiologists have stated that the “SpanishFlu” originated in China. However, that is not a widely heldor consensus opinion due to the lack of hard evidence.
Medical records from China were not in abundance to be
consulted as there was no centralized collection ofrecords. This was due to the unrest and regional strife bycompeting warlords throughout the country during thewhole era. The Tirst estimate that was done in 1991 statedthat between 5-9 million deaths from the virus. However,more recent studies have held a much lower mortality
rate in the country. Another estimate stated that between
1 and 1.28 million died in the pandemic.
Some historical virologists believe the virus started
in a UK military hospital center and receiving station in
France in 1918 during World War I. The camp was close toa piggery and live poultry was frequently delivered to thecamp mess halls. Also, common lore in the USA has the
Tirst inTluenza case being detected at Camp Funston, now
a part of Fort Riley in Kansas, USA also in March, 1918.
One soldier stationed at Camp Funston was from Haskell
County, Kansas. He was the Tirst identiTiable case, and Tirst
known fatality, of the inTluenza virus in the USA. However,some scientiTic researchers have stated they now believe
the virus actually began as early as 1915 as a low-level
infection and later spread. The origins of the virus remaina contentious matter to this day.
There is no conclusive evidence to prove the virus’s
exact origin to any one speciTic location, although there
have been several places of origin purported. Although theworld has seen inTluenza epidemics in the past, thisparticular pandemic quickly became extremely virulent.

According to some virologists, this was due to a number ofcontributing factors: malnutrition, poor nutrition orundernourishment, severe wartime stress, chemical
attacks that weakened the victim’s immunity systems,
poor hygiene in military and medical camps and hospitals
caused a bacterial superinfection. In a personal letter
dated 1918 to his parents from my mother’s uncle, Vernon
Blake, a young US Army soldier in France during WorldWar I, he commented that the dead were piling up so fast
there they were burying the corpses without cofTins.
Pandemic analysis
Another analysis of the pandemic included variable suchas school openings and closings, temperature span of theoutbreak and human behavioral changes in response to
the pandemic. All these factors were important, but thefactor of human behavior was found to be paramount on
its effect of the virus.
Soldiers who contracted a mild strain of the virus
stayed where they were. Soldiers who contracted a severstrain of the virus were sent to hospitals in the rear areas
pandemic was much deadlier than the Tirst. The Tirst wave
had resembled typical Tlu epidemics. Those who were themost at risk were the sick and elderly, while younger,
healthier people recovered easily. It is commonly agreed
that World War I increased the severity of the pandemic.
Normally, in civilian life, natural selection favors a mild
strain. Those who get infected stay at home. Those whoare mildly ill spread a milder version of the strain. In the
trenches, the pattern is reversed. Those who got a mild
strain of the virus were kept in the trenches. Those who
were gravely ill were sent to the rear areas in trains or
ambulances and conTined to over-crowded Tield hospitals
where many of the victims died.
As US troops began deploying to Europe during
World War I the virus quickly spread among the massed
troops conTined at close quarters. It is believed these
conditions allowed the virus to mutation and become
more deadly. The Tlu rapidly spread through the USA after
it was Tirst detected, but there were no initial efforts tocontrol or suppress the virus. This lack or reaction washarshly criticized later when the true extent of the
medical disaster was fully known. However, nothing likethe inTluenza pandemic had never been see in the USA or
elsewhere where in the world. The medical personnel at
the time were virtually helpless in the face of the rapidly
spreading virus and could offer only palliative care, at best
due to the lack of antibiotics and other modern medical
treatments and devices.
Other Contributing Factors
One of the problems is health workers did not initiallyrecognize the pandemic and its symptoms for what it
actually was, having never experienced the virus before
that time. Some patients were diagnosed as having
contracted dengue fever, cholera or typhoid fever. The
greatest majority of deaths in the USA were people who
were under 65 years old and half the deaths wereconcentrated in people 20 to 50-years-old. Modern
studies have shown that the virus to be particularly lethal.
This was due to a cytokine storm being triggered (i.e.;severe overreaction of the body's immune system) andEubios Journal of Asian and International Bioethics 30 (3) (April 2020)
thus killing the patients. This reaction especially ravages
the stronger immune system of young adults. This verystrong response by the immune system hastened young
people’s deaths, whereas a weaker immune system
response in very young and older people resulted in far
fewer deaths. It was later determined some older people
had been subjected to a milder form of the Tlu virus andthey had stronger immunity systems. In one study it
showed that human behavioral responses had the greatest
impact on lessening the effects of the pandemic.
Some scientists have posited that the original of thevirus were avian, then it spread to humans who theninfected swine. But there is still no agreement on theorigin. Epidemiological research continues to try andlocate then determine the genetic make-up and origin of
the virus if only for historical and scientiTic purposes.
Conclusion
There is much than we can glean from the historical
records of the “Spanish Flu” and the private and publichealth responses pandemic of a century ago. The major ormost relevant points to control the pandemic are social
distancing, isolation or quarantine of infected patients,
repeated hand-washing with sanitizer or soap, wearing aface mask, sufTicient respirators and medical treatment
facilities including hospital beds. Undoubtedly, the mostimportant point to combat the pandemic is especially anearly recognition of the emerging threat of the Tlu virus,
planning the correct response and the coordinated effort
by all government ofTicials, public healthcare experts andmedical practitioners to take the pandemic seriously andact quickly.
All of these lessons for this current pandemic havebeen embraced, or not embraced, by various governments
and individuals around the globe to the extent they are
actually believed, or do not believed, of the actual problem
existence. Some have stated the virus is a hoax. But
skeptics and non-believers are quickly being persuaded of
the serious of the problem in light of the overwhelming
and rapidly mounting evidence. Eventually, over time, thevirus will fade, both in reality and in memory. It is aquestion if the lessons from 1918-1920 and 2019-2020
will be retained to be useful for the next outbreak ofanother virus. That is the only certainty we can rely on.
Mankind has not seen the end of Tlu outbreaks or more
pandemics. If one had to bet, then the problem will
become more severe in the future, not less.
References
Barry, J. M. (2004, January). The Site of Origin of the 1918
InTluenza Pandemic and its Public Health Implications.
Journal of Translational Medicine, 2(1), 3.
Brundage, J. F., and Shanks, G. D. (2007, December). What really
happened during the 1918 InTluenza Pandemic? The
Importance of Bacterial Secondary Infections. The Journal of
Infectious Diseases, 196(11), 1717-1718.
Bynum, B. (2009, March 14). Stories of an InTluenza Pandemic.
The Lancet, 373(9667), 885-886.
Chandra, S., and Christensen, J. (2019. March 2). Re:
Reassessing the Global Mortality Burden of the 1918
InTluenza Pandemic. American Journal of Epidemiology,
188(7), 1404-1406.

83

Gagnon, A., Miller, M. S., Hallman, S. A., Bourbeau, R., Herring, D.
A., Earn, D. J., and Madrenas, J. (2013). Age-speciTic
Mortality during the 1918 InTluenza Pandemic: Unravelling
the Mystery of High Young Adult Mortality. PLOS One, 8(8),e69586.
Hammond, J. A. B., Rolland, W., and Shore, T. H. G. (1917, July14). Purulent Bronchitis: A Study of Cases Occurring
Amongst the British Troops at a Base in France. The Lancet,
190(4898), 41-45.
Hirsch, E. F., and McKinney, M. (1919). An Epidemic ofPneumococcus Broncho-pneumonia. Journal of Infectious
Diseases, 24(6), 594-617.
Killingray, D., and Phillips, H. (2003). The Spanish InTluenza
Pandemic of 1918-1919. London, UK: New Perspectives/
Routledge.
MacCallum, W. G.
(1919).
Pathology of the Pneumonia
Following InTluenza. JAMA: The Journal of the American
Medical Association, 72(10), 720-723.
Mayor, S. (2000). Flu Experts Warn of Need for Pandemic Plans.
British Medical Journal, 321 (7265), 852.
Morens D. M., and Fauci, A. S. (2007, April). The 1918 InTluenza
Pandemic: Insights for the 21st Century. The Journal of
Infectious Diseases, 195(7), 1018-1028.
Oxford J. S., Lambkin, R., Sefton, A., Daniels, R., Elliot, A., Brown,
R, and Gill, D. (2005, January). A Hypothesis: The
Conjunction of Soldiers, Gas, Pigs, Ducks, Geese, and Horses
in Northern France during the Great War Provided theConditions for the Emergence of the "Spanish" InTluenza
Pandemic of 1918–1919. Vaccine, 23(7), 940-945.
Plaspohl, S. S., Dixon, B.T., and Owen, N. (2016). The Effect of the1918 Spanish InTluenza Pandemic on Mortality Rates in
Savannah, Georgia. Georgia Historical Quarterly, 100 (3),332.
Phillips H., and Killingray D. (Eds.). (2003). The Spanish Flu
Pandemic of 1918: New Perspectives. London and New York:
Routledge.
Rice, G., and Bryder, L. (2005). Black November: The 1918
InYluenza Pandemic in New Zealand. (2nd Ed.). Christchurch,
NZ: Canterbury University Press.
Saunders-Hastings, P. R., and Krewski, D. (2016 December 6).
Reviewing the History of Pandemic InTluenza:
Understanding Patterns of Emergence and Transmission.
Pathogens, 5(4), 66.
Shanks, G. D. (2016, January). No Evidence of 1918 InTluenza
Pandemic Origin in Chinese Laborers/Soldiers in France.
Journal of the Chinese Medical Association, 79(1), 46-48.
Sherman I. W. (2007). Twelve Diseases that Changed our World.
Washington, D.C: ASM Press, 161.
Spreeuwenberg. P., Kroneman, M., and Paget, J. (2018, December1). Assessing the Global Mortality Burden of the 1918
InTluenza Pandemic. American Journal of
Epidemiology,187(12), 2561-2567.
Worobey, J., Cox, J., and Gill, D. (2019). The Origins of the Great
Pandemic. Evolution, Medicine, and Public Health, (2019)1,
18-25.

NEW: POSTGRADUATE CERTIFICATE IN EPIDEMICS
AND ETHICAL GLOBAL HEALTH
American University of Sovereign Nations (AUSN) has justlaunched a new Postgraduate CertiTicate Program - classes
from March 2020. Do not delay to join us to prepare
yourself and your community to respond to COVID-19.
Email to: provost@ausn.info:
https://ausn.info/
postgraduate_certiTicate_in_epidemics_and_ethical_global_health84

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Ethical and social challenges of
COVID-19 in Iran
- Mahta Baratipour
Iran
Email: maniyaa1998@gmail.com
Health is one of the most valued concepts in Iran. There
are more than a million medical students in a populationof 81 million people. There are 61 medical schools and 50of them are free for the students. Students learn somebasic information about the human body in the Tirst yearof high school. People get vaccinated from childhood, andthey are required to have ofTicial certiTicates that proves
they had their vaccines from health institutions to enterschool and university. Students are also required to go
through a health check process in a public healthinstitution every 3 years.
Some schools teach Tirst aid to their students andany person regardless of his or her age, can go to ‘Red
Crescent' organization and learn Tirst aid for free. Still we
can see from people’s actions that basic knowledge of how
to prevent an epidemic spreading in a population is
insufTicient. It is in that context that we can consider theshock that people in Iran, as in other countries, have felt
to be living with a pandemic.
During the COVID-19 coronavirus pandemic, Iranreported its Tirst conTirmed case on 19 February 2020 in
Qom (1). However, many people and many healthorganizations believe that the virus was in Iran before
that reported date, and that the virus kept spreading
without people being aware of it. Some said it was
because some government ofTicials wanted to only
conTirm the case after the election (2). A map of Iranshowing the intensity of COVID-19 cases is shown in
Figure 1.
One of the most important issues was people
insisting to travel despite all the warnings not to travel
because it may spread the virus (3). These people selTishly
gave themselves the right to use their Iranian new year
holidays (from 19 March) by traveling. They kept
spreading the virus, and put themselves and others’ life indanger. According to BBC Persian News Service, morethan 2000 people with COVID-19 symptoms traveledthrough the New Year holidays.

Figure 2: Photograph of one holiday trafTic jam at Iranian
New Year (ignoring the trafTic restriction)

On the other hand, there is a lot of misinformation
on social media. Some fake methods to prevent the virus
were suggested on the Internet, and some of them arereally dangerous. Hundreds of people got extremely sickfrom drinking methanol, and 44 deaths were reported (4).
Because drinking alcohol (ethanol) is prohibited due toreligious law, some criminals sold methanol to people
who falsely believed that drinking alcohol could prevent
COVID-19.
Since hospitals are full of COVID-19 patients, there
aren’t enough beds for more people. Also, there is limitedaccess to medical treatments for other sick people, e.g.
people who need dialysis treatment, especially in thisemergency situation. The focus is on COVID-19 infections
so other illnesses are almost ignored; the hospitals andclinics are not safe for them, and they should just stay athome.

Figure 1: Relative infection rates across Iran (Source
wikipedia; Date: 20 March 2020)
In addition, students at schools and education
systems are in a bad position. Education has been
supposed to be continued via social media and online
methods, but a lot of schools and universities either had
no capacity, or ignored their duty to continue education,
so the educational system is Tinding it very difTicult toprovide even basic education. Many students are notsatisTied with the materials they are receiving. Only a few
professors share some pdf Tiles. The schools immediately
closed on February 23 and other public places like malls,
restaurants, mosques and religious places closed a few
days after schools (5). In the Tirst few weeks people werein shock and started buying all masks and otherdisinfectant products but after a month all industries(even non-related ones) started producing healthproducts rapidly to make sure most people now haveaccess to these products (6).
The doctors and nurses have been stuck in thehospitals with sick people for months and there is a lot ofvolunteers who are helping the healthcare team bynursing patients. The army joined to help people; they arebuilding open air hospitals and keep disinfecting thestreets.
15 cities closed their roads by putting up physicalbarriers and will not let anyone in to prevent the wider

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
spread of the virus more than what it already has (7). Also
there are some Tinancial penalties for travelers (8).
As a student of computer sciences I am interested in
the way the information has spread. There is a lot of
information about the virus on social media(@dr.saeednamaki the minister of health). Lots of popular
instagramers like @milad_khahhh and @erfanalirezai
keep encouraging people to stay home. So they are having
a positive impact, especially on young people. Though
there is some misinformation going around about fakeprevention methods, in general, social media had many
beneTits for society in this situation.

85

short term interests and not acting in social solidarity.
Some commentators from outside are also surprised that
Iran has let people travel freely because they thought thatthe country is very authoritarian. However the balance
between individual liberty and public control is more
complex than it appears. The vast majority of citizens
share in the common ethical goal to protect the weak andvulnerable, and to overcome the viral pandemic.
References
1. radiozamaneh.com (Feb 19th)
2. iranintl.com (Mar 28th)
3. bbc.com/persian (Mar 20th)
4. bbc.com/persian (Mar 10th)
5. tasnimnews.com (Mar 7th)
6. yjc.ir/fa/news (Mar 27th)
7. aa.com.tr/fa (Mar 7th)
8. shomanews.com (Mar 26th)
9. Wikipedia.com

Commentary on Baratipour- Marites V. Fontanilla
Program Chair, BSIT, St. Paul University QC, the Philippines
Email: mfontanilla@spuqc.edu.ph⚫ = Deaths 🔵 = Recoveries 🔴 = Active Cases
Figure 3: The Reported COVID-19 cases in Iran (Source: Ministryof Health, Iran)Popular religious leaders also tried their best to keeppeople safe and in their homes; they canceled all religious
reunions like prayers on Friday and told people thatstaying safe and healthy is the most important element ofIslam. Most people in Iran are Muslim, but minority
religions also have done the same. Most religious leadersusually use TV and national media as their voice and mostof them do not use other social media like Instagram orTwitter.
As of 23 March 2020, according to Iranian healthauthorities, there had been 1,812 COVID-19 deaths in Iranwith more than 23,049 conTirmed infections. As of 23
March 2020, Iran has the fourth highest number of
COVID-19 deaths after China, Italy and Spain. It is thehighest in Western Asia and the sixth-highest number of
COVID-19 cases in the world (9). Figure 3 shows theincreasing toll.
Overall the COVID-19 pandemic is something thathas challenged people in Iran who are already living invery tough economic conditions because of the sanctions,but there are some examples where the common healththreat has brought people together. Religious leaders havea big inTluence on people in small cities; they trust religion
the most, but people in big cities trust science and doctors
more.
We also have seen social criticism of persons who
seem to be breaking social distancing rules for only their

I can relate to the following ethical and social challenges
pointed out in the paper:“Some fake methods to prevent the virus weresuggested on the Internet, and some of them arereally dangerous.”In the Philippines, this is also true. Most of the Filipinos
are fond of posting and reposting almost everything theysee in the social media. In one instance, I asked one of mycolleagues where she is getting what she is sharing in ourgroup and she cannot tell me right away the source. It is
so annoying that before Tlooding the page with a lot of
messages, links and videos, validation of these has notbeen done. Fake news leads into confusion where people
do not know who and what to believe anymore.
In connection to this, President Duterte was given thespecial power to punish people spreading fake news
about the coronavirus. A last-minute amendment special
powers bill contains the novel coronavirus of the section
on penalties; it now includes punishment of the spread of
fake and alarming information by up to 2 months inprison and up to P1 million in Tines.
Section 6(6) punishes "individuals or groups creating,perpetuating, or spreading false information regarding
the COVID-19 crisis on social media and other platforms,
such information having no valid or beneTicial effect on
the population, and are clearly geared to promote chaos,panic, anarchy, fear, or confusion."“Since the hospitals are full of COVID-19 patients,
there are not enough beds for any more people.”
On a personal note, I believe that each and every one of us
should do our fair share to help stop the virus. Observing
the following measures below, could prevent shortage of
hospital beds, equipment or doctors:
Social distancing by working from home, switching toonline classes, visiting loved ones by electronic devices
instead of in person and the like.

86

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Self-quarantine by using standard hygiene and washinghands frequently, not sharing things like towels andutensils, staying at home, not having visitors, staying atleast 6 feet away from other people in your household andthe like.
Hospitals across Metro Manila are stretched to their limits
that results into telling the coronavirus-positive patientsto go home and self-quarantine. Political leader s
explained that it was not a matter of national policy, but aneed for hospitals to improvise given the lack of resources
and manpower.
“Education has been supposed to be continued via
social media and online methods, but a lot of schools
and universities either had no capacity...”In our university, we did not stop teaching our students.
We reached out to them and conducted online classes
using our learning management system. However, wecannot get 100% participation of both faculty members
and specially the students due to Internet connectivity
concerns. To address this, guidelines were formulated andimplemented in favor of the faculty members andstudents’ concerns. Rappler Philippines’ webpage
reported that in a bid to contain the spread of the virus,
the whole island of Luzon is on lockdown since March 14,
2020. Classes in all levels in Metro Manila andgovernment work were suspended until April 14, with aduration of 30-day lockdown in the capital region.
Following the Consumer on Higher Education (CHED)
advisory which encourages schools to use available
distance learning, e-learning, and other alternative modesof delivery in lieu of residential learning if they have theresources to do so, several schools have opted to make up
for lost time with online classes. However, student
governments of top Philippine schools submitted thepetition to CHED and aired their concerns abouttransitioning to e-learning in the middle of the pandemic.
In response to the students’ petition, CHED requested
universities and colleges to be more lenient as classes
shift online and help the students during these times.
Wherever we are in this part of the globe right now, we all
have some share of the good and bad experiences of thispandemic. The best that we can do is to follow theguidelines to contain the virus to be safe and pray for eachand every one.
References
CHED tells universities to 'be lenient, help students' as classes
shift online. (2020). Retrieved 28 March 2020, from https://www.philstar.com/headlines/2020/03/17/2001653/chedtells-universities-be-lenient-help-students-classes- shiftonline
Coronavirus patients sent home as PH hospitals reach limit.
(2020). Retrieved 28 March 2020, from https://www.rappler.com/nation/255472-coronavirus-patientssent-home-philippines-hospitals-reach-limit.
Coronavirus, Social Distancing and Self-Quarantine. (2020).
Retrieved 28 March 2020, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/
coronavirus/coronavirus-social-distancing-and-selfquarantine.
Duterte's special powers bill punishes fake news by jail time, up
to P1-M Tine. (2020). Retrieved 28 March 2020, from https://www.rappler.com/nation/255753-duterte-special-powersbill-coronavirus-Tines-fake-news.

Students of top 4 PH schools urge CHED to suspend online
classes. (2020). Retrieved 28 March 2020, from https://www.rappler.com/nation/255852-students-top-schoolsphilippines-call-ched-suspend-online-classes- coronavirusoutbreak.

Commentary on Baratipour- Leonard H. Le Blanc, III, PhD
Dean, American University of Soveiregn Nations, USA
Email: leblancleonard@gmail.com
Iran is a textbook case of powerful social, environmental
and other factors that have made Iran one of the leading‘hot-spots’ of the COVID-19 pandemic. The people’s
immune systems have been weakened due to heavy air
pollution, economic sanctions, and other societal stresses
such as strict religious rules and relations that governinterpersonal relations. Overcrowding in urban areas, alack of social distancing and a lack of medical supplies likeface masks have had a negative impact on the Iranian
government’s efforts to control the outbreak.

Return to ourselves: Psychologicalreflections over compulsory
physical distancing during the
COVID-19 outbreak- Zehra Edisan, Ph.D,
TurkeyEmail: zedisan@hotmail.com
Abstract
COVID-19 as a potentially fatal disease has been one of themost serious global public health concerns of recent
times. Extensive measures have been administered atnational and international levels to control the outbreak.
To reduce person to person transmission the community
has engaged in a sustained and intensive hygiene
campaign. Restrictions and controls were brought intosocial life by suspending social events; schools wereclosed, and people were advised to avoid international
travels. Physical distancing rules were set into practice.
Fewer face to face interactions and living isolated for an
indeTinite time can lead to psychological problems amongpeople. In this study psychological reTlections ofcompulsory physical distancing during COVID outbreak
will be discussed. Furthermore, some recommendations
will be made to overcome these problems.
Introduction
Coronavirus disease (COVID-19) is a contagious and apotentially fatal disease that is of great global publichealth concern. Person-to-person transmission of
COVID-19 infection led to the isolation of patients who
subsequently received various treatments.
Comprehensive measures to diminish the transmission of
COVID-19 have been applied to control the current
outbreak (1).

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
The community has engaged in a sustained andintensive hygiene campaign. In order to prevent the
spread of the epidemic around the World, countries haveclosed their borders, Tlights were suspended, many publicareas like libraries, cinemas, playgrounds, cafes, pubs, andrestaurants have been told to close to avoid infections.
Social activities were curtailed, schools were suspended.
People are being asked to keep distance from each otherand to reduce face-to-face contact to minimize the spreadof the virus. Many people are facing periods of enforced
isolation if they are believed to have COVID-19 or havebeen in contact with someone who has (2).
Different contamination measures such as “social
distancing”, “isolation” and “quarantine” come to theagenda in this novel COVID-19 outbreak. The meanings ofthese concepts are sometimes confused.
Conceptual Issues: social distancing, isolationand quarantine
Social distancing, which refers to creating physical space
between one another and avoiding large gatherings,
comes from public health and epidemiology lexicon (3).
Through a variety of means, social distancing is an action
taken to reduce interactions between people in a broader
community, in which individuals may be infectious but
have not yet been identiTied hence not yet isolated. As
diseases transmitted by respiratory droplets require acertain proximity of people, social distancing of persons
will reduce transmission and the possibility for new
infections (4, 5). In this context social distancing involves
using common sense by keeping a distance of 6 feet (2meters) between people when possible (6).
According to a technical report of the European
Centre for Disease Prevention and Control (ECDC), social
distancing measures, as one category of nonpharmaceutical countermeasures, can be handled at
individual level and at group level. Individual social
distancing measures include isolation of cases, quarantineof contacts and staying at home. At group level some ofsocial distancing measures are: closure of educational
institutions and workplaces, mass gathering cancellations
for cultural (theaters, cinemas, concerts, festivals andconferences) and sporting events, mandatory quarantineof a building or residential area (sanitary cordon), andmeasures for special populations (long-term carefacilities, homeless shelters, prisons, psychiatricinstitution) (5).
The goal of social distancing interventions is to
reduce the overall illness attack rates and theconsequential excess mortality attributed to a pandemic,
to delay and reduce the peak attack rate, reducing
pressure on health services, and allowing time to
distribute and administer antiviral drugs and possibly
suitable vaccines (7). This brought up the term ‘Tlattening
the curve’, which means to slow the rate of COVID-19
infection so hospitals have room, supplies, and doctors forall of the patients who need care. Even people who
appear to be healthy are being directed to practice social
distance and personal isolation, strategies designed toslow the spread of a disease and protect themselves andvulnerable groups from becoming infected (2,8).

87

From the perspective of psychology ‘social distance’
also refers to the sense of afTinity or dissonance and isdeTined as ‘the extent to which people experience a senseof familiarity (nearness and intimacy) or unfamiliarity(distance and difference) between themselves and people
belonging to different social, ethnic, occupational, andreligious groups from their own.’ (9). Other terms usedduring COVID-19 outbreak are “isolation” and“quarantine”, both of which refer to “social distancing
measures” (5). Isolation is the separation of ill persons
with contagious diseases from non-infected persons toprotect the non-infected. It usually occurs in a hospitalsetting, but can be done at home or in a special facility.
Usually individuals are isolated, but the practice may be
applied in larger groups (4,10). Self-isolation ofindividuals with symptoms of a respiratory infection is
one of the most important measures for reducing diseasetransmission and limiting the spread of the virus in thecommunity during an epidemic (11).
Quarantine is the restriction of movement or
separation of well persons who have been exposed to acontagious disease, before it is known whether they will
become ill. It may be applied at the individual, group, orcommunity level and usually involves restriction to thehome or designated facility. Quarantine may be voluntaryor mandatory (10,12). Like isolation, quarantining
exposed people may delay the peak of local epidemics
during the early stages of an epidemic, thus helping to
reduce the burden of disease and delay further spread(11).
While isolation serves the same purpose asquarantine, the main distinction between isolation andquarantine is that isolation is a control measure applied tosick people, keeping infected people away from healthypeople to prevent the sickness from spreading, whereas
quarantine is applied to people who might get sick—usually because they have been exposed to an infected
person (6,13).
Physical distancing vs social distancing
The government, media organizations and meme
creators have all embraced the term “social distancing”
when discussing how to stem the novel
coronavirus pandemic (3). The term ‘social distancing’focuses on reducing physical contact as a means ofinterrupting transmission, but while reduction of social
contact may be an outcome of that, it is not a speciTic aim(5). Some experts are concerned that the semantics of theterm “social distancing” is misleading and its widespread
usage could be counterproductive. The World HealthOrganization (WHO) has come to the same conclusion anddecided to change the term by using “physical distancing”
instead. People do not need to socially disconnect fromtheir loved ones, ‘social connectedness with physicaldistance’ is expected and wished by practicing social
distancing (3).
WHO epidemiologist Dr. Maria Kerkhove said in apress brieTing: "We're changing to say physical distanceand that's on purpose because we want people to still
remain connected. Technology right now has advanced sogreatly that we can keep connected in many ways without
actually physically being in the same room or physically88

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

being in the same space with people," (14). It is seen moreconvenient to use the term “physical distancing” insteadof “social distancing” in this study, too.
Psychological reflections
Physical distancing is shown as the most effective way tolimit the spread of COVID-19 in the community. Many
governments are attempting to force everyone to selfisolate as the coronavirus continues to spread around theWorld (15). Physical distancing interventions such as
staying at home and not leaving it, not going to work,school or public areas, reducing social and community
contacts, living physically isolated during this time, havethe beneTit to prevent the transmission of the virus bymoving and the beneTit to reduce the infection rate;
however, people may develop various psychological andmental health concerns over time (16,17). Going into aperiod of physical distancing, isolation or quarantine may
feel daunting or overwhelming, and can contribute tofeelings of helplessness and fear (16).
People in isolation who are affected by COVID-19
and are being treated for the infection, people inquarantine who are potentially infected, and people athome who have to comply with staying at homerecommendations to protect themselves from infection,
all will feel different psychological troubles depending oneach protection measure. Some people Tighting against thedisease worry about being able to breath and survival,
some fear about being infected, and some fear lonelinessby staying at home.
The COVID-19 epidemic brought to people not only
the risk of death after virus infection, but also unbearable
psychological pressure (17). People may be feeling afraid,
worried, anxious and overwhelmed by constantly
changing alerts and media coverage regarding the spreadof the virus (16). Because of their evolving nature andinherent scientiTic uncertainties, outbreaks of emerging
infectious diseases can be associated with considerable
fear in the general public or in speciTic communities,
especially when illness and deaths are substantial. Fear isfurther fueled when infection control techniques andrestrictive practices such as quarantine and isolation are
employed to protect the public’s health (18).
The continuous spread of the epidemic, strict
isolation measures and delays in starting schools,
colleges, and universities across the country are expected
to inTluence the mental health of college students. There
have been reports on the psychological impact of theepidemic on the general public, patients, medical staff,
children, and older adults (19, 20, 21)
In the absence of interpersonal communication,
depression and anxiety are more likely to occur andworsen (17). It is now widely recognized that indepression the immune system, which plays an importantrole by protecting the body against viruses and Tighting
against them, may be down-regulated (22, 23). Besides
depression, anxiety is also inevitable. It is a general feelingof apprehension about possible danger. Anxiety can beseen as both a cause and an effect of illness. Individuals
with high levels of anxiety are predisposed to a number ofailments known as “somatization”. For example, anxiety
may produce symptoms such as tension headaches, peptic

ulcers, and hypertension. Anxiety is also considered to bea mediator between stressful life events and ill health(24).
While it's crucial to slowing the spread of COVID-19,
practicing physical distancing will result in fewer face-toface social interactions, potentially increasing the risk ofloneliness and social isolation (2). Especially for theelderly, for lonely people, without a surrounding or not
successful in using communication tools, physicalisolation can lead to social isolation. Social isolation isdeTined as the process of people losing their contacts withother social resources or their willingness to participate.
Social isolation is a grave and widespread problem
especially among seniors in society causing many harmful
health conditions (25).
Humans are innately social. From history to themodern-day we've lived in groups - in villages,
communities and family units. While we know social
isolation has a negative impact on health, we don't knowwhat the effects of compulsory (and possibly prolonged)social isolation could be. But it is expected to increase therisk of loneliness in the community. Loneliness isthe feeling of being socially isolated. Recent reports haveindicated that loneliness is already a signiTicant issue
for young people. Loneliness and social isolation areassociated with a similar increased risk of earlier death,compared to someone not lonely or socially isolated.
People who are socially vulnerable, such as older people,
are likely to struggle more through this uncertain period(2). Uncertainty can be about when they might be let out
again. COVID-19 is not the Tirst outbreak humankind has
faced and it won’t be the last. Communication about therisk of infectious diseases and the psychological effects of
microbial threats has become an important public healthissue in recent years (26).
Taking lessons from history
During the 2003 outbreak, severe acute respiratory
syndrome (SARS) spread to more than 30 countries. Not
only did it cause severe health problems but it also
imposed a great psychological impact on the public(26,27). A survey study found that individuals who had
been quarantined or indirectly exposed to SARS during
the epidemic, tended to experience depression symptoms
possibly due to SARS impact, the economic downturn,poor health conditions, and inadequate social support. It
seems that, compared to other disastrous events, those
impacted had experienced alienation because of thestigma of the disease and hostility from the public in amore severe way (26).
The Tirst lesson of SARS from a psychologicalperspective was that the costs of interpersonal isolationneed to be borne in mind when widespread infection
control procedures are implemented (28). Physicalisolation should not lead to “social isolation”. Even if
people are distant from each other, they should continuesocializing, because social isolation could often be a causeof emotional isolation. An American Psychological
Association article ran the headline: "Social isolation: It
could kill you." The lack of meaningful emotional
relationships can be devastating for human beings (oreven simply the perception that you lack them) (29).

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Recommendations
Indeed, the success of physical distancing measures thatare implemented over an extended period may depend on
ensuring that people maintain social contact – from a
distance – with friends, family and colleagues (5). Whilepeople cannot replace the value of face-to-faceinteractions, they need to be Tlexible and think creatively
in these circumstances (2). Internet-based
communications are therefore a key tool for ensuring a
successful social distancing strategy (5). Equipping
especially older and lonely people with the needed
technology if they don't have access, or teaching them
how to use their devices if they are unsure, are useful
efforts (2).
To avoid possible psychological problems, people
must change their perspectives and try to concentrate on
the positive aspects of this process. Although they are
isolated, this should not interrupt communication. As longas their technological possibilities allow them,
theyshould be in contact with family, friends and those aroundthem. If smartphones are available, video calls instead ofjust speaking on the phone would be more useful. This
period can be an opportunity for people to connect moredeeply. This may be a chance to spend more time withelderly parents and children at home. Extra attention andreassurance can be given to them.
The sense of unity has to be strengthened by helping
others, and by trying to provide Tinancial and moral
support for them. Helping others will enhance thewellbeing of both the giving hand and the receiving hand.
Instead of hurting their own situation, people should try
to provide Tinancial and moral aid to those who are in aworse situation. Staying at home in this process can be aluxury for those who have no economic guarantee;
therefore, non-infected people shouldn’t complain aboutstaying at home, because it’s a chance for protection andsurvival.
Every moment of life is already uncertain. It is not atime for depression or anxiety it is a time for people toreturn to themselves, and to deal with others. It is time forrealizing plans which were postponed at an uncertain,
unknown leisure time; a time that never was found until
now. A long delayed book can be read now, a movie canbe watched. There are many beneTicial things which canbe done. Being alone doesn't have to mean feeling alone,
and isolation can help people to rediscover theirunderlying humanity, connect with what is mostimportant to them, and deepen the compassion they needso badly in these challenging times (29).
This time should be regarded as unique anddifferent, not necessary bad. It is a compulsory stop, abreak in stressful hustle and bustle of life. It’s a time toquestion the life one has lived. A time for thinking andplanning for changes. It’s a time for people to care forthemselves, to take time for themselves and to lookaround. Being aware of every moment experienced andknowing the value of what is owned, and what is
important: health, time, family, loved ones, and freedom.
And the most important thing is to be aware and know thevalue of each breath that can be taken!

89Conclusion
During the recent COVID-19 outbreak, people in allaffected areas had to comply to compulsory physicaldistancing rules. To avoid psychological problems amongpeople experiencing these measures, it is of great
importance that physical distancing will not lead to social
distancing. Scientists who realized this, have changed theterm social distancing as physical distancing. As a social
being, people facing distance rules need each other morethan ever and they have to stay connected. Every person
needs to use this period as a chance to stop and think.
People tend to postpone everything while rushing inroutine life. The hustle and bustle of life causes people toforget themselves and their surroundings. Sometimes asmall virus can change the course of everything andremind humans and the whole humanity what is really
important in life.
References
1. Rothan HA, Byrareddy SN.(2020). The epidemiology andpathogenesis of coronavirus disease (COVID-19) outbreak.
Journal of Autoimmunity, https://doi.org/10.1016/
j.jaut.2020.102433
2. Lim MH, Badcock J. (2020). Lonely yet? How to overcome
isolation in an age of social distancing. The Courier. https://www.thecourier.com.au/story/6684355/lonely-yet-how-toovercome-isolation-in-an-age-of-social-distancing/
3. https://www.washingtonpost.com/lifestyle/wellness/socialdistancing-coronavirus-physical-distancing/2020/03/25/
a4d4b8bc-6ecf-11ea-aa80-c2470c6b2034_story.html
4. Wilder-Smith A, Freedman DO (2020). Isolation, quarantine,social distancing and community containment: pivotal role forold-style public health measures in the novel coronavirus(2019-nCoV) outbreak. Journal of Travel Medicine, 2020, 1–4.
5. European Centre for Disease Prevention and Control.
TECHNICAL REPORT Considerations relating to social
distancing measures in response to COVID-19 – second
update 23 March 2020 https://www.ecdc.europa.eu/sites/
default/Tiles/documents/COVID-19-social-distancingmeasuresg-guide-second-update.pdf
6. C l e v e l a n d c l i n i c
D r. G o r d o n
https://
health.clevelandclinic.org/COVID-19-understandingquarantine-isolation-and-social-distancing-in-a-pandemic/
7. Kelso JK, Milne GJ, Kelly H. (2009).Simulation suggests that
rapid activation of social distancing can arrest epidemic
development due to a novel strain of inTluenza BMC Public
Health, 2009, 9:117.
8. Maragakis LL. Coronavirus, Social Distancing and SelfQuarantine. Johns Hopkins Medicine.
9. https://www.hopkinsmedicine.org/health/conditions-anddiseases/coronavirus/coronavirus-social-distancing-and-selfquarantine
10.Hodgetts D, Stolte O. (2014) Social Distance. In: Teo T. (eds)
Encyclopedia of Critical Psychology. Springer, 2014, New York.
11.Cetron M, Maloney S, Koppaka R, Simone P. (2004). Isolation
and Quarantine: Containment Strategies for sars 2003. İn
Learning from SARS: Preparing for the Next Disease Outbreak:Workshop, Knobler S, Mahmoud A, Lemon S et al ed,The
National Academies Press, Washington, D.C. 2004.
12.European Centre for Disease Prevention and Control.
TECHNICAL REPORT Guidelines for the use of nonpharmaceutical measures to delay and mitigate the impact of
2019-nCoV February 2020, https://www.ecdc.europa.eu/
sites/default/Tiles/documents/novel-coronavirus-guidelinesnon-pharmaceutical-measures_0.pdf

90

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

13.Cetron M, Landwirth J. (2005). Public Health and Ethical
Considerations in Planning for Quarantine, Yale Journal of
Biology And Medicine, 2005, 78:325-330.
14.Moore J. (2007). Pandemic InTluenza and the Law: Isolation,
Quarantine, and Other Legal Tools for Containing Outbreaks,
NC Med J, 2007, 68(1):59-61.
15.WHO urges public to practice 'physical,' not social, distancing
ABS-CBN News Posted at Mar 24 2020, https://news.abscbn.com/news/03/24/20/who-urges-public-to-practicephysical-not-social-distancing
16.O t t o w a P u b l i c H e a l t h . ( 2 0 2 0 ) . h t t p s : / /www.ottawapublichealth.ca/en/public-health-topics/socialdistancing.aspx
17.Lifeline (2020). Mental health and wellbeing during theCoronavirus COVID-19 outbreak.. https://www.lifeline.org.au/get-help/topics/mental-health-andwellbeing-during-the-coronavirus-COVID-19-outbreak
18.Xiao C. (2020). A Novel Approach of Consultation on 2019
Novel Coronavirus (COVID-19)-Related Psychological and
Mental Problems: Structured Letter Therapy.
Psychiatry
Investig 2020;17(2):175-176.
19.Person B, Sy F, Holton K, Govert B, Liang A and the NCID/SARS Community Outreach Team (2004). Fear and Stigma:
The Epidemic within the SARS Outbreak. Emerging Infectious
Diseases, 2004, 10(2): 358-363.
20.Q. Chen, M. Liang, Y. Li, J. Guo, D. Fei, L. Wang, L. He, C. Sheng, Y. Cai, X. Li, J. Wang, Z. Zhang (2020).Mental health care for
medical staff in China during the COVID-19 outbreak. The
Lancet Psychiatry. 2020, 7(4):e15-e16.
21.Y. Yang, W. Li, Q. Zhang, L. Zhang, T. Cheung, Y.T. Xiang(2020).Mental health services for older adults in China during
the COVID-19 outbreak.The Lancet Psychiatry,2020, 20:30079-1.
22.Cao W, Fang Z , Hou G, Han M , Xu X , Dong J , Zheng J. (2020).
The psychological impact of the COVID-19 epidemic on college
students in China, Psychiatry Research, 2020, doi: https://doi.org/10.1016/j.psychres.2020.112934
23.Olff M. (1999). Stress, depression and immunity: the role ofdefense and coping styles. Psychiatry
24.Research,2020, 85(1): 7–15.
25.Raison CL, Broadwell SD, Borisov AS, Manatunga AK, Capuron
L, et al. (2005).Depressive symptoms and viral clearance inpatients receiving interferon-α and ribavirin for hepatitis C.
Brain, Behaviour, and Immunity, 2005, 19 (1): 23-27.
26.Cheng C. (2004). To be paranoid is the standard? Panic
responses to SARS outbreak in the Hong Kong special
administrative region. Asian Perspective, 2004, 28 (1): 67-98.
27.Püllüm E, Akyıl RÇ.(2017). Loneliness and Social Isolation
among Eldely People. Meandros Med Dent J 2017;18:158-63.
28.Ko CH, Yen CF, Yen JY, Yang MJ (2006). Psychosocial impact
among the public of the severe acute respiratory syndrome
epidemic in Taiwan. Psychiatry and Clinical Neurosciences,
2006,60: 397–403.
29.Peng EYC, Lee B, Tsai ST, Yang CC, Morisky DE, Tsai LT, Weng
YL, Lyu SY (2010). Population-based Post-crisis PsychologicalDistress: An Example From the SARS Outbreak in Taiwan. J
Formos Med Assoc; 2010, 109(7):524–532.
30.Maunder R. (2003). The experience of the 2003 SARS
outbreak as a traumatic stress among frontline healthcare
workers in Toronto: lessons learned. Phil. Trans. R. Soc. Lond,
2003, 359:1117–1125
31.Williams W. (2020). Social isolation doesn't have to meanemotional isolation. https://www.newsweek.com/socialisolation-emotional-isolation-tech-1493889

Commentary on Edisan- Dennis Alfaro
St. Paul University QC, the Philippines
Email: dlalfaro@spuqc.edu.ph
This paper of Zehra Edisan is very informative and helpfulat this time of the pandemic outbreak of COVID-19. When
the World Health Organization declared it as a global
pandemic, most of the countries implemented different
policies so as not to spread the virus. In a matter of weeks,
the virus that started in Wuhan China has rapidly spreadfrom one country to another. It has been mentioned that
one measure to control the spread of the virus is toprevent people from interaction with one another; somecall it people distancing and in the Philippines we call itsocial distancing.
It is also mentioned that many countries have closed
their boarders, commercial establishments are also
closed, Tlights cancelled, schools and universities canceledclasses and many social events where cancelled andpostponed. To Tlatten the curve, people where advised topractice social distancing and social isolation. Thesemethods are considered the most effective way to stop the
spread of the viruses that became a public health issue inthe past like SARS and MERS.
I agree with Zehra Edisan that when we practicesocial distancing or social isolation, we limit ourselvesinteracting with other people and that can make us feellonely, bored, or lack physical activities. To overcome
these problems that might occur, one has to dealt with it
through a positive outlook in life. I have read about somepositive effects during this community quarantine. Likefor example, the earth will have time to heal itself because
it minimizes air pollution, lessens the garbage, and people
can reTlect about life.
Here in the Philippines, there are people who took
photos from the roof top of the buildings to show how the
air pollution was minimized because they can now see themountains from afar that we usually don’t see because ofsmogs.
She also mentions that the use of technology canovercome the psychological problems that may occur insocial distancing. We have now, Skype, Zoom, Messenger
wherein we can see and speak to our relatives and friends.
Another example of using technology is virtual
conferences where we share and present different ideas.
Maybe we just need to be dynamic, patient and look at thebright side of what is happening now. Let us try to makethings that can beneTit us and others withoutcompromising our and others’ health. Learn from one
another, from one country to another on ways how we will
Tight this pandemic. Remember what happened in the pastand let us not repeat the mistakes that occurred and get
the positive side of things. Learn how to be creative.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Health care in India in theprevailing COVID-19 pandemic
scenario- Dhastagir Sultan Sheriff, MD, PhD
Reprolabs, Chennai,TN,India
Email: drdsheriff@gmail.com
Abstract
Healthcare in India is undergoing changes to meet thedemands of citizens from villages to metropolitan citylevel. The National Health policy announced in 2017 is
focused on "wellness" of patients and guarantees
healthcare with suitable insurance coverage from primary
to tertiary care. Ayushman Bharat Mission is a policy that
promotes healthcare with a center-state cooperation.
Program Indra Dhanush aims to cover immunization ofchildren in rural and urban areas including those who
were not covered in the previous program like Pulse Polio.
In general healthcare is to provide and promote qualitycare, focus on emerging diseases and invest in promoting
and preventive healthcare. The policy is patient centricand quality driven. It addresses health security andmaking drugs and devices free for use in India. Yet the
Healthcare policy and its implementation face many
hurdles in the form of funds, primary care, doctor-patient
ratio, and communication. With the focus being shifted
more on non-communicable diseases from infectious
diseases, the centers for testing of various infectious
diseases and viral diseases have taken a back seat. This isvery relevant today when the world is reeling under the
pandemic threat of Coronavirus disease (COVID-19). India
reported its Tirst case of COVID-19 on 30 January 2020.
The Indian Council of Medical Research and Ministry of
Health and Family welfare have reported nearly 640
active cases, 66 cured cases and 17 deaths in the country.
The rate of infection for COVID-19 is 1.7. India has
declared a lock down for the whole country for 21 days.
The COVID-19 poses a great challenge to India to treat
COVID-19 positive cases as it needs more ventilators andother facilities with a population of around 1.3 billion
people. The present pandemic may help reduce the gap toimplement its National Health Policy.
Introduction
Republic of India, a South Asian country, is the seventh
largest nation by area, the second most populous country
and the most populous democracy of the globe. One of thefundamental rights of Indian constitution is the ‘right tolife’ which translates to “right to health”. India is a Federal
country with 29 states and 8 union territories.1 Indian
healthcare is administered by both State Governments
and the Central Government. The State Governmentorganizes and delivers healthcare and the Central
Government takes the responsibility of international
health treaties, medical education, prevention of foodadulteration, quality control in drug manufacturing,national disease control and family planning. Indian
healthcare is run by the public as well as private sectors.
The public sector provides free healthcare to people whoare below the poverty line. Indian public health sector

91

caters 18 percent of total patient care and 44 percent of
total in-patient care.
The total expenditure for healthcare is around 4.2
percent of the GDP and out of pocket expenses are around69 percent. The cost of healthcare is around 1700 Indianrupees /capita/year.2
National health policy
The national health policy was formulated on therecommendations of Bhore Committee3 in 2017, topromote the “wellness” of patients with suitable
insurance cover total healthcare. To encourage center-state cooperation, Ayushman Bharat Mission was formed.
Rashtriya Swasthya Bhima Yojana (RSBY) is the central
government policy to provide health insurance coveragefor poor families. RSBY is reported to have beneTitted 57
percent of target population.
Healthcare delivery
The healthcare delivery system is a network of primary
health sub centers which are the Tirst point of contact
between the village community and healthcare workers.
Each sub center caters to 3000 to 5000 population. Six
sub-centers clusters together form primary healthcare(PHC), the Tirst contact point between the community andthe doctor. It has a doctor, few healthcare workers with 3
to 5 beds. PHCs cater to the health needs of 20,000 to
30,000 people.
The next level of the healthcare system is thecommunity healthcare center (CHC). It has specialists inmedicine, surgery, gynecology and pediatrics. It has 30
bed strengths with paramedical and healthcare workers, alab, X-ray unit and a pharmacy. It takes care of the healthof 80,000 to 1,20,000 population. The next level is districtlevel hospitals who work around the clock to provide
emergency services for obstetric care and blood bank.
There are about 6.3 hundred thousand beds in the nation
with 2 hundred thousand beds in rural areas. The private
sector provides extra care to wealthier patients whose
services are regulated by national accreditation andcertiTication body.
There are about 29,000 PHCs controlled by 25,000
doctors which still need 3500 more doctors. About 11
hundred thousand doctors are registered with Indian
Medical Council to man the healthcare delivery. Yet thenation has not reached the WHO guidelines of 1 doctor
per 1000 people. It is roughly around 0.7 per 1000 people.
To support and add to the shortage of physicians India
launched Ayush program (Ayurveda, Unani, Siddha andHomeopathy) in Nov, 2014. There are about 7.5 hundred
thousand of such Practitioners. 2
There are 529 Medical Colleges in India, 269
government medical colleges admitting 35,000 medical
undergraduates and private medical colleges with another
35,000 admissions. Yet India needs more doctors. India
has a population of nearly 1,30 billion with 29 states with
22 different languages in 13 different dialects. There are
6.5 hundred thousand villages and 4000 cities2. Some of
the megacities are thickly populated with Mumbai having
the largest number of people (22 millions), Delhi (18.5
millions) Bangaluru (10.1 millions), Chennai (4.6
millions) and Kolkata (4.5 millions), respectively.1

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Healthcare delivery in India is therefore, very
complex though highly organized. Children in rural areas
are 1.6 times more likely die before the completion of 1
year and 1.9 times before the age of Tive years. Neonatal
mortality rate is high and with additional incentive,
funding, facilities, India is looking forward to improve its
healthcare delivery in the public sector.2
Coronavirus disease (COVID-19)
Providing healthcare in a pandemic scenario has to berelied more on preventive measures. The coronavirus
pandemic demands a very competent handling of thehealthcare of the citizens. COVID-19 has taken all nations
by surprise because of its wildTire spread. Coronavirus isone of retro viruses with RNA genome. Coronavirus 19 is
the seventh virus with a structure that has spikes, helping
the virus to bind to the host cells. It is a zoonotic virus
which has mutated to a form that has resulted in thetransmission of the virus through human contact. Wuhan
the epicenter of the COVID-19 threatens the whole world
with nations under-prepared to face the attack. Highlyorganized advanced nations like Italy, USA, and UK Tind it
difTicult to tackle the pandemic because of lack ofpreventive measures. Shortage of medical equipment,
ventilators, face masks, sanitizers have created a grimsituation for ordinary people to get the needed healthcare.
The doctors, nursing staff, paramedical staff andaccessory health staff have taken the huge responsibility
to provide the best medical care to the needy risking theirown lives, all over the world. 4
Without proper drugs or vaccines to treat, safetymeasures like personal hygiene in the form of proper
hand washing, social distancing and other WHO
recommended methods of community care arerecommended to Tight the pandemic. It has led most of thenations to lock down the cities and towns demanding thecitizens to stay at home.
India has declared total lock down for 21 days
including the cancellation of all modes of travel, air, train
and buses. Previously about 75 Districts throughout India
have been locked out. The Ministry of Health and Family
Welfare and Indian Council of Medical Research regulate
the dissemination of information, healthcare, and otherrelated activities with the help of state governments.5 The
Ministry of Health and Family Welfare had reported 640
active COVID-19 cases, 66 cured cases and 17 deaths as of
26 March.
The ICMR centers help in the diagnosis of COVID-19
along with 6 private sector labs. The test kits for
COVID-19, RT-PCR kit is manufactured in India by Mylab,
Pune. Each test kit can test 100 cases. One can test 1000
cases per day. The company is reported to produce 1
hundred thousand kits per week. 5
Mahindra groups of Company have converted theirholiday resorts into rehabilitation centers, and havedirected their production units to manufacture
respiratory ventilators. Reliance Industries have opened
up 100 bed hospitals totally devoted to treat COVID-19
patients in Mumbai.
Yet the challenge is enormous. Stay home, keep
distance, avoid crowded places, maintain personal
hygiene like personal hygiene, test if advised and follow

the instructions given by the government to follow are thedictum to be followed by citizens. Physical distancing is
the most important criterion that has to be followed byevery nation, taking the example of how one case like
No31 COVID-19 in South Korea unknowingly by church
visits and dinner in a hotel was responsible forconsiderable spread of the infection in the country.
Bill Gates of Microsoft in one of the Ted Talks in 2015
had warned that the world is not prepared to tackle a viral
pandemic, particularly coronavirus. He had warned thatevery nation must prepare on a war footing for preventive
measures, healthcare facilities including diagnostic
centers and therapy. He said the world has to bring
together world’s best scientiTic minds to prepare amethod of cure or a vaccine in place. He emphasized thatevery nation like military exercise must have healthcare
exercise periodically to train the medical personnel andthe community to face such a pandemic. Military exercise
includes testing communications, planning, decisionmaking and thinking. By planning an exercise one gets arough idea of what to expect. When one performs theexercise it provides a practical idea how the stakeholders
play their parts to the expected levels. It is important thatevery nation has a machinery to Tight a viral pandemic like
COVID-19 like disaster management, as a priority. In
future, “We need to make sure that every country in theWorld has the capacity to identify new diseases and treat
them.”
References
1. Know India: https://knowindia.gov.in/my-india-my-pride/
interesting-facts-about-india.php
2. Anuradha S, Sheriff DS - Health Care Delivery in India - SWOT
Analyses. Int Arch Public Health Community Med 2019;3:024. doi.org/10.23937/2643-4512/1710024
3.Ravi Duggal, Bhore Committee and its relevance today. Indian
Journal of Pediatrics 1991;58:395-406.
4. Centers for Control and Prevention of Diseases, USA-About
Coronavirus Disease 2019 (COVID-19)
5. Ministry of Health and Family Welfare, India
6. Bill Gates. predicted Corona Virus Pandemic. TED Talk.
Mercury News,2015.

Spiritual universal ethical values
for a global health system usingchange theory: results of adisintegrated approach in the 2020
pandemic- Suma Parahakaran, PhD
AUSN Visiting Professor of Bioethics and Environmental
Education, Malaysia
Email: suma@ausn.info,
Abstract
Despite powerful strategic approaches in the healthsystems in many afTluent countries, the pandemic that has
hit us has cascaded beyond the imagination of many civilsocieties around the world. There is a call for a higher
understanding and practice as the contents in the social

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
media reTlected an urgency to understand more on thehealing effects of the body, mind and spirit. In fact,contents in social media highlighted many coping
mechanisms which were related to religious, cultural andspiritual values. The public expressed information that
included remedies for the body, mind and the spiritual
aspects of humanity and their interconnectedness withthe environment. These narratives were equally assigniTicant as the logistic arrangements, professional andpolitical decision making among the healthcare
professions and members of other inter-related healthnetworks. The results of the COVID-19 outbreak has
created a deeper understanding, of a higher
consciousness as populations around the world recognizethat the world works as one large organism trying tobalance the ethical and unethical practices rampant in oursocieties.
This paper proposes the integration of “change
theory” to explore the various existing elements innarratives of the public and research studies fromhealthcare practices. An exploratory analysis of contents
in social media and the related literature in healthcare
and nursing studies has revealed speciTic patterns which
helped put the theory in perspective and to formulate amodel for future understanding on what common
universal values exist in the commonly existing patterns.
Introduction
This paper introduces the concept of change theory andthe possibility to provide a deeper understanding of the
Tield of bioethics through the lens of current practices andits implementation in the Tield of health services andsustainable development. The rise of COVID-19 pandemic
and the impact it had on many people were clearly
demonstrated in social media. Countries such as China,
Malaysia, Thailand, Hong Kong, Macau, Thailand, Hong
Kong, Macau, Japan. South Korea, Taiwan, Vietnam,
Singapore, France, Australia, Nepal and the U.S. were
afTlicted with the virus at the beginning stages of thepandemic. Totally there were fourteen afTlicted countries
at the initial stages of the outbreak and the conTirmed
cases reported globally were 1316 with forty one deaths
as of January 24th, 2020 (https://www.buro247.my/lifestyle/news/COVID-19-virus-in-malaysia-latestupdates.html).
The contents in social media at the end of January
demonstrated the public’s lack of knowledge of thesymptoms, treatment methods citizens were exploring tofollow and the inability to cope. People from the public did
not understand why they had to take stringent measuresof control until the number of deaths increased. As aresult, the coping mechanisms for the afTlicted, vulnerable
groups, youths and household members were notadequately addressed. At the beginning of March,governments in few countries reacted instantly withstringent measures and many people were signiTicantly
affected.
Social media was an effective mode ofcommunication during these difTicult times.
Health and medical staff had to respond for the sakeof the survival for many. This was the period whenhumanitarian efforts had to be implemented by all
members so that lives can be saved. At the same time,

93

people had a deeper understanding of the meaning of life
and the impact man had on the environment was evident.
During the crisis, several people around the world had tocope with stress, ill health, fear, mental unpreparedness
and emotional distress. It was only in such real life andprofound experience that this catastrophe led people to
go inwards, in deeper meaningful reTlections to look formeaning in life and the causes and consequences ofprevious actions. The resulting expressions through social
media indicated that many people started to realize thatdisease outbreaks could be a result of an imbalanced
relationship between humans and animals and poor
practices leading to unhealthy conditions. The local
conditions in one city cascaded to a global pandemic. Thusa deeper inquiry and the interconnectedness of all living
systems had to be explored. Bioethics, an umbrella which
encompasses all spiritual and ethical discourses can help
us have a greater understanding of the world.
Missing gap in education system
Content related to lifelong learning for wellbeing andhealth is missing in current school curriculum. A
compelling need has come at this time of the pandemic toaddress the Tield of bioethics on a common platform, andon why a common value system is required to addressthese issues for life-long learning and sustainable
development in all Tields of life. An integrated approach toinclude our usage of food, water, medicines, plant life andanimal life seem important for the future sustenance of
the world. Several bioethical questions can be raised. Do
we as human beings consider ourselves as the centre of
the world (anthropocentrism); are humans a part ofvarious living species (biocentrism); a holistic approach to
the whole ecosystem which includes the environment,
politics, culture and lifestyle (eco-centrism) ; or theassumption that the earth is just one part of the entire
cosmos (cosmocentrism)? (UNESCO, 2010).
The different empirical data from current researchstudies available in healthcare case studies and tests canaddress the paradigm shift required for this change. The
disadvantages of cognitive focused approaches in
education and training in the Tield of health in tertiary
education have shown the negative consequences formany people. If the affective processes were included in
all areas of learning and training, the coping strategies
maybe higher. For example, if environmental education
had a core content of education and the bioethical issues
were discussed along with the human-humanrelationship, human to environment relationship andhuman-man-plant-life sustenance methods, civilians
would be more aware of what is required of them. If
subjects are taught without an integrated approach, thenlearners proceed with practices that may lead tounsustainable societies. Although the pandemic comes incycles there is a huge possibility that with affective
processes integrated in curriculum and training for healthand education, a paradigm shift can take place in the wellbeing of the planet.
Moreover, several research studies illustrated inTable 1 indicate the necessity to include a holistic
approach when facilitators teach for wellbeing. The Tieldof bioethics which is a Tield of inquiry within the contexts

94

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)of science, culture, health, environment, technology andsociety will be able to bring in common perspectives ofpeople’s value systems, cultural pluralism and ethicalprinciples to a global platform related to current contexts
in societies. The different critical perspectives of moral
theories and various types of ethical theories which arevaluable on their own may not converge to a system ofuniversally agreeable values and a commonly agreed
applied Tield of “ethical principles” unless there arecommon derivatives from major religious, cultural,
traditional and spiritual practices.
The United Nations worked on common goals
through analysis of empirical data which are in agreement
between member states. There are possibilities of
exploring and Tinding common values among different
ethical systems and universally agreed ethics (UNESCO,2010). These common values can be appreciated only if
tried and elicited by practitioners with descriptive andcritical discussions made among various cultures.
Why spiritual universal values?
The current ethical theories can only be understood intheir own contexts and does not converge to a holistic
understanding of how they can be used globally. With thispandemic, it is important that our philosophies merge andTind a common space. The recent pandemic we are facing
have also taught us that humans are only part of theenvironment and the natural resources. These two factors
and their usage have a huge impact on the well-being of
the planet. As a result there is a compelling need for
exploring common spiritual universal values and a solid
foundation in bioethics which is deTined simply by Dr
Darryl Macer as the “love of life”: “Bioethics is both a word
and a concept. The word comes to us only from 1970
(Potter, 1971), yet the concept comes from human heritage
thousands of years old (Macer, 1994). It is the concept oflove, balancing beneYits and risks of choices and decisions.
This heritage can be seen in all cultures, religions, and inancient writings from around the world. We in fact cannot
trace the origin of bioethics back to their beginning, as therelationships between human beings within their society,within the biological community, and with nature and God,
were formed at an earlier stage than our history would tellus”.
Studies related to health and wellbeing
In the Tield of healthcare and mental well-being, there areseveral studies related to consumption practices, mental
stress, and disharmony in patients and learners’ lives. A
few of the many examples are listed in Table 1.
Table 1 indicates the new emerging Tield for mental
well-being. Apart from medicines, there are other healing
methods which patients receive from healthcare givers.
Spiritual aspects encompass practices such as
mindfulness, meditation and mantra chanting. These are
few of the many ways in which we can resolve the innerconTlicts. These practices also help us raise awareness of
how an individual can recover and take control ofsituations which are not under his control.

What is spirituality?
Spirituality is about applying the principles of being
mindful of who you are and what you need to do to
overcome and address a particular issue/challenge in life.
An individual can choose to live in joy or live in misery.
They can tell themselves that they don’t want to be
negative about their situation (Dhall & Dhall, 2018).
Spirituality, according to Dr Pal Dhall, assists theindividual to realize his or her true nature and experiencea balanced life between material and spiritual world.
Spirituality helps with the development of individuals toincrease their capacity to pacify themselves to control
their impulses and emotions. Other added changes
include an increase in awareness, positive self-identity,
becoming socially conscious, eliciting a sense of gratitude,
humility, inner freedom, intuition and self-conTidence, andetc. Thus the individual has a mastery over the inner andouter world (Dhall & Dhall, 2018). Spiritual practices
include different activities and actions as prayers, rituals,
practicing mindfulness, getting involved in religious
observance, display of feelings and emotional literacy.
Such people connect with others in meaningful ways
(Nita, 2019).
Spiritual wellness and spiritual universal values
This new emerging Tield of mindfulness and spirituality
within healthcare for mental wellness and well-being is
indicative that mental and physical health depend on how
much one goes into reTlective awareness. What faculties
lie underneath the normal person? “It has been proved
also by psychologists that there are many kinds offaculties lying hidden in what is called the sub-conscious
and the unconscious mind of man” (Chander, n.d. p.39).
There are many examples from social media where people
have turned to spirituality for guidance and a few
examples from studies are given below.
Excerpts from social media
Love for the environment by Meaghan Wray (Posted
March 18th, and updated on March 23rd ). Her title reads“Dolphins returned to Italy’s coast amid the corona virus
lockdown-Nature just hit the reset button”.
“Venicehasn’t seen clear canal water in a very long time,”
they wrote. “Dolphins showing up, too. “Nature just
hit the reset button on us.” A collage shows footageof two dolphins swimming in an Italian port, as wellas Venice canal waters running clear for the firsttime in a long time, thanks to a decrease in watervehicle pollution”.
Source: https://globalnews.ca/news/6697281/dolphinsitaly-coronavirus/
The Church of Jesus Christ of Latter-day Saints shareda link.(March 27). President Russell M. Nelson invites
members of The Church of Jesus Christ of Latter-day
Saints and friends throughout the world to unite in faithand fasting for physical, spiritual, and other healing fromCOVID-19 this Sunday, March 29.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

95

Table 1: Current research trends: an emerging Tield in healthcare systems
Title of research areas

Interventions

Expected outcomefor Health andSustainability

Target _ields

Education for sustainable
cConsumption through mindfulness
training: Development of aconsumption-speciTic intervention(Stanzsus et. al., 2017)“Mindfulness through reTlective
processes using both cognitive andaffective processes(Process: reTlection of individual
values and actions in each given
moment and therewith to potentiallystrengthen peopleís ability todeliberatively focus their mind in a
way that they become more sensitive
for their own values, emotions andensuing actions)”.

Program to develop
self-compassion andemotional resources
for healthy people,
loosely based on
MBSR

HealthReTlective practice: Transforming
education and improving outcomes(Sara Horton-Deutsch, Gwen D
Sherwood, 2017)

ReTlective practices through bothcognitive and affective processes

Integrated
knowledge with
continued learningfrom multiple
sciences andincrease newawareness andinsights, promoting
a spirit of inquiry

Health“Use of mindfulness-based
interventions to prevent relapse in
major depression and for the selfmanagement of chronic physicalhealth conditions (e.g. pain), but theevidence in other domains of mental
health work is still emerging”.

Thoughtful decision
makingHealth practices

Mindfulness and Bodily distress(Fjorback, 2012).

“Use of mindfulness therapy tointervene in social and economic
consequences of bodily distresssyndrome is signiTicant andmindfulness therapy may have apotential to signiTicantly improvefunction, quality of life andsymptoms, prevent a social decline,
and reduce societal costs”

Mindfulness therapy
appears to produce
improvements
within the range of
those reported in the
STreSS-1 trial

Healthcare
practices forpractitioners andpatients

Nature-nurture interaction inreligious and spiritual development(Granqvist,P. & Nkara, .F.
(2016).Religion & spiritualdevelopment has been understoodas an expression of evolved cognitive
modules (nature) on the one hand,and of socialization and social
learning (nurture) on the other, or insimilar albeit additive terms (e.g.,nature produces the brain/mind,
culture Tills in the details).

“However, micro and macro systems
can also experience disharmony. For
example, a child taught at home that
God is real but immaterial can attend
school in a secular rationalist
education system that featuressecular / materialist metaphysics,
and where God is rarely mentioned if
ever mentioned”

Relationship of frequent mantram
repetition to emotional and spiritualwell-being in healthcare workers(Granqvist & Nkara, 2017)“Mantram repetition incorporates
spirituality, a factor that is becoming
recognized as a vital component inhealth and well-being”

What and who? Mindfulness in themental health settings (Russell, T. A.,& Sigmund, G.2016).

Child development
and education

Health and wellbeing

Health practices

96

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Documentary analysis

Cultural beliefs andValues systems
THEORY OF
CHANGE

Bioethics for Sustainable
Development
Spiritual Universal Values

Religious principles andpracFces
Ethical theories andpracFces
Figure 1: Adapted from Theory of Change to arrive at common goals for Bioethics

The multi-billionaire Gates, 64, who donated £85 million tocombat the virus last month, believes that despite the chaos,
there is ‘a spiritual purpose behind everything that
happens’. In an open letter, entitled ‘What is the Corona/
COVID-19 Virus Really Teaching us?’, he wrote:‘A SpiritualPurpose’. “I’m a strong believer that there is a spiritual
purpose behind everything that happens, whether that iswhat we perceive as being good or being bad. “As I meditate
upon this, I want to share with you what I feel the Corona/
COVID-19 virus is really doing to us.
1) It is reminding us that we are all equal, regardless of ourculture, religion, occupation, Yinancial situation or how
famous we are. This disease treats us all equally, perhaps
we should too.
2) It is reminding us that we are all connected andsomething that affects one person has an effect onanother. It is reminding us that the false borders that wehave put up have little value as this virus does not need apassport. It is reminding us, by oppressing us for a shorttime, of those in this world whose whole life is spent in
oppression.
3) It is reminding us of how precious our health is and how
we have moved to neglect it through eating nutrient poor
manufactured food and drinking water that iscontaminated with chemicals upon chemicals. If we don’t
look after our health, we will, of course, get sick.
4) It is reminding us of the shortness of life and of what ismost important for us to do, which is to help each other,
especially those who are old or sick.
Our purpose is not to buy toilet roll.
5) It is reminding us of how materialistic our society has
become and how, when in times of difYiculty, we rememberthat it’s the essentials that we need (food, water, medicine)as opposed to the luxuries that we sometimes unnecessarily
give value to.
6) It is reminding us of how important our family and home
life is and how much we have neglected this.
It is forcing us back into our houses so we can rebuild theminto our home and to strengthen our family unit.
7) ‘Our true work’: it is reminding us that our true work is
not our job, that is what we do, not what we were created todo.

Mary Mount University (Hospice, March 27, during the
COVID-19 epidemic). “The nurses, healthcare assistants,
catering staff and ward managers on Marymount's St
Catherine’s palliative care ward recently sang their own
version of Nancy GrifTith's 'From a Distance' to boost
morale, practicing social distancing all the while”
India
Questions by the youth to an Indian Guru: Could you share
more light on building resistance using home remedies?
Can we start giving preventive medicines to those on
quarantine which had been established many years back?
There are simple remedies which are time testes. Thereare enough remedies. Under Ayush Ministry there areeight lakh vaidyas and 80000 staff? Can they be allowed
to do house to house survey?
Prayers“During Chaitra Navratri Ram Nawmi we intensify ourprayers. Welcome Maa Kushmanda in your home andprotect you and your family. A special heartfelt prayer &dedication to All our National Health Medical warriors the Police Force - all serving as front-liners on the terrain
daring [during] COVID- 19 to save our lives.
Applying the theory of change for sustainable
development in the field of bioethics
The theory of change for sustainable development canhelp to explore the Tield of bioethics and sustainable
development. The different phases from the original
Change theory which is integrated into this model are
Sequence of Required Events; Logical model; Context,
Intermediate outcomes and Long term outcomes. Applying
the context related to COVID-19 pandemic, a documentary
analysis will help provide the above details for every
phase. A Conceptual framework of the Theory of Change is
implemented in Figure 1.
Change theory and its application in healthcare
and environment
The pandemic was sudden and the community reaction
was instantaneous. News, blogs, announcement sectors
were busy displaying statistics of the rise of the COVID-19
cases. Communities expressed their values, beliefs andEubios Journal of Asian and International Bioethics 30 (3) (April 2020)
attitudes (affective processes) in many ways. Therefore
the model derived from the literature in health care andsocial media was used to look at how common elements
can be derived and used to list spiritual universal values.
For this purpose, the evidence must include descriptive
analysis of events, patterns in societies and both shortterm and long term outcomes of the pandemic. They also
include environmental issues and issues related toeducation.
Various steps are involved in the Theory of Change• Sequence of Required Events: This area will explore
the applied ethical practices in health andsustainable development• Logical model: evidence based patterns incommunities• Context: Issues in the health Yield and sustainable
development for lifelong learning• Intermediate outcomes: A mapping of intermediateoutcomes• Long term outcomes: An assumption of long term
outcomeConclusion
Narrative discourses, documentary analysis and the
profound teachings of various religions and cultures will
help identify common spiritual universal values. Theremay be impending disasters due to climate change andpollution in the future which could lead to negative
consequences in the future as claimed by researchers. An
approach using “spiritual universal values” in Bioethics istherefore an imperative for our common future where theglobal community becomes a collective community. The
crisis has shown us that every single individual matters
including the violence of animals.
References
Borman et al., (2006). Relationship of Frequent Mantram
Repetition to Emotional and Spiritual Well-Being in
Healthcare Workers. The Journal of Continuing Education in
Nursing37(5):218-24.
DOI: 10.3928/00220124-20060901-02. Source: PubMed
Dhall, P. & Tehseen, D. (2018). Introductory course on Human
Values. (June 11-15, 2018). Kuala Lumpur. Malaysia.
Fjorback, L.O. (2012). Mindfulness and bodily distress. Dan Med
J. 2012 Nov; 59(11): B4547
Granqvist,P. & Nkara, .F.(2017). Nature meets nurture in
religious and spiritual development. British Journal of
Developmental Psychology, 35(1). DOI:10.1111/bjdp.12170
Macer, D. R. (1994). Bioethics for the people by the people.
Christchurch, New Zealand: Eubios Ethics Institute.
Macer, D. R. (1998). Bioethics is Love of Life. Christchurch,
New Zealand: Eubios Ethics Institute.
https://
www.eubios.info/BLL/BLL1.htm).
Nita, M. (2019). ‘Spirituality’ in Health Studies: Competing
Spiritualities and the Elevated Status of Mindfulness. J Relig
Health 58, 1605–1618 (2019). Retrieved from https://doi.org/10.1007/s10943-019-00773-2
Picciotto, R. (2003). International Trends and Development
Evaluation: The need for ideas. American Journal of
Evaluation, 24(2), 227-234. Retrieved from https://wmich.edu/sites/default/Tiles/attachments/u58/2015/
International_Trends_and_Development_Evaluation.pdf
Russell, T. A., & Siegmund, G. (2016). What and who?
Mindfulness in the mental health setting. BJPsych

97bulletin, 40(6), 333–340. https://doi.org/10.1192/
pb.bp.116.054122
Scott SA. Personalizing medicine with clinicalpharmacogenetics. Genet Med. 2011;13(12):987–995.
doi:10.1097/GIM.0b013e318238b38c
Sara Horton-Deutsch & Gwen D Sherwood (2017). Transforming
Education and Improving Outcomes. Second Edition.Sigma
Theatre Tau International. Honor Society of Nursing. USE:
Indiana polis
Stanszus et al., (2017). Education for Sustainable Consumption
through Mindfulness Training: Development of a
Consumption-SpeciTic Intervention. Journal of Teacher
Education for Sustainability, 19(1), pp. 521, 2017. DOI:
10.1515/jtes-2017-000.
UNESCO (2010). Universalism and Ethical Values for theEnvironment. UNESCO OfTice Bangkok and Regional Bureau
for Education in Asia and the PaciTic. Accessed on 26.3.20
from https://unesdoc.unesco.org/ark:/48223/
pf0000188607.
Weiss. C. (1995). Nothing as Practical as Good Theory: Exploring
Theory-Based Evaluation for Comprehensive Community
Initiatives for Children and Families in ‘New Approaches to
Evaluating Community Initiatives’. Aspen Institute.
Websites
https://www.theoryofchange.org/what-is-theory-of-change/
toc-background/toc-origins/

Bioethics at the time ofcoronavirus crisis; an ethicalreflection on good public policies
and a better future- Mireille D’Astous, PhD
Quebec, Canada
Email: mireille.dastous.1@ulaval.ca
In the Tirst epistemological reTlections in a pandemic, an
ethicist said a sentence that keeps nourishing myreTlection within the last days: “Coronavirus crisis reTlects
on who we are, as a society.” I am realizing how quickly
fear can take us, as a new disease spreads in multiple
countries. As WHO declared it as a pandemic on March 11,
2020. Information can be viral, even quicker than an
actual virus. Access to the Press is our daily life, but
complex thinking takes time. We live in a technologicalsociety with a lot of data collected minute by minute, dayby day. But real-world massive medical data is notavailable, and can have a crucial impact in the early stageof a pandemic. Hopefully, there is never only one way tosolve a complex problem.
The quality of information we have, and above all
our way to understand and select scientiTic information,
data, guidelines and lessons learned from previous
pandemic is crucial. Do we have all data we need for gooddecision-making and is it accurate? There was, and there
is still uncertainty: What is the fatality rate?
Dangerousness? What is the proTile of patients? How cantechnology, and how can testing, help track and identify
cases, so the number of persons infected can becontrolled? Do we have the medical supplies (ICU units
and ventilators), the protective personal equipment (PPE)
to protect healthcare workers? Can each national

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

healthcare system provide the best care to all criticalpatients? If we cannot, what can be done? Is the solution
implementing social distancing (physical distancing) andquarantine? How will leaders react, at a local, national,
international level? Each uncertainty needs to be clariTiedby public health authorities and experts. We need to reevaluate locally, frequently, rapidly, with the best means.
There is also issues about sharing informationtransparently, even more at an international level, with
the Tirst countries affected.
It is well known, decision-makers are looking forspeciTic data. Data they can rely on to make gooddecisions. Each misevaluation in a pandemic with adangerous virus can lead to more people infected(including healthcare providers) and more deaths. On theother hand, the lack of information on the lethality of thevirus on the population scale can lead to more lockdown
days and other non-pharmaceutical measures imposed on
populations, industries and enterprises. We should keep
asking : what are our blind zones?
The words “Flattening the curve” will remain a key
word in the management of the coronavirus pandemic.
Epidemiologists have a strong voice in this model.
Nonetheless, they are not the unique voice. What are themedical opinions? As we are submerged by the current
situation, which voices should take the lead? Whichethical and moral reasoning can help to choose the best
actions and the best scenario? What is relevant, andwhen?
It is very hard to say if we are taking the gooddecisions if we don’t have accurate and good data. We
should be very careful about it. As we know, fake news cancirculate very easily, and none of us is totally immune to it,
especially when a global situation like a pandemic occurs.
Pandemic can be dangerous. False viral informations areharming. Blind leaders too, in different ways.

population’s daily quality of life. Stress, pollution, chronic
diseases, mental health’s vulnerability and chronic mental
health’s diseases, incurable diseases, etc. There is so muchto be done to live a healthy life. Strongly deeply efTicient
caring healthcare institutions for all is an ideal we haven’t
reach yet.
In pandemic time, health and “saving lives” become
the main issue. Caring for ourselves and the vulnerable
implies prudence and low-risk actions. Still, I dare ask:
Are we driven by fear of sickness, fear of losing control,
fear of death? Those fears tell us something about us: ourbodies are vulnerable. We have to act acknowledging ourfrailty. Right now, it means for most of us to listen to
public health authorities, respect their knowledge and act
in accordance with the best sanitary practices.
As it was raised in the medias, our current
economical system can also dive into fearful areas, withadverse events. The Tinancial burden of a recession isheavy, especially for younger generation alreadysupporting population ageing. Can we take the time to
discuss new social policies, new laws, new good public
policies?
As climate change is again addressed, do we have thestrength and willingness to transform deeply ways ofliving and a system that will provoke environmental
adverses events we don’t want? Knowing theconsequences of our actions is the basis of all ethical andmoral thinking. Can we remove our blinders? We have to
make better choices to reduce pollution on an
unprecedented scale. It’s a matter of protecting our healthand health of our communities. We don’t want to beforced to make cruel or difTicult choices whenenvironmental catastrophes will occur in a future that
becomes closer and closer every decade. How can we becreative in order to live in a better world, in a hugecollective international effort?

What is the crucial data in pandemic and in
public policies?
We should keep asking: Do we have the real data about
the virus and the damage it will effectively cause? How
can we manage well the situation if crucial data is lacking?
Numbers have to be interpreted carefully. What exactly is
the crucial data in a pandemic? Can we have more data on
the fatality rate, including asymptomatic patients? The
accuracy of the fatality rate has to be interpreted carefully,
since it usually implies that patients will receive care, andthat the health system won’t be overwhelmed. Good
decision-making is based on good data. Is the public andthe governments always well-informed? What is the roleof emerging technologies, like AI? This crisis reveals theneed for accurate information and accurate public policies
in a complex society. Georgetown University has alreadycreated an open research dataset with more than 44,000
articles about COVID-19.

Difficult choices in medical ethics are a lastresort; we should act ahead if we can
In ethics and bioethics, one of the worst situation is being
forced to choose between two scenarios and knowing wewant neither one. The Tirst time a student of philosophy
asked me to answer to the trolley problem, I didn’t want
to. Who wants to choose who will survive, and who willdie (at least it was a theoretical philosophical problem)?
Recently, my roommate had the same reaction. This
repulsive reTlex (usually with a stressful or sad facial
expression) can teach us something: we need to act andmake efforts to live in a society, to participate ininstitutions and to act as citizen and in civic life, so we
don’t have to be forced to make difTicult choices or worst,
cruel choices. We should act ahead if we can. But thetrolley problem remains: when unexpected and adverse
events occur, will we be forced to decide who will get
healthcare, especially when there is scarcity of resources?
Bioethicists already had guidelines, which is now updated
for COVID-19 (Ezekiel et al., 2020). The fact remains thatthe best scenario would be not to get there.

Ethical remarks
In bioethics, the pillar of caring for vulnerable population
stands. Mistrust in healthcare systems is linked to theconcrete inability to help and to fully care for people whoneed it. While quality of life can be a criteria in ethicaldecisions making, there are so many conditions that alterEubios Journal of Asian and International Bioethics 30 (3) (April 2020)Three axis for public policy decision-making
model in pandemic
In a time of large-scale restructuring and adjustment, weneed to make the best possible decisions. As we have dataon other countries’ cases and pandemic management
model, how accurate is this data? Are we being guided byreason?
Three main axis can be identiTied and can help
decision-making. As mentioned above, accurate scientiTicand epidemiological data is crucial, prior to decisionmaking. This model doesn’t address medical logistic andmedical supply needed. It is meant for public policy
decision-making, with a focus on public engagement,
beneTits and burden for a society seen as a whole.
Is it possible that pandemic management takes theform of preventive relentlessness, or to the opposite point,
recklessness? What are the criteria and equilibrium point
for each phase in a pandemic? With the aim to conduct
such a reTlection, I propose a three axis decision-making
model.
Axis 1 - Non-Pharmaceutical Public Health Measures to betaken (or release) step by step
We have to think seriously which preventive publichealth measures should be imposed and when, based onrisk-adjusted data. WHO described those nonpharmaceutical public health measure in a report in 2019.
It was made for the global inTluenza programme. The
evaluation of the effectiveness of those measures are now
better known, with mathematical epidemiological data.
Each restriction minimizes the risk of viral propagation.
Precautionary principle can take the lead. It can also be
evaluated proportionally to dangerousness. When
lockdowns are implemented, it is unknown anduncommon to reduce so much economic, cultural,
educative and social activities. Taking those preventive
public health measures too quick can be seen as
preventive relentlessness. But, waiting too long is
recklessness. A Tine line has to be trace.
Axis 2 - Evaluation of life value
This axis has also to be considered cautiously.
Insurance companies are familiar with the “value ofstatistical life”. President Donald Trump has used some ofthose arguments lately, he mentioned the annual numberof people dying of car accidents and added: "We don’t stopusing cars and building cars."
Even with the best preventives measures, caraccident still occurs. There is no zero risk and we stillchoose to drive cars. The point slowly appears: does
stopping the economics worth it? Some wisdom can be
Tind in the words of Tom Frieden, published in the
Washington Post, on March 25 : “The choice is not
between health and economics but about optimizing the
public health response to save lives while minimizing
economic harm.”
We can also ask: Is the prior criteria to save all the
lives (no fatality)? In absolute terms, we all want a good
future. Nobody wants to die young of course, elderly
persons wants to preserve healthy years ahead, andvulnerable populations want to be protected. A new99

disease is bad news. Can we accurately evaluate the shortterm and long-term impacts?
It is uncomfortable, but legitimate to compare theestimated number of COVID-19 deaths with otherdiseases or accidents - like cancer annual number ofdeaths, or tuberculosis annual number of deaths. It caneven becomes a criteria to decide which measures should
be taken, and when? Maybe what scandalized a lot, is that
this criteria does not prevent or treat the disease. It has
impact on which actions we should do. Also, as we allwant to live in good societies, these statistics shouldn’t be
downplay. We don’t want our leaders to play Russianroulette with our lives.
On 21 March 2020, David Soiegelhalter published anarticle entitled: “How much ‘normal’ risk does Covid
represent?” I quote him: “It’s always useful to rememberthat we’re all going to die sometime, and the rate at which
we do so is faithfully recorded in the life tables provided
by the OfTice For National Statistics”. Another measure,
QALY, which means quality-adjusted life year, should be
calculated and be publicly available. Months equivalentrisk, which represents the risk in terms of months of‘normal life’, has been calculated by age range.
Axis 3 - Current progress and availability of efYicient
medicine (anti-viral treatments, public vaccination)
For now, the scenario is the current: As theavailability of more efTicient medicines (anti- viraltreatments, public vaccination) hopefully will happen
soon, non-pharmaceutical public health measures will be
released. When the threats will Tinally be fully known andcontrolled, restrictive measures will be taken off. We stillneed data to evaluate the risks and the impact for the
population and health care workers. We can improve ourcapacity to identify and evaluate the threats on the healthof each of us, and minimize the risks. We have to act withprudence.
Good information is still crucial in the managementof the pandemic in order to decide which scenario is thebest. When the entire world focuses on COVID-19, when
so much research is conducted in order to Tind effective
treatments and vaccines, good solutions may emerge.
Future ahead: hope for a better world
Beliefs are powerful and shape the world transformation
and beginning of new eras, hopefully lead by collective
intelligence. Will this pandemic lead to a new sense ofsolidarity and peace? Our economic model is based on theimperative of growth, which means roughly more
activities and gaining added value. Maybe we have tochange deeply our international economical system, but
who can take the lead? Equity, justice, environmental
issues should not be left behind in a better world. We
need changes, but we don’t fully know how. Stopping
excessive consumption and creating simpler and happier
lives is a complex problem. Sadly, yet, Tinancial elites don’t
seem to be the best leaders, especially when they don’t
fully recognized complexity and deny the relevance of vast
domains of knowledge. We need to decolonize knowledge.
A switch of value is occurring: health is the imperative,
and it can lead our choices. It can lead politics, public
policy and daily life. Even economy has to adapt, which is

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

an unseen situation: a calm revolution is happening. As
proverbial wisdom says: “Necessity is the mother of
invention." Good leaders will emerge with a new wisdom. I
hope we will re-evaluate the value of everything.
Transport. Quality of food. Food security. International
collaboration. Individual choices. Safety. Solidarity. Caring
for others.
During lockdowns, everybody can gain knowledge
and have moral reTlection. It is fascinating to observe theadaptations and creativity that governments and humanbeings are deploying right now. In a better world, theimpact of each action on others have to be taken into
account. In a pandemic, there are public campaigns thatraise collective awareness: protect your community, stayat home, reduce consumption to the essentials. While
being at home, why don’t we take the time to value what
we already have (books, access to informations on
Internet, public radio)? It is a good time to prioritize
quality of relationship, gratefulness for what we have.
Each of us can ask: what can I do to improve my healthand quality of life for me and others (good nutrition,
exercise, etc.)? It is a special time to learn from home
(some Ivy League university course are online)... Since thepandemic has such impact on the economy, isn’t the timeto evaluate why we’ve let the previous economical system
drives our lives so deeply, while alternatives are possible?
Links and references
Academic Journals and References
Ezekiel et al. (2020). “Fair Allocation of Scarce Medical
Resources in the Time of COVID-19”, The New England
Journal of Medicine.
Kim, E. et al. (2020). “Microneedle array delivered recombinantcoronavirus vaccines: Immunogenicity and rapidtranslational development”, EBioMedicine (March 18, 2020).
Kuhse, H. et al., eds. (2009). A Companion to Bioethics. Second
Edition, Wiley-Blackwell.
Kupferschmidt, K. et al. (2020). “Can China’a COVID-19 strategy
work elsewhere?”, Science (March 6, 2020).
Lewnard, J. A. et al. (2020). “ScientiTic and Ethical Basis forSocial-Distancing Interventions Against COVID-19”, The
Lancet Infectious Diseases (March 23, 2020).
Rosenbaum L. (2020). “Facing COVID-19 in Italy - Ethics,
Logistics, and Therapeutics on the Epidemic’s Front Line”,
The New England Journal of Medicine (March 18, 2020).
Wang, H. et al. (2020). “Phase-adjusted Estimation of the
Number of Coronavirus Disease 2019 Cases in Wuhan,
China”, Cell Discovery (February 24, 2020).
WHO. Global inTluenza program (2019). Non-Pharmaceutical
Public Health Measures for Mitigating the Risk and Impact of
Epidemic and Pandemic InTluenza.
Zavascki, A. P. et al. (2020). “Clinical Characteristics of COVID-19
in China”, The New England Journal of Medicine (March 27,2020).

Other references
Frieden, Tom (2020). “When Will it Be Safe to Go Out Again”, The
Washington Post (March 25, 2020). URL: https://www.washingtonpost.com/opinions/when-will-it-be-safeto-go-out-again/2020/03/24/7cb2e488-6de1-11ea-aa80c2470c6b2034_story.html
Harmon, A. (2020). “Some Ask Taboo Question: Is America
Overreacting to Coronavirus?”, The New York Times (March
16, 2020). URL: https://www.nytimes.com/2020/03/16/
us/coronavirus-hype-overreaction-social-distancing.html?
action=click&module=Well&pgtype=Homepage&section=US%20News&Tbclid=IwAR20NSAphTIUg5fBfH0SR8yoo5_5sgel
TioASCEdBp7OzMcvEfO4T-NJtcE
Hodgson, C. (2020). “The mystery of the true coronavirus death
rate", Financial Times, March 30, 2020. URL : https://w w w. f t . c o m / c o n t e n t / f 3 7 9 6 b a f - e 4 f 0 - 4 8 6 2 - 8 8 8 7 d09c7f706553
OfTice for National Statistics. URL: https://www.ons.gov.uk/
p e o p l e p o p u l a t i o n a n d c o m m u n i t y /birthsdeathsandmarriages/lifeexpectancies/bulletins/
nationallifetablesunitedkingdom/2016to2018 (March 31,
2020)
Pueyo, T. (2020). “Coronavirus: Why You Must Act Now.
Politicians, Community Leaders and Business Leaders: What
Should You Do and When?”, Medium (March 10, 2020 ; updated March 19, 2020). URL: https://medium.com/@tomaspueyo/coronavirus-act-today-or-people-will-dief4d3d9cd99ca
Rubenfeld, G. (2020). “The Coronavirus is the Chance to Have theEnd-of-Life Conversations We Need”, The Globe and Mail
(March 16, 2020). URL: https://www.theglobeandmail.com/
opinion/article-the-coronavirus-is-a-chance-to-have-thee n d - o f - l i f e - c o n v e r s a t i o n s - w e / ?
Tbclid=IwAR0g5O9raHX4eLCURaLQMNR4CgqyMBm0_mZPF
NGesXLf9h0iF7Gf_RnmViE
Spiegelhalter, D. (2020). “How much ‘normal’ risk does Covid
represent?”, Medium (March 21, 2020). URL: https://
medium.com/wintoncentre/how-much-normal-risk-doescovid-represent-4539118e1196 (March 31, 2020).

Pandemics from the lens of former
peace keeper : COVID-19 response
Purusottam KC,
Retired Colonel, Nepalese Army, Nepal
Email: kcpuru9@gmail.com
Introduction
As a former peacekeeper in conTlict-ridden areas of Africa
and Middle East, I had the Tirst-hand view of anxiety,hopelessness and uncertainty of people in the community
at a large scale and subsequent turmoil and instability atnational level. When the international community falters
to respond to such tragedy in the timely manner, thetragedy gets manifested in the form of war or megadisaster or pandemic.
Moreover, as a scholar of American University ofSovereign Nations (AUSN) I have been advocating theimperatives of timely improvement of response
mechanism on such precarious situation unearthing the
Tlaws of human response in the past for it provides a
prologue of past and present crisis while the guidelines
can be drawn to save human and economic toll. Moreover,the lesson that we learn can provide additional insights
into legal and ethical issues in response to pandemic
mitigation and suppression.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Emergency in pandemics
Be it a pandemic or disasters of larger scope, they all
overwhelm the resources and the providers need toprioritize as to who has a priority to these scarce
resources. This is exactly what happened even in the caseof most developed countries during COVID-19 pandemics.
Health professionals were given implied instruction toprioritize the resources: literal meaning being “You chose
who deserves to leave or die.” Pandemics are devastating
natural or willful events that results in damaging
economic and social consequences for the people theyaffect, loss of life and physical and emotional hardship.
When failure of civil administrative and operational
systems occurs, the role of military becomes vital to keep
the society running. They work in coordination withemergency managers and responders are responsible forintervening before and during such events, to minimize
the harm disasters/pandemics cause and to restore order.
The large scale, high complexity, profound urgency, andintense scrutiny that attend pandemics (e.g. COVID-19)
provide a powerful motivation for responders to be goodat response.
Peace keepers invariably work on foreign soil which
is a challenge in itself but comes with a great deal of goodthings. They have international credibility, understandingof local situation, unbiased approach and expertise. Most
importantly, peace keepers bring to doorstep the sense of
belongingness, engagement and hope.
Background
Pandemics have been around the world ever since its
inception. Every religion and holy books talk about thecollective plights of human being and ultimate dooms day.
Throughout the course of history, disease outbreaks haveravaged humanity, sometimes changing the course ofhistory and, at times, signaling the end of entire
civilizations. COVID-19 is not only the pandemics humans
have faced in the annals of its history. There were manyand pandemics are certain to appear in the future. Why
we got alarmed this time is it caught us by surprise: notthat we didn’t know about it but we didn’t want to learn
form the past pandemics. The following pandemics weresome of the brutal killers in the annals of human history:a. Prehistoric epidemic: Circa 3000 B.C. About 5,000
years ago, an epidemic wiped out a prehistoric village in
China. The bodies of the dead were stuffed inside a housethat was later burned down.
b. Plague of Athens: 430 B.C. People in good healthwere all of a sudden attacked by violent heats in the head,and redness and inTlammation in the eyes, the inward
parts, such as the throat or tongue, becoming bloody andemitting an unnatural breath"c. Great Plague of London: 1665-1666.The Black
Death's last major outbreak in Great Britain caused a mass
exodus from London, led by King Charles II. By the time
the plague ended about 100,000 people, including 15% of
the population of London died.
d. Spanish Flu: 1918-1920. An estimated 500 million
people from the South Seas to the North Pole succumbedto Spanish Flu.

101

e. AIDS pandemic and epidemic: 1981-present day. AIDS
has claimed an estimated 35 million lives since it was Tirst
identiTied.
f. H1N1 Swine Flu pandemic: 2009-2010. Ebola ravaged
West Africa between 2014 and 2016, with 28,600
reported cases and 11,325 deaths.
g. COVID-19. COVID-19 is the disease caused by the newcoronavirus affecting respiratory system that emerged in
December 2019.More than conTirmed 801,061 cases and38,748 deaths as of 31 March 2010 ( Exactly 3 months
from the Tirst formal report).
Coronavirus appears to be different from otherpandemics. We know much about this virus but we also
don’t know so much about it but it is absolutely necessary
to tell others what we do know about this pandemic. The
virus has size of 50-140nm (reports still vary). It isdangerous due to its size that it can Tloat in the air for atleast 2 hours, let alone on your clothes or on othermaterials. Recent studies in India reported that the
mutation of virus differed in different continent.it isreported that the mutation of virus is only one-time vsthree times in Italy. What we can say is we have to wait forsome time until scientists come of up with actually what it
is and what needs to be done to deal with COVID-19.
Many people could be asymptomatic posing major thereat
to health care workers and people you associate with.
As a past peace keeper for the United Nations, mytake away based on my personal experience is that while
ensuring peace to vulnerable community peace keeper
faces another set of challenges arising form pandemics
like COVID-19. The peacekeeping radio stations like Radio
Miraya in South Sudan and other parts of the world isserving as a lifeline for communities by putting out rightand timely information. The main challenge is to keep
yourself safe from such disease while ensuring safety andsecurity of targeted population. The peace keepers prone
to diseases are likely to spread the same to the very
community they intended to protect: case in point is thatof Haiti 2010.
People tend to think that the UN is an independent
entity with its own mandate and scope. Partly true, butthere are lots of protocols to follow given thecommitments of individual nations in support of long- andshort-term cause.
International response framework
Pandemics do not respect international borders.
Therefore, they have the potential to weaken manysocieties, political systems and economies. The onlyinternational framework governing how WHO and its
member States should respond to infectious disease
outbreaks is the International Health Regulations (IHR).
The focus of IHR is on the prevention and containment ofpublic health emergencies of international concern.
Member States commit themselves to building corecapacities in the areas of national legislation, policy and
Tinancing, communications, surveillance, response, andpreparedness.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Table 1: Timeline of Pandemic of Some Nations (Date format dd/mm/yy)
PARTICULARSCHINAS KOREA IRAN

First Report

3 1 / 1 2 / 20/1/20
2019

First death

11/1/20

2/20/20

Second report 1 / 2 0 / 2 0 23/1/20-139
Deny Entry/
Exit

ITALY

SPAIN

USA

NEPAL

JAPAN

19/2/2 31/1/20 – 2 x 31/1/20
0cases

1/ 21/20

24/2/20

16/1/20

19/2/2 22/2/20
0

2/8/20- in NA
Wuhan

5/3/2021/2/2 2 2 Fe b - 6 0 O n
2 4 A few days 24/2/20
0 : 1 3 cases
February
later incases
Chicago14/2/20
24/1/20

3 / 9 / 2 0 1/31/20
different
dates forcities

3/7/2012/2/20NA

4/2/20/ 5/3/20 1/31/20
Int’l 24 20
February

Massquarantine/
lock down

1/23/20NA

3/13/20

3/22/20

5/2/20Total
Infection/
Death as of
3/31/20

81,518/33 9786/16 44,605 105,792/12,4 94,417/8,18 75,066/1,08 7/005
2/ 2829 28
90NA

8/3/20

The relationship between individual, national andinternational security is related to the introduction ofconcepts such as “human security” and “sovereignty as
responsibility” in the post-cold war era. When thisInternational regime boils down at the national level,
different committees are created under Ministry/
secretary of health.
Being realist, states would only commit resources tohuman security when they derive some direct beneTit
from it. Thus, we see discrepancies in real time while
responding to such pandemics. Some of the reasons why
this happens are:a. Difference in understanding of the situation among
countries.
b. Individual political interest within a country.
c. Face saving approach at the outset by nations/Stigma
d. Lack of commitmente. Lack of capacity of individual nations to identify/
respond.
Best practices around the world
Countries that have Tlattened the curve made testing
widely and freely available, using innovative approaches
like mass drive-thru test centers. The United States, South
Korea, India and China are investing heavily to come up
with viable test kits and suppression methods. We willneed to act urgently, and aggressively to adopt Tive key
measures that helped to Tlatten the curve in places like
Japan (initial confusion but adopted stringent policy to
Tlatten the curve later), Hong Kong, Singapore, and South
Korea.
1. Testing. Testing also allows clinics and hospitals to
become better prepared, as they know how many cases to
expect. And, crucially, testing helps us to know where thedisease is, how it is evolving, and where to target our

3/12/202124/56

efforts to control it. It identiTies the hot spots of infections.
South Korea has been conducting around 12,000-15,000
tests every day, and has the capacity to do 20,000 daily.
While it is hard to get accurate estimates, the CDC reportsthat only around 25,000 tests have been conducted in
total nationwide by CDC or public health labs in the U.S.
2. Communicate and coordinate. In Singapore, forexample, “there are almost daily meetings between
Regional Health System managers, hospital leaders, andthe Ministry of Health.” Clear COVID-19 plans andprotocols are in place so that all key players at all levels of
the health system know what they are supposed to do.
There’s also explicit, detailed information given daily tothe public on the state of the outbreak.
3. Use physical distancing to protect the vulnerable. A
critical tool for breaking this community transmission is“social distancing”—staying away from places where
people congregate (movie theaters, bars, restaurants,
shopping centers), avoiding mass gatherings (likereligious services and concerts) and but renew love andpassion within your own family. What we should
understand is the lockdown method adopted by somecountries may not be effective to other countries/
societies.
4. Protect our health workers and security personnel.
Rapidly scaling up and deploying the production ofprotective equipment for health workers is not just apublic health necessity. It’s also a moral emergency and amental Tight.
5. Expect and plan for a rise in cases. Every health caresetting across the country, especially hospitals, shouldtake steps to prepare for a rise in cases, including scaling
up their supplies of equipment such as ventilators. But itshould primarily come from the top policy level.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Way forward
We should learn from the past and gear ourselves to takeup the challenges of future. Vision, preparation and robust
mechanism to swiftly spring into action with international
engagement. People got exposed because policymakers
failed to stop the spread. Some recommendations are:a. there should be a global cooperative entity working at
local level to ring alarm bell to international community
b. once the pandemics is positively identiTied the world
should act to stop the spread.
c.
associate health policy commitments with global
economic and human security to elevate the level ofpriority and produce results. The country itself must
unsure that high end production houses retain its
versatility to switch to the production of desired healthequipment in time of crisis.
d. Create a global and a national pandemic inTluenza
preparedness plan. It is now widely recognized that
effective prevention and response to a pandemic requires
national health systems to Tit into international systems.
Universal health-care coverage is not the only an answer
in strengthening health systems but many states, such as
China, need it desperately.
e. IHR compliance needs to be understood through aregional lens and supported by global institutions. The
preparedness plan vis a vis National law enforcement
agencies and national supply chain link must be revised tomeet the global challenges by its core ability to switch tointernational mode from the national one.

Evaluation of public health andclinical care ethical practices
during the COVID-19 outbreakdays from media reports in Turkey- Sukran Sevimli, MD
Department of Medical History and Medical Ethics, Dursun
Odabas Research Hospital, Faculty of Medicine, Van
Yuzuncu Yıl University, Zeve Campus, 65080 Van, Turkey
E-mail: sukransevimli@gmail.com
Abstract
Objective: This main aim of the study is to explore
COVID-19 pandemic problems from the perspective of
public health-clinical care ethics through online mediareports in Turkey.
Method: This research was designed as a descriptive
and qualitative study that assesses COVID-19 throughonline media reports on critics between the periods ofMarch 11, 2020 and April 2 2020 as a quantitative as
number of reports and qualitative (headline analysis)
study, across Turkey. Reports were from Turkish Medical
Association websites which included newspaper reports.
Study data were presented as statistically and qualitative
data case and headlines. No ethical or ofTicial permission
was sought as the study was conducted through open
access internet news sites.
Results: This online reports analysis retrieved about
6723 articles about the COVID-19. According to study

103

data, information about COVID-19 were themed asfollows: general deTiciencies in taking action and isolation(1,800), lack of isolation (160), passengers and transport
vehicles not quarantined (247); insufTicient diagnostic
tests (361), decision to test after healthcare professionals
become infected (361), lack of equipment (560), lack ofevaluation outbreak countries (389 ) [Table 2].
Conclusion and Suggestions: COVID-19 is a pandemic
and is a global public health problem that concerns every
individual and needs to be handled carefully. This requiresa multi-faceted preparation and education. In this context,
healthcare professionals should be well trained in this
aspect and have all the necessary equipment throughout
the process. Additionally, it should work systematicallywith the cooperation of all health organizations, theMinistry of Health, local governments and of course themedia, in order to inform society, fairly distribute theresources and to implement the safety measureseffectively. BrieTly, lack of transparency, insufTicient
information, limited resources, lack of public healthprotection measures such as partial quarantine decision,
partial implementation of the scientiTic board's
re c o m m e n d a t i o n s fo r e c o n o m i c re a s o n s , a n dcontradiction of the explanations are revealed as serious
ethical problems.
Key words: COVID-19, public health ethics, clinical ethics,
pandemic
Introduction
Public health is a science that aims to protect humanityfrom diseases by improving environmental healthconditions with organized community studies, preventing
infectious diseases, providing early diagnosis andtreatment of diseases, and developing a life level that will
maintain the health of each individual (Binns & Low,2015). While public health aims to protect the health ofsociety by making a long-term plan with the data itcollects in order to protect the health of society, it alsoplans and practices to protect the whole society against
natural and human disasters. Therefore, public healthpreparedness and practices are important as well as
clinical treatments during disaster. A pandemic is a publichealth and public health ethics problem due to its
multidisciplinary features and its' worldwide healththreat (HUBAM, 2020; Zohny, 2020). The current
pandemic that the world is facing is COVID-19.
COVID-19 was Tirst publicized on January 13, 2020
when it was discovered in Wuhan Province, China. The
World Health Organization (WHO) declared COVID-19 asa pandemic due to the epidemic spreading to more than
114 countries by 11 March 2020 (WHO, 2020a). It has
spread to all continents except Antarctica. Meanwhile,
since this is a novel virus, there is no vaccine to counter it
and the presented vaccines have not been able to preventthe serious health problems it has developed in different
ways or to even minimize its spreading speed. People have
only taken some preventive measures to control COVID-19
such as hygienic measures, physical distance adjustment,
isolations and self-quarantine as their own decision or asa government order.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Table 1: Differences between natural/man-made disasters and the COVID-19 Pandemic.
COVID-19 Pandemic

Natural or man-made disaster

The enemy is invisible and “Patient Zero” is important.

Insufficient health resources.

The enemy has some visible points and there is no first
victim term.
It has geographical boundaries and it is effective withinthese boundaries.
Victims/survivors in that specific location constitute therisk group.
Usually sufficient health resources

Forced physical distance among people

Not applicable

Authorities cannot create a control area during pandemic

Authorities can create control areas

Patients are stigmatized as an enemy; ageism
discrimination became more visible
The time of the pandemic is much longer than otherdisasters, it is almost impossible to determine a clear timeframe.
It can only be terminated when scientists find drugs or
vaccines
It ignites scientific discussions

Victims are innocent

It does not only pose a health problem, it causes to question
all socio-economic, political and all existing institutions andorganizations and attitudes
Fear/anxiety/hopelessness spreads to almost the entire
planet
It provokes conspiracy theories.

Only the possibilities of existing geography or victims,
policies and people's attitudes are criticized.

The pandemic risk group or risk is not limited to ageographical location.
Healthcare professionals are the primary risk group.

Disaster times are usually limited; mostly disastercontains its own duration.
Precautions to be taken against others are clear, losses
can be mitigated by these measures
Scientific data are already available

Fear/anxiety/ hopelessness exists in the affected area
No conspiracy theories.

Source: channel 24 KSA (29 March 2020, 20:00: Hrs)

Correspondingly, COVID-19 has led to the emergence of
new and extraordinary demands for both public healthresources and the clinical care process. Moreover, it has
begun to render the existing health system as well as
hospitals to be inadequate and ineffective. For this reason,
it has caused panic and fear to spread and continue much
more strongly around the world. For example, in the caseof a pandemic, it showed that there are insufTicient
hospitals that will provide healthcare services in theaffected areas, as well as shortage of equipment such as
intensive care beds and ventilators, and high Tiltration
N-95 masks for health care workers (WHO, 2020c).
Moreover it has revealed that there are also now
shortages of hospitals and healthcare facilities fordiabetes, oncology, hypertension or any other emergency
health problems patients. In other words, almost all thedeTiciencies and faculties of the current system have hit
everyone’s faces just like a bioterrorist attack. On theother side, it has revealed that some persons (including
journalists, scientists, physicians, for example) who
criticize the present health system, health practices, andother socio-economic policies may be either heard or
punished (Haber, 2020; Hegarty, 2020).

Differences between COVID-19 and natural/
man-made disasters:
As these differences can be seen in (Table 1), pandemic
COVID-19 contains different risks and thus indicates newmeasures. We should take consideration of thesedifferences (Table 1). Because, there is a need for new
development of an appropriate package of public healthpreparedness and practices by assessing the serious
differences between natural and human-made disasters(e.g. earthquake, nuclear issues, mass accidents, tsunami)
and pandemic (COVID-19). To distinguish thesedifferences is important, because, if we put all thedisasters in the same basket then we cannot evaluate theirdeTiciencies and inadequacies, so that the measures will
not be as effective as desired.
To distinguish these differences is highly important.
Because, if we put all the disasters in the same basket thenwe cannot evaluate their deTiciencies and inadequacies, sothat the measures will not be as effective as desired.
Public Health ethics and Clinical care ethics
All infectious diseases require higher accountability as
they utilize both public health and clinical ethicalpractices. Because infectious diseases are twofold, either

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
they require soft paternalistic applications of publichealth ethics; or they require treatment of patients within
the framework of human rights in patient care (Mann,
1997). COVID-19 covers the clinical ethical practices of
the clinical treatment process of the patients, as well as
the application of preventive measures taking into
consideration the public health ethical values during thecontrol of the pandemic process.
Therefore, during pandemic period, the government
should follow public and clinical care and their ethicalprotocols related to sharing up to date information to the
public and ensuring that the shared information isaccurate and reliable (Ives et al., 2009). Second, is to share
the available information from a comprehensive website
and to provide it to both healthcare professionals and to
civilians instantly. Third, information given should provide
how, to whom and where to seek help from healthcare
system and healthcare professionals (e.g., especially forthe clariTication of the preliminary diagnosis, the tools andequipment related to the tests should be supplied
quickly). Fourth, providing the medical, social andeconomic needs of healthcare professionals; in this case,the healthcare worker provides a better service byovercoming his / her concerns other than healthcare. And
the Tifth is to ensure that the society is easily adaptable tothe quarantine and isolation process by eliminating healthand social-economic concerns by the state.
Moreover, in the clinical care service, the values andprinciples of medical ethics should be applied as far as
possible in the context of human right in patient care.
Persons under monitoring (PUMs) and persons underinvestigations (PUIs) should have the right to get
information about their COVID-19 tests as soon as
possible. Of course, the suspected individual does nothave the right to refuse treatment or to quit thequarantine period because of the possibility of infecting
the greater community. However, the suspected individual
has the right to obtain accurate and sufTicient information
about his/her current condition and the planned action
for treatment. This right does not disappear in any way.
Beyond this, face-to-face visitor meetings may be
restricted due to possibility of infection, but
communication can be provided with suspectedindividuals and their relatives in appropriate situations
through technology. Some media reports in Turkey haveindicated that there have been serious violations to bothpublic health ethics and clinical care ethics. Theseviolations have created trust problems between thecommunity, healthcare professionals, and authorities whotake COVID-19 pre-cautionary measures such as in thiscase; where some suspicious persons are not quarantined
because of their socio-economic status; nepotism(Hrsimple, 2018) and making this practice unethical,
dangerous and criminal. That is why such public healthethics violations should be evaluated by criminal law. In
fact, success in such extraordinary situations depends on
the strength of mutual trust. Another problem is test
process which is taken a long time, and test results can befalse negative. Therefore, it is important to evaluate inclinical Tindings.

105

How to maximize the delivery of benefits ofpatient care ethics during COVID-19 pandemic?
Here, the main goal is to increase the effectiveness andefTiciency of healthcare both at the social and individuallevel, and to ensure that human rights in human care are
realized. Correspondingly, treatment process provided isin a manner that is in accordance with human dignity
without ignoring bioethics and its sub-branches, publichealth ethics and clinical ethical values and principles.
Healthcare professional had of course received ethicaltraining, and before starting their duty they signed asocial contract with the Hippocratic Oath (Güven & Ersoy,
2000; Kavas et al., 2015)and patient rights regulation that
determines their limitation and obligation. Where they
indicated that both on their behalf their professions andon themselves, they will not hesitate to perform theirduties under all kinds of difTiculties and dangerous
conditions. However, they should protect themselves not
only for their job but also for their lives. But, the COVID-19
pandemic creates special conditions and the Tirst line ofhealth professionals risk group has increased. That is why
the researcher has proposed some suggestions for the
COVID-19 Guidelines:
1. Maximizing the beneTit and reducing harm of medical
ethics principles needs a guide for practice. The Tirst
section of this guide should be about healthcare
professionals; where they should be protected Tirst,
diagnostic tests should be repeated, equipment, training,appropriate environment and their families should begiven the necessary support (Emanuel et al., 2020)
2. Risk assessment tools of the infectious disease (like
COVID-19) should be considered in the identiTication andranking of risk groups, protection measures, treatment
and vaccination. This tool contributes to the prevention of
all forms of abuse, discrimination [(e.g., ageism, social
status etc.(Stall & Sinha, 2020)] and also ethical problems.
3. Maximizing the beneTits; using limited resources needssome rules to provide medical-humanistic priorities; sothat people can have equal treatment possibilities and toarrange treatment models of humans based on medical
reasons provided that it is intended to maximizing the
beneTits (Emanuel et al., 2020). This also prevents wealth,social status, and other gender-social-cultural-agereligious discrimination and social injustice. If theextraordinary conditions caused by the lack of medical
resources force the healthcare professional to choose,then the choice can be made taking into account thepossible life span after treatment. Thus, besides
maximizing the beneTits involves both more people andmore life-years are also taken into consideration.
4. Prioritizing the treatment of healthcare professionals is
a must, because the healthcare worker who survives thetreatment themselves can resume the treatment of other
patients. This contributes signiTicantly to more people
getting health care. In the event of an outbreak, thepriority should be to test health professionals(Emanuel etal., 2020). Because by evaluating the health status ofhealthcare workers, it prevents them from getting
infected, including other healthcare workers, tosuspicious or uninfected people, and also increases the
beneTit by ensuring that healthcare professionals start106

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

their treatment in a shorter time and return to theirduties.
5. Vaccination should be administered considering therisk groups (Emanuel et al., 2020). This method
contributes to maximizing beneTit when the vaccine islimited. If a vaccine is developed for COVID-19, the vaccine
should be given primarily to healthcare professionals,
other hospital staff, the group at risk of spreading theinfection (market workers, drivers, etc.), and thecommunity.
6. Application of triage in the pandemic process is vital.
Because the triage will help physicians prioritize
emergency cases as well as maximize the beneTits
involved (Centers for Disease Control and Prevention,
2020; Petrini, 2010; Sztajnkrycer, Madsen, & AlejandroBaez, 2006), and the effective use of time in the ongoingpandemic. After the Tirst triage is performed, patients whoare considered to be prioritized in the Tirst triage can bere-evaluated if their current treatment opportunities arelimited and by that time the necessity to make a newcompulsory choice (Klıtzman, 2020) may arise between
two patients with the same disease level. It is useful todetermine the criteria related to this kind of situation in
guidelines (doctors of other countries have encounteredsuch conditions in the pandemic process).
7. In this process, it is vital to Tind the suitable treatment
in a short time and it should be supported with intensive
research (Bioethics, 2020; Emanuel et al., 2020; WHO,
2020b). In order to apply the guideline models suggested
above, voluntary patients with severe symptoms should
be preferred Tirst, and then volunteers with mild
symptoms should be next.
Public health and clinical care ethical practices play a
key role in solving the current COVID-19 pandemic
dilemma and not just the application of its philosophicalvalues.

study criteria’s. Second, separated articles according toheadlines and excluded irrelevant articles by using key
words such as COVID-19, public health ethics, clinicalethics, pandemic 6723 online reports were taken into
consideration.
Data analysis: Standard descriptive statistics were used
to describe the data.

Research question
This study has two main research questions related toTurkey directly facing COVID-19 after March 11 2020.
1. Did the country took the necessary measures taking
into account the problems faced from previously
affected countries like China, Italy, Iran and Spain?
2. Did the critics in the media news take into account theterms of limiting the pandemic?

34

MethodThis research was designed to assess the COVID-19
pandemic in online media reports on critics between 11
March 2020 and 2 April 2020 as a quantitative study
using the number of reports and a qualitative study(headline analysis), across Turkey. Reports were from
Turkish Medical Association websites which included
newspaper reports. For this study, the chosen Google
search engine has entered the word COVID-19 and foundmore than 182,000 articles. These consisted of websites,
newspapers, magazines and other online sources,
therefore collected online newspaper news and Turkish
Medical Association declarations present somesuggestions, reporting current shortcomings andinforming healthcare professionals. Study criteria: After
collecting the data, we organized the online reports by

Table 2: Headline Classifications
Information about COVID-19 (sufficient, insufficientor wrong information)
General deficiencies in taking action [e.g., preventing
trips to Saudi Arabia/ Umrah area and not controlling
Iran and Syria borders (irregular refugees), Istanbul
airport, Izmir port]
Autonomy and informed consent

1800

Lack of isolation control for many of those travelingabroadNo forced quarantine for ships, aircraft crew andpassengers
Nepotism, some persons returning from travel do not
engage in isolation due to their status or are removed
from the isolation before the period is completed
Insufficient diagnostic tests, and decision to test after
610 healthcare professionals become infected(decision criticism negative and positive)
Insufficient number of healthcare professionals andintensive care units, protective and therapeutic
equipment (N-95 mask, ventilator, etc.) in case of the
spread of COVID-19
The outbreak in Italy, Spain and Iran has not been
sufficiently evaluated and Turkey was not prepared
Deficiencies in providing socio-economic support tothe society in case of quarantine emergency in the
country
Turkey has launched donation campaigns like Iraq,
Lebanon, Sri Lanka, Senegal and South Africa(criticism and support articles)
Applause campaign for health professionals launched,
but violence continues
News about those who fled from quarantine

160News on how to perform Friday prayers (Mosques are
not closed)
International news about the COVID-19 pandemic andWorld Health Organization's explanations
Statements by professional organizations (Turkish
Medical Association, Turkish Pharmacists Associationetc.) on COVID-19
Statements by the President, the Ministry of Healthand the Science Committee

35

512

5

213
247

361

560

389
780

89

13

1018
512

95

Results and Discussion
The number of COVID-19 cases exceeded 1 million
worldwide and was detected in 204 countries and regions.
The data of 4 April 2020 reported that COVID-19 cases
totaled 1,210,422 with recoveries summing up to 251,822
and deaths recorded were 65,449. On the same day, thenumbers of cases in Turkey were 23.934 recoveries were
786 and the death toll being 501 on 5 April 2020 (SabahNewspaper, 2020; Worldometer, 2020). This study used
Google search engine and used the keywords COVID-19,
COVID-19, public health ethics, and clinical ethics,

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
pandemic and found more than 65,000 articles. However,in accordance with the criteria and limits of the study, weonly evaluated the news including public health andclinical ethical problems, these related reports also
appeared in more than one press organs, and they were
evaluated by eliminating repetitions. General Tindings areshown in Table 2.
The newspaper headlines in (Table 2) also revealed
the reasons for the emergence of public health ethics andclinical care ethics that arose during the pandemic
timeframe. Because this situation did not only reveal the
problem of treatment, but also the necessity to isolate
COVID-19 with serious social reorganization and hospitalneeds reorganization.
These articles provide information on thedeTiciencies in the necessary infrastructure to face thepandemic, both in the community and in the healthorganization. This is actually the case for many countries
that face the COVID-19 pandemic after China. Authoritiesof states couldn’t not imagine the COVID-19 pandemic
would harshly hit the current advanced health system.
Because they thought that scientists would develop thevaccine in a short time and Tind the treatment model. Dueto this negligence, states did not fully understand thedanger posed by the outbreak and did not take it seriously
enough. Correspondingly, they have not taken into
account the report published by the World HealthOrganization stems and doctors, scientists, journalists andother thinkers who tried to explain the magnitude of thedanger this pandemic poses. BrieTly, some of states haveavoided taking aggressive measures with economicpolitical concerns. Therefore newspaper headlines are of
special importance for understanding this process andreasons of “Pandemic Ethics” problem.
Some details and examples about the problems statedin the table above are as follows: When the contents of
the articles in Table 2 are analyzed, it is seen that there
are generally criticisms and warnings also related eachother topics. Therefore, chosen some themes and given
explanations and examples like below.
1. Headlines on general de_iciencies in taking
necessary action: There are warnings and criticisms
about articles not taking serious measures: Because
Turkey did not want to stop people travels and did notisolate passengers despite the emergence of the epidemic.
This situation caused COVID-19 to spread all over thecountry in a short time. “Moved from Istanbul and Izmir
from Europe, Anatolia from Saudi Arabia-Umrah, thosefrom East and Southeast from metropolitan cities andcontact with Iran and Iraq, Mediterranean from Europe
and other cities, Black Sea from Europe and metropolitan
areas. Late measures taken for travels, which play a majorrole in the spread of the pandemic, played an importantrole in the rapid spread of COVID-19 (ABC-Newspaper,2020)”. Because, in serious health problems with apotential pandemic, the country's health committee
should be competent, due to politicians are with highpolitical concerns. It reveals that negligence in this mattershould adopt new transparency rules in post-corona(Juliet Williams, 2020; Köylü, 2020).
2. Headlines on lack of information: The second
important criticism is on COVID-19 cases declared only by

107

numbers (Köylü, 2020). For example, how many patientsare there in which cities, what their age and gender havethese patients, these patients brought the virus fromwhich countries abroad, did these patients get in theirown neighborhoods, and when started local cases; cases
information is belong to which neighborhood or city. Thiskind of information could play an important role in thecreation of isolation or quarantines.
3. Headlines on lack of isolation/quarantine
precautions: The third criticism and warnings are;
COVID-19 cases number started to increase, some of
precautions started, however, while education wasinterrupted, shopping centers, mosques, cafeterias, etc.
were still open, so people continued to go to these placesin groups. However, after the spreading rate rose to acertain extent, the places in question were closed
completely except mosques. Some of the reasons for thisissue have been included in the press as follows. If we give
two examples of this; football matches were not delayed,matches without spectators were held. This caused
COVID-19 to spread among many coaches (Fatih Terim,
Albayrak etc.) and sportsmen. Due to these criticisms like
this, some television programs were punished by the stateboard that issued the programs (Fanatik, 2020) .
Moreover, workers/laborers, civil servants in freelance,
private company and government sector are not giving
paid vacation. Critics related to this situation are made as
in similar countries.
3. Headlines on lack of diagnosis tests: The third
important online reports were about not having enough
diagnostic tests are done. Also, there is a margin of error
in the tests used for the detection of the virus, and that thelung tomography of the suspect should be taken. (Öztürk,2020). Some of online reports criticized that a limited
number of tests have been prevent understanding theextent of the outbreak; they warned authorities it causes
lack of outbreak related measures.
Professor Dr. Necmettin Ünal from Ankara University
Intensive Care Department said that "At this stage, thedissemination of the tests will determine the scenario wewill encounter as well as preventing the number of patientscoming to intensive care." (Yüce, 2020)
Some of the articles in this context have drawn attention
to the emergency and intensive care units and warned
that "the number of intensive care beds, the number ofdoctors who can work in intensive care, the number ofhealthcare professionals who can work in intensive care,and the capacity to increase the number of intensive carebeds" will not be sufTicient when cases increased(Gündoğdu, 2020; Yüce, 2020).
4. Headlines on lack of healthcare professionals’
protective equipment and booked hotels: The articles
on this issue are generally about our health system being
ready for the coronavirus outbreak, both the staff and thenumber of intensive care beds, ventilator as well asprotective equipment . In addition, healthcare
professionals carry the greatest risk of contamination due
to COVID-19 patients, so not only themselves but theirfamilies are at risk. Therefore, some hotels may be booked
to health professionals during this epidemic process. In
this way, another precaution can be also taken against therisk of spreading.

108

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)“We can easily say that no health system in the world is fully
prepared for such a pandemic. Turkey's health system isalso unfortunately not in better condition than many otherexamples. The fact that we do not have enough intensive
care beds, doctors, medical staff and that we cannot
increase them quickly gives us a very clear
message.” (Sözcü-Newspaper, 2020)“It is clear that the number of hospitals, intensive care beds
and personnel capacities will start to be Yilled in a shorttime, the palms opened to applaud yesterday will betightened and turned into Yists. Everyone should be awareof the fact that the policies, media attitude and inadequate
and complex legislation implemented so far in our country
will result in this result. It was time to enact a law
protecting health care workers” (Istanbul Family Medicine
Association Chairman of the Board. Dr. Kutbettin Demir)(Sözcü-Newspaper, 2020)
The statements of health professionals show that wehave started to experience serious problems and losses atthe beginning of the pandemic.
“The nurse was under quarantine; hospital manager iscalled for a seizure and is on duty at the clinic right now.
Nurse stated that the same clinic has health professionals
who are both quarantined and working ” (Gerçek-Gündem,2020).
“Adana state hospital is opened a corridor for COVID-19
patients in the intensive care unit, but healthcare
professionals do not have dressing rooms and healthcare
professionals cannot connection with hospital managers.”“The nurse stated that they did not have protective
materials, so they paid for them personally and received
protective materials.” (Atam, 2020)“Corona virus was detected in a total of 610 healthcare
professionals working in different cities of Turkey.”.
(Independent, 2020)
While some hospitals consider the contact abroadfor the COVID-19 test, some hospitals take into account
whether there is fever, cough, and lung involvement
outside this criterion, considering that it has started in thelocal case. There is no consensus yet. Doctor Doğaç
Ergezen is 29 years old said that “there is still a lot more tosay but now I am both exhausted and very angry. I don't
want to talk angrily. Please take this virus seriously” (Tele1,2020).
Professor Dr. Necmettin Ünal, said that “The mostimportant factor for intensive care is protective equipment.
It is not a different approach to bring any of the intensive
care team (doctor- nurse- caregiver- cleaning staff) without
protective equipment into the patient's room than to send
them with a knife on the machine gun. If you lose theintensive care staff, there is no staff to replace them” (Yüce,2020) "
The above examples reveal that health professionals
should be given priority. Many research and statehospitals have healthcare professionals who are under
treatment as COVID-19 patients across Turkey. Thissituation is doubled risks here because healthcare
professionals are facing serious life risk and at the sametime the sick doctors cannot treat their patients.
5.Headlines on autonomy and informed consent:
Medical ethics principles and concepts must be applied
intelligently, kindly and thoughtfully in difTicult

circumstances (Aydın & Ersoy, 1995; Civaner, 2015; Ersoy,1994). In the early days of the pandemic, some people
announced via social media that they were isolated andtested, but were not informed about the results of the test.
After their videos were published on social media, they
had learned that they were COVID-19 positive.Stating that61-year-old father-in-law died after a heart attack andvisited 4 h hospitals, the citizen said,"The corona test was done in the hospital, but the result
was not disclosed. But all the procedures were done likecoronavirus. It doesn't state anything in the report. The
ofYicials of the Ministry of Health came to the neighborhood
and asked their neighbors before the death of his father-inlaw, the citizen said, “Now everyone is looking at usabnormally.” (Akdemir, 2020).
In the video he published on Twitter, the server
Burak Akkul, stated that he had been tested withcoronavirus in a hospital in Istanbul with his wife, but thatthe test result was not told to him right after, but later tobe explained that the test results came back positive (T24,
2020)"Details about the death of the former Land Forces
Commander Aytaç Yalman, who died after Aytaç Yalman's
diagnosis of COPD, became clear. On the 11th of March,
Aytaç Yalman's wife and brother died in quarantine, andFenerbahçe Orduevi, where he played sports, went to an
alarm. " This late information also caused A.Yalman's
relatives and also other victims to be diagnosed late andnot to be infected during this period (Sözcü, 2020).
No explanation was made from the healthinstitutions or doctors about the situation in question, andit was probably to avoid announcing the bad news to thepatient, patient relatives and the society. However, thiscontributed not only to unethical behavior, to violation ofpatient rights, but also to increased infection..
6. Headlines on commercialization of hospitals andnepotism: Some articles were concerned that private
hospitals, which have increased in recent years, will not
be functional in handling the pandemic. So, the otherreason is related to the health system main aim whether
to save proTit and populist practices. If a health system isbeing commercialized that time this system has neither
the capacity, neither equipment nor personnel to be
sufTicient in such extraordinary cases. In this process, we
can see how disadvantaged countries in which the healthsystem is specialized have faced such a disaster (e.g.,
Spain, Italy, US, France etc.)
These articles stated that without reducing the riskthat healthcare professionals face COVID-19, withoutcompleting all the health needs of hospitals, without
making diagnostic tests widespread, most of private
hospitals not conducting COVID-19 diagnostic testing andtherefore they don't received COVİD-19 patients, namely
temporary or permanent expropriation and without
taking serious precautions regarding quarantine (e.g.,
nepotism practices: some people are not taken underquarantine like celebrities, high status people or religious
place visitors etc.); public health and public health ethics
does not apply, if public health ethics is not implemented
it means opening the road to death for its public.
The evaluation results of these online articles aresupported by the report published by the consulting Tirm

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)of Le Beck "Turkey’s crisis with the transfer method will
reduce the effectiveness of the measures to be taken
against the virus, “a false sense of security” was recorded
it was created" (Le-Beck, 2020).
Limitations
The present study data were collected from online
newspapers by Google research engine (e.g., Yeniçağ,Sözcü, Cushuriyet, Evrensel, Gazete Duvar, Birgün,
Fanatik,Sabah, Hürriyet,T24 and ABC newspapers ) andalso from websites that take ofTicial data into
consideration and compare them. However, the pandemic
has just begun in Turkey, so the articles in question arelimited to the timeframe speciTied. Furthermore there wasa possibility of some unreachable/unnoticed articles orresources. Of course, the synthesis f COVID-19 pandemic
data may involve more than the data's context but
also in different contexts or interpretation.
Acknowledgements
I would like to thank all healthcare professionals, andexpress my condolences to the families of the deceased
and I offer my wishes for a recovery of health to thecurrent and recovering patients.
Conclusion
The online newspaper news provides a map of thepandemic measures and deTiciencies. This map also shows
the factors that contribute to ethical problems andviolence against healthcare professionals (Sevimli, 2020).
In this context, Tirst, this study reveals these criticalreports, the differences between the pandemic and otherdisasters. This approach is important for public healthpreparations after post-corona. Second, this study also
indicated that public health ethics and clinical care ethicalproblems are not only reasoned by medical/healthcare
professional’s attitude but also from socio-economicpolitic system. Moreover, this study shown the need for a
detailed ethical guideline that covers the decision making
process in the context of medical ethics and public healthethics. This guide will save the individual doctor fromacting on his own conscience and from the great
psychological burden that may occur later. Because,casuistry/heart-searching is relative and may varydepending on the situation (García Gómez & Monlezun,2015). The decision of the individual doctor withreasoning may involve a heavy burden for him/her. The
healthcare professional should be freed from this heavy
burden. Therefore, in order to remove or expand/detailed
theoretical rules from a particular situation, we should
avoid future ethical problems by reorganizing andapplying these rules with detailed examples, taking into
account the problems in the pandemic process. Of course,
this is possible with the participation, solidarity andsupport of competent ethicists, scientists as well as legal
authorities. So, we can create a better life by human rights
in patient care, social justice, love, and dignity.
References
ABC-Newspaper. (2020). Salgına yakalananlar anlattıkça ortayaçıktı: İşte koronavirüs Türkiye’ye böyle yayıldı (Pandemic
captured by those who told emerged: That's like coronavirus

109

has spread to Turkey Source). Retrieved from https://abcgazetesi.com/salgina-yakalananlar-anlattikca-ortayacikti-iste-koronavirus-turkiyeye-boyle-yayildi-95726
Akdemir, Ö. (Producer). (2020). Yakınını kaybeden kişi: Özelkıyafetli görevli gömdü, korona mı değil mi söylemediler(The person who lost his relatives: Buried in special clothes,
they did not tell whether it is corona or not). Retrieved fromhttps://www.evrensel.net/haber/400469/yakininikaybeden-kisi-ozel-kiyafetli-gorevli-gomdu-korona-mi-degilmi-soylemediler
Atam, H. (2020). Hemşirelerden ‘ekipmanlarımız yetersiz’çağrısı!('Our equipment is insufTicient' call from nurses!).
Retrieved from https://www.sozcu.com.tr/2020/gundem/
hemsirelerden-ekipmanlarimiz-yetersiz-cagrisi-5725576/
Aydın, E., & Ersoy, N. (1995). Tıp etiği ilkeleri. Türkiye Klinikleri
Tıbbi Etik Ankara-1995.
Binns, C., & Low, W. Y. (2015). What Is Public Health? Asia-PaciYicjournal of public health / Asia-PaciYic Academic Consortiumfor Public Health, 27, 5-6. doi:10.1177/1010539514565740
Bioethics, N. C. o. (2020). Research in global health emergencies:
ethical issues. Retrieved from https://www.nufTieldbioethics.org/topics/research-ethics/researchin-global-health-emergencies
Centers for Disease Control and Prevention, C. (2020). Triage ofSuspected COIVD-19 Patients in non-US Healthcare Settings.
Retrieved from https://www.cdc.gov/cpr/healthcare/panTlu-app/desktop/d.index.html
Civaner, M. (2015). Halk sağlığı etiği ve meslek ahlakı. Türkiye
Halk Sağlığı Dergisi, 13(2), 170-171.
Emanuel, E. J., Persad, G., Upshur, R., Thome, B., Parker, M.,
Glickman, A., . . . Phillips, J. P. (2020). Fair Allocation of Scarce
Medical Resources in the Time of COVID-19. N Engl J Med.
doi:10.1056/NEJMsb2005114
Ersoy, N. (1994). Klinik etiğin önemli bir sorunu: Aydınlatılmış
onam. Turkiye Klinikleri Journal of Medical Ethics-Law andHistory, 2(3), 131-136.
Fanatik. (2020). Fatih Terim'den yaylım ateşi: İstediğini
şampiyon yapın' (severe criticise from Fatih Terim: Make thechampion you want '). Fanatik. Retrieved from https://www.fanatik.com.tr/fatih-terimden-yaylim-atesi-bizcanimizi-disarida-mi-bulduk-2129149
García Gómez, A., & Monlezun, D. (2015). Casuistry. In (pp. 1-12).
Gerçek-Gündem. (2020). Vahim iddia: Karantina altındakihemşire nöbete çağrıldı hastalara baktı (Grave claim: Nurse
under quarantine called for seizure looked at patients).
Retrieved from https://www.gercekgundem.com/saglik/
168073/vahim-iddia-karantina-altindaki-hemsire-nobetecagrildi-hastalara-bakti
Gündoğdu, O. (2020). 4 soruda hastanelerin yatak kapasitesi
gerçeği: 5 yataktan biri özel hastanelerde (The bed capacityof hospitals in 4 questions: One of the 5 beds in private
hospitals). Retrieved from https://www.birgun.net/haber/4soruda-hastanelerin-yatak-kapasitesi-gercegi-5-yataktanbiri-ozel-hastanelerde-292197
Güven, T., & Ersoy, N. (2000). Tıp Etiğinde Yeni Bir Yaklaşım:Erdemler. Turkiye Klinikleri Journal of Medical Ethics-Law andHistory, 8(1), 51-59.
Haber, S. (2020). Gerçekleri saklamaya devam etmek için Dr.
Çınar’a özür dilettiler (To continue keeping the facts, they do
makeDr. Çınar apologized ). Retrieved from http://siyasihaber4.org/gercekleri-saklamaya-devam-etmek-icindr-cinara-ozur-dilettiler
Hegarty, S. (Producer). (2020). The Chinese doctor who tried towarn others about coronavirus. BBC News. Retrieved fromhttps://www.bbc.com/news/world-asia-china-51364382
Hrsimple. (2018). Nepotism: favoring relatives and friends in theworkplace.
Retrieved from https://www.hrsimple.com/
blog/nepotism

110

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Hacettepe Üniversitesi Biyoetik Merkezi (HUBAM) “COVID 19
Pandemisi ve Etik” (Hacettepe University Bioethics Center(HUBAM) “COVID 19 Pandemic and Ethics”), (2020).
Independent. (2020). Sağlık Bakanı Koca açıkladı: Virüs tümşehirlerde görüldü, 601 sağlık çalışanı enfekte (Health
Minister Husband explained: The virus was seen in all cities,
601 healthcare workers were infected). Retrieved fromhttps://www.independentturkish.com/node/156606/
haber/sa%C4%9Fl%C4%B1k-bakan%C4%B1-kocavir%C3%BCs-t%C3%BCm-%C5%9Fehirlerdeg%C3%B6r%C3%BCld%C3%BC-601s a % C 4 % 9 F l % C 4 % B 1 k %C3%A7al%C4%B1%C5%9Fan%C4%B1-enfekte
Ives, J., GreenTield, S., Parry, J. M., Draper, H., Gratus, C., Petts, J. I., .
. . Wilson, S. (2009). Healthcare workers' attitudes toworking during pandemic inTluenza: a qualitative study. BMC
Public Health, 9(1), 56. doi:10.1186/1471-2458-9-56
Juliet Williams. (2020). California cities want transparency rules
waived in pandemic. Associated Press. Retrieved fromhttps://www.pbs.org/newshour/health/california-citieswant-transparency-rules-waived-in-pandemic
Kavas, M. V., Yalım, N. Y., Şahinoğlu, S., Acıduman, A., İlgili, Ö., &Arda, B. (2015). Uygulamalı aydınlatılmış onam alma becerisi(UAOAB) eğitim programının geliştirilmesi: AnkaraÜniversitesi Tıp Fakültesi deneyimi (2004-2013). Sağlık
Bilimlerinde Etik Eğitimi Sempozyum Kitabı. Ankara: AnkaraÜniversitesi Yayınları, 107-130.
Klıtzman, R. (2020). How hospitals will decide who lives andwho dies in the COVID-19 crisis. Retrieved from https://thehill.com/opinion/healthcare/490034-how-hospitals-willdecide-who-lives-and-who-dies-in-our-coronavirus-crisis
Köylü, H. (2020). Muhalefet ve meslek örgütleri daha fazlaşeffaTlık istiyor (Opposition and professional organizations
want more transparency). Retrieved from https://w w w. dw. c o m / t r / m u h a l e fe t - ve - m e s l e k%C3%B6rg%C3%BCtleri-daha-fazla%C5%9FeffaTl%C4%B1k-istiyor/a-52958754
Le-Beck. (2020). Turkey underestimated, created false sense of
security. Retrieved from https://www.newsmaker.news/c/
2020/04/turkey-underestimated-created-false-sense-ofsecurity.html
Mann, J. M. (1997). Medicine and public health, ethics andhuman rights. Hastings Cent Rep, 27(3), 6-13.
Öztürk, F. (Producer). (2020). Koronavirüs - Türk Tabipler
Birliği: Test yeterli değil, mutlaka akciğer tomograTisi deçekilmeli (Coronavirus - Turkish Medical Association: The
test is not sufTicient, absolutely must be a lung tomography).
BBC. Retrieved from https://www.bbc.com/turkce/haberlerturkiye-51836529
Petrini, C. (2010). Triage in public health emergencies: ethicalissues. Intern Emerg Med, 5(2), 137-144. doi:10.1007/
s11739-010-0362-0
Sabah-Newspaper. (2020). Türkiye'de corona virüsü vakası veölü sayıları (4 Nisan 2020 Cumartesi) illere göre güncel
rakamlar (The corona virus cases in Turkey and the numberof dead (Saturday April 4, 2020) The current Tigures by
province). Retrieved from https://www.sabah.com.tr/video/
haber/son-dakika-turkiyede-corona-virusu-vakasi-ve-olusayilari-4-nisan-2020-cumartesi-illere-gore-guncelrakamlar-video
Sevimli, S. (2020). An analysis of violence against healthcare
professionals in Turkey from online media reports. Eubios
journal of Asian and international bioethics: EJAIB, 30(3).
Retrieved from https://eubios.info/yahoo_site_admin/
assets/docs/EJAIB32020.7685702.pdf
Sözcü-Newspaper. (2020). Etkin bir sağlıkta şiddet yasasının
tam zamanı (The time for an effective violence law inhealth ). Retrieved from https://www.sozcu.com.tr/2020/

saglik/etkin-bir-saglikta-siddet-yasasinin-tamzamani-5723857/
Sözcü. (2020). Aytaç Yalman’ın corona virüsü nedeniyle öldüğü
kesinleşti (Aytaç Yalman became certain that he died due tothe corona virus). Retrieved from https://www.sozcu.com.tr/2020/gundem/son-dakika-aytacyalmanin-corona-virusu-nedeniyle-oldugukesinlesti-5689088/
Stall, N., & Sinha, S. (2020). COVID-19 isn’t the only thing that’sgone viral. Ageism has, too.
Retrieved from https://www.theglobeandmail.com/opinion/article-COVID-19-isntthe-only-thing-thats-gone-viral-ageism-has-too/
Sztajnkrycer, M. D., Madsen, B. E., & Alejandro Baez, A. (2006).
Unstable ethical plateaus and disaster triage. Emerg Med Clin
North Am, 24(3), 749-768. doi:10.1016/j.emc.2006.05.016
T24. (2020). 4 gündür Koronavirüs test sonuçlarını alamadığını
açıklayan Burak Akkul: Test sonuçlarım pozitif çıkmış,tedaviye başlandı (Burak Akkul, who explained that he could
not get the coronavirus test results for 4 days: My test results
were positive, and treatment was started). Retrieved fromhttps://t24.com.tr/video/4-gundur-koronavirus-testsonuclarini-alamadigini-aciklayan-burak-akkul-testsonuclarim-pozitif-cikmis-tedaviye-baslandi,26801
Tele1 (Producer). (2020). ‘Dr.Dodo’ koronavirüse yakalandı:Hem bitkinim hem çok öTkeliyim ('Dr. Dodo' caught thecoronavirus: I'm both exhausted and very angry). Retrieved
from https://tele1.com.tr/dr-dodo-koronaviruse-yakalandihem-bitkinim-hem-cok-oTkeliyim-147482/
WHO, W. H. O. (2020a). Coronavirus disease 2019 (COVID-19)
situation report—59. Retrieved from https://www.who.int/
docs/defaultsource/coronaviruse/situation-reports/
20200319-sitrep-59-COVID-19.pdf?sfvrsn=c3dcdef9_2.
WHO, W. H. O. (2020b). Ethical standards for research during
public health emergencies:Distilling existing guidance tosupport COVID-19 R&D. Retrieved from https://apps.who.int/iris/handle/10665/331507
WHO, W. H. O. ( 2020c). Rational use of personal protective
equipment (PPE) for coronavirus disease (COVID-19)
Retrieved from https://apps.who.int/iris/bitstream/handle/
10665/331498/WHO-2019-nCoV-IPCPPE_use-2020.2eng.pdf
Worldometer. (2020). Coronavirus Cases:. Retrieved fromhttps://www.worldometers.info/coronavirus/
Yüce, M. (2020). Yoğun bakımlar doluyor, agresif tedbir şart('Intensive care is Tilling, aggressive precaution is a must).
Retrieved from https://www.gazeteduvar.com.tr/gundem/
2020/04/04/yogun-bakimlar-doluyor-agresif-tedbir-sart/
Zohny, H. (2020). Pandemic Ethics: COVID-19 Shows Just How
Much of Ethics Depends on (Good) Data. Retrieved fromhttps://blog.practicalethics.ox.ac.uk/2020/03/pandemicethics-COVID-19-shows-just-how-much-of-ethics-dependson-good-data/

NEW: POSTGRADUATE CERTIFICATE IN EPIDEMICS
AND ETHICAL GLOBAL HEALTH
American University of Sovereign Nations (AUSN) has justlaunched a new Postgraduate CertiTicate Program - classes
from March 2020. Do not delay to join us to prepare
yourself and your community to respond to COVID-19.
Email to: provost@ausn.info:
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healthEubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Impacts of COVID19 Pandemic on
Care of the Patients with Cancer
Esra Bilir, M.D.
1. D e p a r t m e n t o f O b s te t r i c s , G y n e co l o gy, a n d
Reproductive Sciences, University of California San
Diego, La Jolla, CA 92093, USA
2. American University of Sovereign Nations, Sacaton, AZ
85147, USA
L2W502 A11, UC San Diego Altman Clinical andTranslational Research Institute, 9452 Medical Center Dr,
La Jolla, CA 92037, USA,
Email: esragbilir@gmail.com
ORCID: https://orcid.org/0000-0003-4499-6543
Abstract
COVID-19 was declared as a pandemic by WHO on 11
March 2020. Three days later, the U.S. Surgeon Generalrecommended stopping elective surgeries. The healthcare
capacity that is either required now or soon expected, forthe treatment of COVID-19 is limited all over the world.
Hence, we need to Tlatten the curve of hospital
admissions. We need to ethically examine under which
ethical criteria canceling or postponing so-called nonurgent surgeries to an unpredictable date is a reasonable,
although difTicult decision during the pandemic. The
major impacts of COVID-19 pandemic on patients withcancer could be listed as i) age as a common risk factor forcancer and COVID-19 caused mortality; ii) patients are
considered to be immunocompromised that means they
have a higher risk of getting the infection; iii) themainstream treatment of various cancers involves
surgeries, after which patients might need ventilators; iv)
the postponed treatments will likely advance their cancer
stages by time; v) the cancer survivors have regularfollow-ups requiring hospital visits; vi) COVID-19 causes
anxiety which could be predicted to be detrimental for themental health of patients with cancer and may potentially
impair their immune system. These issues collectively
might be expected to cause an increase in cancer-related
mortality rates. Therefore, immediate action plans areneeded to provide the best care for patients with cancer
during the pandemic.
Keywords: Cancer, COVID-19, pandemic, ethics, oncology,
surgery, chemotherapy, radiotherapy, mortality,
healthcare system
Introduction
Coronavirus disease 2019 (COVID-19) is caused by severe
acute respiratory syndrome coronavirus 2 (SARS-CoV-2).
COVID-19 is not simply an airborne disease. The SARSCoV-2 causing the disease can transmit mainly via
respiratory droplets but also via touching the surfaces
contaminated with the virus and then the face. Hence,
keeping physical distance, wearing masks, and frequent
hand washing are the mainstream precautions forcontrolling the further spread of the virus. The number ofventilators, intensive care units (ICU), healthcare
professionals, and many other crucial parts involved in
the treatment of the COVID-19 that are either required

111

now or soon expected, for the treatment of COVID-19 islimited all over the world. Hence, we need to Tlatten the
curve, which means that with protective measures, we
aim not to exceed healthcare system capacity (Figure 1).

Figure 1: Flattening the Curve. Adapted from: CDC, 2007
COVID-19 was declared as a pandemic by the World
Health Organization (WHO) on 11 March 2020 (WHO,2020). Three days later, the United States (U.S.) Surgeon
General Jerome Adams M.D. recommended stopping socalled elective surgeries (Ambulatory Surgery Center
Association, 2020). Although canceling or postponing
surgeries to currently unpredictable dates are bothreasonable and difTicult decision against the COVID-19
pandemic to Tlatten the curve, this decision would affectpatients with different diseases in different levels. We
need to ethically examine under which ethical criteriacanceling or postponing so-called non-urgent surgeries toan unpredictable date is a reasonable, although difTicult
decision during the pandemic. This mini-review aims toprovide the potential impacts of the COVID-19 pandemic
on patients with cancer. Since our knowledge regarding
COVID-19 has been changing very rapidly since thebeginning, it is valuable to state that this mini-review
contains the literature until 5 April 2020.
COVID-19 General Clinical Considerations
The Centers for Disease Control and Prevention (CDC), thenational public health institute of the U.S., suggests
obtaining the specimen from the nasopharynx to test for
SARS-CoV-2 (CDC, 2020). SARS-CoV-2 causes severe
pneumonia which might require a ventilator usage for an
extended period during which the patients stay in theintensive care unit (ICU). During hospitalization, patientsmight need to have a chest x-ray (CXR) and computed
radiography (CT). The two most important risk factors for
COVID-19 caused mortality are age and comorbidities
including diabetes mellitus, hypertension, coronary heartdisease, chronic respiratory disease, and cancer (Wu et al.,2020; Zhou et al., 2020). The current treatment involves
supportive care and many other experimental options,such as remdesivir and hydroxychloroquine (McIntosh,2020). On April 4, 2020, WHO shared that globally there
are 1,051,635 conTirmed cases and 56,985 deaths where
the mortality rate is 5.4% (WHO, 2020). However. the
COVID-19 mortality rates have been changing very
rapidly, depending on the country's existing health caresystem capacity and their national precautions.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Advancements in Treatment of Cancer
The U.S. cancer-related mortality rate decreased by almost
30% since 1991 (Miller et al., 2019). Moreover, the mostconsiderable annual decline in the U.S. was from 2016 to2017, according to the study published in 2019 (Miller etal., 2019). The recent advancements in treatment andscreening programs should have played crucial roles inthis achievement. It is widely accepted that age is the
single most important risk factor for developing cancer(National Cancer Institute, 2015).
The COVID-19 pandemic also endangers the cancer
research that might be either basic science research or
clinical research. The concerns about animal researchmainly can be stemmed from the risk of animal infection
with SARS-CoV-2, the risk of shutting down the researchfacilities, and the grant-related issues such as deadlines.
Clinical research, including phase I, II, and III trials, plays acrucial role in cancer treatment. Clinical trials involve
regular visits, including administration of the
medications, blood tests, and imaging studies. Currently,
people are discouraged from visiting the hospitals unless
it is an emergency. The major question that requires
immediate attention is that how we should assess
outcomes of the clinical trials, primarily the survival if thepatients are passing away due to the COVID-19. The
institutions should develop action plans in order to beable to maintain our progress in cancer research.
The Impacts of COVID-19 on Care of Patients with
Cancer
The deTinition of patients with cancer should include four
populations: i) people with known cancer and currently
receiving treatment, ii) people with a known cancer
history also referred to a cancer survivor, iii) people whohave not diagnosed with cancer but currently has it, andiv) people with known cancer and living at a hospice.
Given the fact that SARS-CoV-2 affects lungs, patients withlung cancer can be considered to be at higher risk for the
infection and mortality compared to patients with othercancer types. A recent study from China, including 18
COVID-19 patients with a history of cancer, revealed lungcancer as the most common cancer type (Liang et al.,2020). A meta-analysis revealed that 2.1% of patientsdiagnosed with COVID-19 had a history of cancer or havecancer (Desai et al., 2020). Italian data demonstrate that
20% of the COVID-19 patients with comorbidities whodied also had cancer diagnosis (West, 2020).
Firstly, age is the common risk factor for cancer, and
COVID-19 caused mortality (National Cancer Institute,2015; Wu et al., 2020). Given this information, it is almost
inevitable not to observe a higher mortality rate due to
COVID-19 among patients with cancer than the healthy
population. Secondly, patients with cancer are considered
to be immunocompromised. It means that theoretically,
these patients are more prone to infections than healthy
individuals. Hence, they have a higher risk of getting
SARS-CoV-2. A recent study from a hospital in Wuhan
showed that the incidence of SARS-CoV-2 found to havehigher in patients with cancer than people without cancer(Yu et al., 2020). Thirdly, the mainstream treatment ofvarious cancers involves surgeries such as endometrium
cancer and ovarian cancer. Following the surgeries, somepatients might need ventilators for several days. Due tothe pandemic and delaying the elective surgeries, thepriority to use ventilators would most likely be given to
the people with the COVID-19. Fourthly, the postponed
treatments, including chemotherapy, radiotherapy, andsurgery, will likely advance their cancer stages by time.
Similarly, due to the healthcare access restrictions andstay home policies, people will get diagnosed at latercancer states.
Delaying surgeries based on the U.S. Surgeon
General's recommendation creates three essential
questions: i) how long the delay will last, ii) how toprioritize the patients for surgery when surgeries can be
performed, and iii) how long delay safe is. During cancer
treatments, patients might require transfusion of bloodand blood products. The U.S. Surgeon General was alsodeclared his concerns regarding the potential risk of ashortage of blood during the pandemic (American Red
Cross, 2020). He also encouraged people to donate blood(American Red Cross, 2020). Fifthly, the cancer survivors
have regular follow-ups when they need blood tests andimaging studies to rule out the recurrence, mainly. This
would delay the detection of the recurrence; hence, thechance of early intervention. Overall, it would be leading
to disease progression. Additionally, imaging instruments
the patients receiving treatments due to COVID-19 might
be infected with the virus and further increasing theinfection risk for patients with cancer during the followup visits. The pandemic leads people in a healthy
population to the anxiety of having/getting the virus, fearof death, and various other mental health problems.
Additionally, keeping the physical distance aiming toTlatten to curve might further impact on mental health.
Sixthly, these risks might be seen even more prominent inpatients with cancer and also may potentially impair theirimmune system.
Triage during the Pandemic
In medicine, triage is deTined as the quick assessment of
the patients and making decisions based on their severity
to determine the order of the treatments. This strategy
has been well adopted by emergency departments
worldwide. The triage ethics follow the four principles ofbiomedical ethics: i) respect for autonomy, ii) beneTicence,iii) nonmaleTicence, and iv) justice (Aacharya et al., 2011).
A triage protocol, including the ventilation, was developed
during inTluenza (H5N1) pandemic (Christian et al.,2006). Their triage protocol included the Sequential
Organ Failure Assessment (SOFA) Score together withfour components: i) inclusion criteria, ii) exclusion
criteria, iii) minimum qualiTications for survival, and iv) a
prioritization tool (Christian et al., 2006).
WHO
recommended using
standardized triage tools forpatients who came to the hospital with a severe acuterespiratory infection (SARI) with suspicion of COVID-19(WHO, 2020). During the COVID-19 pandemic, in Italy, thehealthcare system capacity was exceeded that led to thetriage of the patients (Rosenbaum, 2020). They suggested
three principles for the triage i) the healthcare providers
who treat patients and make triage decision should beclassiTied, ii) the triage parameters should be periodicallyreviewed by a central system, and iii) the triage algorithm

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)should be frequently updated according to the novel data
(Rosenbaum, 2020). The triage protocols developed
during the pandemics may not be the ideal because of
insufTicient healthcare system capacity; however, they
adhere to utilitarianism where the healthcare providers
target to beneTit the majority of the patients (Melnychuk
et al., 2006).
Conclusion
Overall, all of the issues ( i) age as a common risk factor
for cancer and COVID-19 caused mortality; ii) patientswith cancer are immunocompromised meaning a higher
risk for the infection; iii) after cancer surgeries patientsmight need ventilators; iv) the postponed treatments will
likely advance their cancer stages by time; v) delaying thecancer survivors' follow-ups would advance their cancer
and delay the early intervention; vi) the burden of
COVID-19 on mental health might be felt more in patientswith cancer and potentially impair their immune system)
collectively will have a negative impact on the cancerrelated mortality rate. Patients with cancer diagnosed
with COVID-19 were found to have poorer outcomes thanpatients without cancer (Liang et al., 2020). Delaying thesurgeries, chemotherapy, or radiotherapy should be very
carefully considered. Furthermore, considering thelimited healthcare capacity and the risk factors for
COVID-19 mortality, it seems likely that patients withcancer would not be at the top of the triage list. It is
expected, in particular, for admissions for ICU. The shareddecision making between the physicians and the patientsshould take place during the discussions. Theinternational, national, and institutional guidelines
regarding the management of the patients with cancer
during the pandemic should be closely followed. To beable to minimize the mortality rate in patients with cancer
during the pandemic, the institutions should immediately
develop action plans for the best interest of their patients,
given their institutional capacity. Most importantly, during
preparing the guidelines the fundamentals of ethics mustbe followed.
References
Aacharya P.R., Gastmans C, Denier Y. Emergency department
triage: an ethical analysis. BMC Emerg Med. 2011; 11: 16.
Ambulatory Surgery Center Association. State Guidance on
Elective Surgeries. April 3, 2020. https://w w w. a s c a s s o c i a t i o n . o r g / a s c a / r e s o u r c e c e n t e r /latestnewsresourcecenter/covid-19/covid-19-state(Accessed on April 4, 2020).
American Red Cross. What to know about the Coronavirus andBlood Donation. https://www.redcrossblood.org/donateblood/dlp/coronavirus--covid-19--and-blood-donation.html(Accessed on April 4, 2020).
CDC. Interim pre-pandemic planning guidance: community
strategy for pandemic inTluenza mitigation in the UnitedStates—early, targeted, layered use of nonpharmaceuticalinterventions. Atlanta, GA: US Department of Health andHuman Services, CDC; 2007. https://stacks.cdc.gov/view/
cdc/11425.
Centers for Disease Control and Prevention. Interim Guidelines
for Collecting, Handling, and Testing Clinical Specimens from
Persons Under Investigation (PUIs) for Coronavirus Disease2019 (COVID-19). March 25, 2020. https://www.cdc.gov/

113

c o r o n av i r u s / 2 0 1 9 - n C o V / l a b / g u i d e l i n e s - c l i n i c a l specimens.html (Accessed on April 4, 2020).
Christian M.D., Hawryluck L, Wax R.S., Cook T, Lazar N.M.,
Herridge M.S. Development of a triage protocol for criticalcare during an inTluenza pandemic. CMAJ. 2006 Nov
21;175(11):1377-81.
Desai A, Sachdeva S, Parekh T, et al. COVID-19 and Cancer:
Lessons from a Pooled Meta-Analysis. JCO Glob Oncol. [In
Press]
Liang W, Guan W, Chen R, Wang W, Li J, Xu K et al. Cancer
patients in SARS-CoV-2 infection: a nationwide analysis in
China. Lancet Oncol. 2020 Mar;21(3):335-337. doi: 10.1016/
S1470-2045(20)30096-6. Epub 2020 February 14.
Melnychuk R., Kenny N.P. Pandemic triage: the ethical challenge.
CMAJ. 2006 Nov 21; 175(11): 1393–1394. doi: 10.1503/
cmaj.061322
McIntosh K. Coronavirus disease 2019 (COVID-19). In:
UpToDate, Post TW (Ed), UpToDate, Waltham, MA. (Accessedon on April 4, 2020).
Miller K.D., Nogueira L, Mariotto A.B., Rowland J.H., Yabroff K.R.,
Alfano C.M. et al. Cancer treatment and survivorshipstatistics, 2019. CA Cancer J Clin, 69 (5), 363-385 Sep 2019
National Cancer Institute. Age and Cancer Risk. April 29, 2015.
https://www.cancer.gov/about-cancer/causes-prevention/risk/age (Accessed on April 4, 2020).
Rosenbaum L. Facing Covid-19 in Italy - Ethics, Logistics, andTherapeutics on the Epidemic's Front Line. N Engl J Med.
2020 Mar 18. doi: 10.1056/NEJMp2005492. [Epub ahead ofprint]
West, HJ. Italian Oncologist Offers Cautionary Advice on
COVID-19 for US Centers. March 20, 2020. https://www.medscape.com/viewarticle/927213#vp_1. (Accessed
April 5, 2020).
World Health Organization. Coronavirus disease 2019
(COVID-19) Situation Report – 75. April 4, 2020 https://www.who.int/docs/default-source/coronaviruse/situationreports/20200404-sitrep-75-covid-19.pdf ?
sfvrsn=99251b2b_2 (Accessed on April 5, 2020).
World Health Organization. Clinical management of severe acuterespiratory infection (SARI) when COVID-19 disease issuspected Interim guidance. March 13, 2020. https://www.who.int/docs/default-source/coronaviruse/clinicalmanagement-of-novel-cov.pdf (Accessed on April 5, 2020).
World Health Organization. WHO Director-General's opening
remarks at the media brieTing on COVID-19 - March 11 2020.
March 11, 2020. https://www.who.int/dg/speeches/detail/who-director-general-s-opening-remarks-at-the-mediabrieTing-on-covid-19---11-march-2020 (Accessed on April 4,2020).
Wu Z, McGoogan J.M. Characteristics of and Important Lessons
From the Coronavirus Disease 2019 (COVID-19) Outbreak in
China: Summary of a Report of 72 314 Cases From the
Chinese Center for Disease Control and Prevention. JAMA.
2020 February 24. doi: 10.1001/jama.2020.2648. [Epubahead of print]
Yu J, Ouyang W, Chua M.L.K., Xie C. SARS-CoV-2 Transmission in
Patients With Cancer at a Tertiary Care Hospital in Wuhan,
China. JAMA Oncol. 2020 March 25. doi: 10.1001/
jamaoncol.2020.0980. [Epub ahead of print]
Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z et al. Clinical course andrisk factors for mortality of adult inpatients with COVID-19
in Wuhan, China: a retrospective cohort study. Lancet.
2020;395(10229):1054. Epub 2020 March 11.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Equality, Positive Health andGlobal Inequality in the midst of
the COVID-19 pandemic.
- Gerry F. Arambala
Chair of Philosophy and Religious Studies
La Salle University Ozamiz City, the Philippines
Email: gerryarambala33@yahoo.com
Abstract
Thomas Pogge presents a historical picture in terms of theunjust distribution of wealth around the world. Unjust
structures contribute to the suffering and misery ofpeople, especially in Third World countries, whose
citizens do not have an easy access to quality but
expensive medical treatment, thus putting them at a
disadvantage. This paper looks into the problem ofunequal resource distribution around the world, using theCapability Approach as lens, and proposes the notion of
positive health as a right that will secure the welfare ofpeople in the midst of the COVID-19 pandemic.
Keywords: Global Inequality, Positive Health, Global
Justice, Global Resources Dividend, Thomas Pogge
Global Inequality and Poverty
Poverty and inequality have become a global pathologythat providing aid and the need to Tinally end them is a
global project and a moral imperative. While majority of
the world’s population is living in dire poverty, the world’s
afTluent nations and citizens are indifferent towards thesuffering of the global poor. Over three billion people, that
is, almost half of the world, live below the poverty
threshold of 2.50 USD per day. And Eighty percent of theworld’s population lives in developing countries where
income differentials are huge and dire poverty exists(Anup,1998). Moreover, the world is producing annually
18 million deaths; with 22, 000 poor children, usually
below Tive years old, dying every day due to poverty
related causes (Anup, 1998). Such severe and extensive
poverty exist while the world’s rich nations are getting
richer. The north is accumulating massive economic
wealth, more often at the expense of the developing
country’s resources, while the number of the global poor
remains to be increasing. In 1990, there were about 1.9
billion people living in extreme poverty; the majority ofthese lived in sub-Saharan Africa and South Asia. This
troubling fact of severe global inequality warrants a
serious moral consideration.
However, it cannot also be denied that over the past
two decades the global economy has grown in anastonishing rate; in less than 10 years the value of theannual global economic production has doubled (Roser
and Ortiz-Ospina, 2019). What this practically means isthat with the rise of the overall global afTluence there
likewise is the rise of the middle-class societies. The
increase of the global economic productivity has led manyto leave their most destitute states of existence. Many ofthe poorest of the poor has improved their state of abject
poverty. Accordingly, more than a third of the world’s
population, that is, 900 million people, live on more than
10 USD per day (Roser and Ortiz-Ospina, 2019). In 2015

the World Bank Organization in reformulating its
proposed “International Poverty Line” lowered thepoverty line index from 2.50 USD in 1990 to 1.90 USD perday. So that in 2015 those who are living below 1.90 USD
per day are considered poorest of the poor. The proposed
index is designed to measure the monetary value of aperson’s consumption (Roser and Ortiz-Ospina, 2019).
The result was an astonishing rise of the global middle
class and the diminution of the poorest of the poor.
Accordingly, “the number of people living in extreme
poverty has fallen from 1.9 billion in 1990 to 650 million
in 2018.” (Roser and Ortiz-Ospina, 2019).
Nonetheless, it is important to emphasize that theinternational poverty line of 1.90 USD per day isextremely low, so that those who are living below thispoverty line index are extremely poor. And to focus simply
our attention to those people who met the standard set by
the international organization is to deny the mostdisadvantaged people of their right to development. Moreso, it does not necessarily mean that those who are living
on or above the poverty line are not considered poor, nor
do they not experience the hardships that the poorest of
the poor person suffers owing to her absolute state ofcapability deTicit. Notwithstanding the relative
development caused by the world bank’s lowering of theinternational poverty line, the world’s poorest of the poorsocieties remained to be the same and had not experience
any sort of amelioration of their state of absolutedeprivation. This stagnation of the development of theworst-off societies globally, if no alternative measures thatthe global community will take to improve the situation,
will eventually lead to an increase of the number of people
who are extremely poor at about 500 million in 2030
(Roser and Ortiz-Ospina, 2019).
Deaths from Poverty and COVID-19
According to the World Health Organization most of thediseases of poorer societies that constitute 46 percent of
their disease burden are consequences of poverty, such as
poor nutrition, lack of access to proper sanitation andhealth education, and lack of access to effective but
expensive health care services (Stevens, 2004). What thismeans is that human poverty and infectious diseases are
inseparable social phenomena that necessarily determine
the fate of the poor in developing countries. The world isconstantly battling against deadly diseases, such as
tuberculosis, malaria, HIV/AIDS, hepatitis B and dengue.
These infectious diseases are prevalent in most lowincome societies, but thanks to the development ofgenetic engineering the world was able to create potent
vaccines that can Tight these diseases, which have led tothe dramatic decline of the number of deaths of poor
people over the last 25 years.
During the Tirst Tifteen years of development, from1990 to 2005, every year the world was producing 18
million deaths from infections and poverty-related causes.
Among these deaths were 50,000 adults and 34,000
children below the age of Tive, and half of these children
were infants in their Tirst month of life. Nonetheless, in theproceeding years of development a remarkable decline of
the number of deaths of poor people was recorded. In
2005 there were only 8.9 million poverty and infectious

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
diseases related deaths and in 2015, 8 million, with 96
percent of these occurring in poorer societies (Alkire etal., 2018). Despite the decline of the number of avoidable
deaths worldwide the fact remains that vast inequality
among the world’s richest and the poorest exist andmillions of poor people dies each year. The rate of poor
children dying of vaccine-preventable diseases incomparison to children of high-income societies remains
scandalously high. Accordingly, children from low-income
societies are 60 times more likely to die of preventablediseases during their Tifth year of life than children fromhigh-income societies. In 2017, an estimated 6.3 million
children died of infections and amenable diseases, some
5.4 million of whom were children under the age of Tive.
One child under 15 years old dies every Tive seconds, withhalf of these deaths in Sub-Saharan Africa and 30 percent
in Southern Asia (World Health Organization, 2018). The
disparities of the ratio of children dying per population in
Sub-Saharan Africa and in high-income societies isdepressingly high; in the former, one in 13 children dies
before their 15th birthday, while in the latter that number
is one in 185 (World Health Organization, 2018).
Moreover, babies in low-income societies are nine times
more likely to die of infections and diseases during their
Tirst month of infancy. In total, in 2017, 2.5 million
children died in their Tirst month. And if no feasible
alternative is taken to stop these deaths in 2030 an
estimated 56 million more children under age Tive will die.
The persistent existence of inequality of opportunityfor quality health care between the rich and the poor
raises problems of social justice. More often than not, therich with their Tinancial capabilities are more likely torefer themselves to the most sophisticated medical careand facilities. They can afford to buy the most expensive
medicine and be admitted to the most expensive private
hospitals. While for the rich longevity and positive healthare possibilities that are readily available, the majority ofthe poorest population can only wish for the same
possibilities. It cannot be denied that those capable ofobtaining the best health care services are in a superior
position compared to those who are not (Kotze, 2016).
People who can afford it are assured of their positive
health.
Notwithstanding, these deaths are caused bydiseases that humanity had long been battling; common
diseases that medical science and advance genetic therapy
can instantly cure if opportunity for positive health isopen and affordable to all. However, the world is currently
facing a global health crisis that is caused by a novel
corona virus which already took thousands of lives allover the world and has posed an imminent threat to theoverall global economy. In March 12, 2020 the World
Health Organization announced the COVID-19 as a global
pandemic inasmuch as it has already infected 199
countries all over the world, and took the lives of some
25,042 people and has affected more than 552, 589
worldwide (at the time this paper is written), inscribing
its global fatality rate at around 4.4 percent and which is
projected to further increase as the pandemic continues toravage the world. The rise of COVID-19 and its devastating
effects to the world and to the socio-economic well-being
and to the overall health of the people has prompted115

insights of the need to embrace a more universal
conception of social justice. A universal principle of justicethat seek to appease and compensate the unnecessary
sufferings the global poor are forced to suffer due to theentrenchment of unjust global institutional orders. The
proliferation of these unjust global structures is rooted by
the design of geopolitics, as a rule, unjust global politics
and structures are aimed at beneTitting the rich nations
while leaving behind the welfare and well-being of thedeveloping states (Maboloc, 2019: 1192). If the Tirst world
countries with their developed and advanced healthcare
systems and medical technologies remained victims to thedreadful effects brought about by this pandemic, howmuch more the poor countries which, in their lack ofresources and knowledge, are left blindly to battle against
a formidable enemy that is new to the world.
World Poverty and Cosmopolitan JusticeIn his attempt of extending the liberal principles of justiceto the global arena, Pogge proposed his theory ofcosmopolitan justice. Such idea of justice is grounded in
the presupposition that the afTluent countries from thenorth owe to the global poor claims of justice. This isbecause the rich countries, having actively participated in
the design of unjust global institutional orders, haveunavoidably harmed and worsen the state of deprivationof the global poor. And that the mere insistence of apositive duty of assistance is inefTicient to give justice tothe atrocities and injustices the rich countries, with theirglobal institutions, have caused the global poor to
unnecessarily suffer. Pogge insist that the Tirst world mustembrace the more stringent duty not to harm the global
poor in order to appease the negative effects the pastactions of the afTluent institutions have proliferated.
Global aids or charities must be transformed into justcompensations for the injustices the afTluent countries
have caused the poorer societies to suffer.
The necessity of extending the liberal principles ofjustice to the international realm is brought about by thepersistent existence of global poverty and inequality. It is
ironic that while some of the world’s afTluent nations are
expanding their wealth and technological developments,
others are left to die on their own being miserably poor
and absolutely deprived. The rich are getting richer while
the poor are getting poorer. And yet it seems like the richcountries from the north have done less if not nothing tohelp alleviate the poorer societies from their miserable
state of existence. Pogge argues that extensive global
inequality and poverty will persist to continue inasmuch
as the afTluent nations do not Tind its eradication morallycompelling and worthy of serious moral reTlection (Pogge,2002). This acquiescence towards global poverty and to
the global poor’s cry for help is caused primarily by the
beliefs that eradication of global poverty is not worthy ofserious moral reTlection and that the afTluent countries in
fulTilling their minimum duty of assistance to the global
poor are actually doing Tine, that there is nothing wrong
with their being acquiescent. To this Maboloc explainsthat “The discriminatory concept of nationhood isprotective of the country’s citizens. Non-citizens are
judged as outsiders. In this respect, the sense of justice in116

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

the world is limited to a mere duty ofassistance” (Maboloc, 2019).
Radical Inequality and Global Resources Dividend
The moral urgency to eradicate global poverty is brought
about by the fact that hundreds of millions of poor people
are unnecessarily suffering and are dying each day. And
the sheer domestication of the problem, by putting all
blames on the political culture and structure of aparticular poor society, is to deny the real culprits of theirmoral obligations to appease the negative effects theiractions in the past have caused some people tounnecessarily suffer. Pogge argues that the poor societies
are poor not entirely because their social and politicalstructures are corrupt and nonfunctioning. They are poor
because the rich countries are doing nothing to eradicate,
if not, to mitigate the effects of their state of absolutedeprivation and poverty. Such indifference on the part of
the world’s afTluent states is caused primarily by their
persistent denial that they have something to do with thesufferings of the global poor; that they have not caused
the unimaginable sufferings the poor peoples in the world
are suffering from. Pogge explains that such resistance iscaused by the conventional understanding that global
poverty is solely traceable to the local-domestic structureof a polity, thereby justifying the acquiescence of mostrich countries of the world towards eradicating global
inequality and poverty. To this Pogge asserts that “[such]illusion conceals how profoundly local factors and theireffects are inTluenced by the existing global order” (Pogge,
2002: 200).
Although it is true that most developing societies arecorrupt and are often suffering from weak and incoherent
bureaucracy; caused primarily by the entrenchment ofdictatorial rulers and faulty social structures. However,
one cannot simply set aside the signiTicant role thepresent global institutional arrangements contribute indetermining the future lives of the poor. The constantpossibility of civil strife, the entrenchment of dictatorrulers and the rise of deprivation among poor societies,
are driven by international factors such as: foreign
monetary bribes from huge companies abroad who help
in winning the elections of corrupt leaders who in turnwill allow their illegal trades to Tlourish in the their
speciTic districts; the two international privileges ofresources and borrowing, being indifferent to how rulers
attain power over their constituents, both necessarily
provide incentives for the proliferation of civil war and theentrenchment of political warlords. Pogge emphasizes
that “The reason is that the citizens and the governmentsof the afTluent countries whether intentionally or not are
imposing a global institutional order that foreseeably andavoidably reproduces severe and widespread poverty. The
worse-off are not merely poor and often starving, but are
being impoverished and starved under our sharedinstitutional arrangements, which inescapably shape theirlives” (Pogge, 2002: 201). It cannot be denied, therefore,that the new global orders have contributed to theproliferation of global inequality and has indirectly caused
the deaths of poor peoples in poorer societies.
A positive duty of assistance, for that matter, may notsound morally compelling, for it reduces the moral

obligation of the afTluent societies towards alleviating thepoor states to sheer duties of beneTicence. And the need tohelp the worst-off societies is dependent on the arbitrary
wills of the afTluent states. But looking at the extent of
global deprivation, the deaths and the injustices the new
global orders have unjustly imposed to the global poor,
the more stringent duty not to harm the worst-off must be
given serious considerations. This is so because, “TheafTluent countries have been using their power to shape
the rules of the world economy according to their own
interests and thereby have deprived the poorer
populations of their fair share of global economic
growth” (Pogge, 2002: 201). What is needed therefore isto conceive a feasible new global arrangement that willsecure the just compensation of the poor who were madeto suffer the negative consequences of the past global
arrangement. To this Pogge proposes his Global Resources
Dividend or GRD. What is being presupposed in the said
global economic arrangement is the idea thatgovernments will not have absolute libertarian rights overtheir owned resources. And that they are required to givea “dividend” of the values of the resources they use or sellto the global poor (Pogge, 2002). The GRD, in principle,
requires the rich countries to give a small portion of thevalue of the resources they use. This is because “the global
poor own an inalienable stake in all limited natural
resources” (POgge, 2002: 196). These payments will thenbe used to help alleviate the state of existence of the
global poor and to capacitate them to self-development
later in their lives.
Moreover, Pogge explains further that therequirement of giving a portion of the value of the usednational resources of the rich countries does notpresuppose that the poor countries can interfere with thedeliberation of the usage and selling of the resources,
neither can they (the worst off societies) insist on large
amount of payments. For as speciTied by Pogge, theamount needed to totally eradicate global poverty is only
1.2 percent, roughly around S300 Billion, of the annual
gross income of the high economy countries in the world.
For Pogge the GRD posits a necessary moral constraint
over the distributive pattern of the global resources, in asmuch as most of the poor societies in the world were
products of past colonization and state lootings by thecolonizing societies, who are now the world’s afTluent
states.
The incorporation of the moral claims of theimpoverished and suffering humanity worldwide in the
global institutional orders, their rights and entitlements
over the shared planetary resources is what makes the
GRD morally compelling. It presupposes that `the richcountries owe to the poor payments for the atrocities andthe horrendous crimes the rich societies have inTlicted tothe poor communities. “The GRD proposal is meant toshow that there are feasible alternative ways of organizing
our global economic order that the choice among thesealternatives makes a substantial difference to how muchsevere poverty there is worldwide, and that there areweighty moral reasons to make this choice so as tominimize such poverty” (Pogge, 2002: 197).

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Human Rights and Global Institution
Pogge is critical to the conventional understanding of
human rights that presupposes a necessary interrelation
between human rights and legal rights. This interactional
idea of rights presupposes that moral claims of individual
rights, in order for them to be truly realized, need to beincorporated in a country’s legal and judicial system.
Pogge writes that “Each society’s government and citizens
ought to insure that all human rights are incorporated
into its fundamental legal texts and are within its
jurisdiction, observed and enforced through an effective
judicial system” (Pogge, 2002: 45). The necessity ofincorporating ideas of human rights to the country’s
effective and functioning judicial system is grounded in
the faulty logic that through the legalization of thesemoral constraints their realization is secured. Such legal
conception of human rights for Pogge may come as toostrong and too weak. Too strong, for a society maybe sowell ordered that every individual’s human rights are
fulTilled even their access is not legally guaranteed. Thatthe human right to nutrition is considered fulTilled even if
its achievement is not inscribed in the judicial system of apolity; so that a society cannot be said to be unjust if acertain human right is fulTilled despite of it not having any
legal prescriptions. Too weak, for even if a polity professto have lists of human rights but if its system ofgovernance is not well functioning, the fulTillment of theserights may not necessarily be secured (Pogge, 2002).
To this, Pogge offers his alternative conception ofhuman rights that is “primarily as claims on coercive
social institutions and secondarily as claims against those
who uphold such institutions” (Pogge, 2002: 44-45). Such,a conception of human rights bears moral claims on theway citizens and the government of a society design thesocial institution that ensure everyone’s rights are upheld.
This idea of human right is detached from any legal andjuridical conceptions. The need to separate human rightsfrom concepts of legal rights is caused by the fact that
adding legal terms to concepts of rights are, for Pogge, ofless importance. He argues that in a society whose
citizens fully embrace religious freedom, thereby allowing
everyone to fulTill their human right to freedom of religion
cannot be referred as unjust simply because there was nolegal speciTication that guarantees such freedom to be
fulTilled (Pogge, 2002: 47).
Pogge further explains that, “Human rights are notsupposed to regulate what government ofTicials must do
or refrain from doing, but are to govern how all of us
together ought to design the basic rules of our commonlife” (Pogge, 2002: 47). Such conception of institutional
moral rights is not addressed to the government neitherof the citizens of the same polity, but to the actual designof the basic institutions of a society. That is, a feasible
conception of human rights must move the citizens andthe government of a polity to design its social and politicalinstitutions that rights of everyone one is proliferated. The
need for an institutional understanding of human rights isvital for the realization of a global institutional reordering.
This is so because the world is undeniably and closelyinterconnected, in terms of, political values, market
trades, and international relations. And that the unjust
ordering of a certain society may have direct effects to117

some; as was noted in the previous sections, theinternational global orders worsen the state ofdeprivation of the global poor. Pogge believes that withthis institutional conception of human rights the poor will
be compensated of the injustices they suffered from theunjust global institutional orders. Pogge adds that, “Suchan understanding would lead us to take the underfulTillment of human rights abroad more seriously –provided we accept that persons involved in upholding
coercive social institutions have a shared moral
responsibility to ensure that these institutions satisfy atleast the universal core criterion of basic justice by
fulTilling, insofar as reasonably possible, the human rightsof the persons whose conduct they regulate” (Pogge,
2002:49).
Positive Health and the Global Pandemic
It was mentioned in the above sections that humanpoverty and infectious diseases are two interrelated
phenomena that deTine the fate of poor people all over theworld. And that efforts in reformulating the global orders
must be directed towards irradiating both instances ofglobal social injustices. Poverty breeds infectious diseases.
The root cause of the deaths and the unnecessary
sufferings of the global poor is absolute poverty; so thatthe complete irradiation of it presupposes the assuranceof positive health. It is when an individual is capacitated tochoose freely from among life’s best alternatives without
any constraints that one can say that she is truly
developed and that the totality of her positive health issecured. Positive health consists in the actual state ofdevelopment of the person, physical, emotional,
intellectual and social wellbeing. It is when one is capableof achieving different life’s functionigs, being wellnourished, being healthy, easy access to medical services,education, and the like. Human development is based on
the positive freedom of the individual to freely choose thelife she Tinds reasonable to live. And that justice demands
that social institutions are so designed that everyone isgiven equal opportunity to achieve their goals in life.
Contrary to what is the case globally, while the wealthy
nations are busy in accumulating massive amount ofwealth, the global poor are getting poorer. And theinevitable effect of such unjust distribution of the global
wealth is the persistently high number of deaths sufferedby the poor worldwide caused by curable diseases. With
the rise of the global pandemic, the urgent need to answer
the problem of global inequality has taken moral
ascendency. Poorer societies are of high risk to thedevastating effects of the virus compare to countries fromthe north. What is needed at this moment of global healthcrisis is that nations, particularly poorer states, must not
be left alone to battle against the pandemic but othernations must embrace the moral responsibility to channel
compensatory aids to the suffering states.
Conclusions
With the world’s current state of health crisis brought
about by the rise of the global pandemic COVID-19, themore stringent duty of formulating a global institutional
order that will secure the lives and well-being of the
global poor has taken a strong moral ascendency compare

118

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

to rather simply providing aid. The lack of resources andeffective social institutional orders that most developing
countries are suffering posit the moral imperative tochannel additional resources that serve not as charitableaids but as just compensations of the past atrocities therich countries have caused to these global poor. COVID-19
posit more threat to the global poor than to the Tirst world
countries, for reasons that poor societies often lackresources and technologies necessary to battle against theimminent threat that the virus brings. Insuring health,being a fundamental object of human right, to everyone
must be one of the vital objectives that every institutional
scheme has to secure. The capability to choose fromamong life’s best alternatives can only be made possible ifpeople are in constant good health and the opportunity toavail for the best possible health care relative to every
state is open to all. Now, inasmuch as the current global
institutional order does affect the structures and systemsof national institutional schemes all over the world, mostespecially that of the poorer societies, the more auniversal idea of justice is necessitated. Understanding
the underlying global danger that the pandemic brings toeveryone will lead one to assert that efforts in dealing
with this crisis must not be limited solely to local national
states but must be extended further to the global arena.
The pandemic does not only posit an immediate threat tothe national welfare of a national state but to everyone in
the world. The need to embrace an all encompassing
sense of moral responsibility that does not limit itself tocaring only for
citizens of a particular state buttranscends to all nations is what is truly needed in order
to win the battle against COVID-19.

Tribal Communities and Nations in
a Time of COVID-19

References

Introduction
Since the founding of the United States, indigenous
populations across the North American continent havebeen subjected to disease, germ warfare, and existential
threats by European settlers. The colonization of North
America, also referred to as the North American holocaust(Thornton 1987), led to the eradication of nearly 12
million Native Americans. Today, the population ofindigenous peoples in the United States is approximately
5.2 million. According to the Bureau of Indian Affairs (BIA
2016), there are 573 federally recognized tribes in the
United States, not counting tribes Tighting for federal
recognition (https://www.ncsl.org).
Historically, the indigenous peoples of the UnitedStates have been subjected to disease and illnesses
brought by European settlers, including but not limited tosmallpox, bubonic plague, chicken pox, cholera,
diphtheria, inTluenzas, malaria, measles, and scarlet fever.
According to Carlos and Lewis (2012), the smallpox
epidemic of 1781-82 in the Hudson Bay region of
Massachusetts devasted indigenous populations living
there. Studies suggest that the smallpox epidemic among
tribal populations had a mortality rate of between 20%
and 50% (Carlos and Lewis 2012; Fenner et al. 1988). In
addition, the U.S. government facilitated a massive
genocide by ordering the distribution by the U.S. militaryof smallpox blankets to indigenous peoples (ValenciaWeber 2002). “In the old day blankets infected withsmallpox were given to tribes in an effort to decimate

Alkire BC, Peters AW, Shrime MG, et al. (2018) The economic
consequences of mortality amenable to high-quality healthcare in low-and middle-income countries. Health Affairs
37(6): 988–996.
Anup Shah, (1998) “Poverty Facts and Stats,” [article online];available from http:// www.globalissues.org/article/26/
poverty-facts-and-stats; 25 April 2018.
Pogge T (2002) World Poverty and Human Rights: Cosmopolitan
Responsibilities and Reforms. Cambridge: Blackwell
Publishing Company.
Roser M and Ortiz-Ospina E (2019) Global extreme poverty. Our
World in Data. Available at: https://ourworldindata.org/
extreme-poverty (accessed 2 October 2019).
Stevens P (2004) Diseases of poverty and the 10/90.
International Policy Network. Available at: https://w w w. w h o . i n t / i n t e l l e c t u a l p ro p e r t y / s u b m i s s i o n s /InternationalPolicyNetwork.pdf (accessed 20 October 2019).
United Nations Development Programme (UNDP) (1990)
Human Development Report 1990. Available at:http://h d r. u n d p . o r g / s i t e s / d e f a u l t / T i l e s / r e p o r t s / 2 1 9 /hdr_1990_en_complete_nostats.pdf
World Health Organization (2018) A child under 15 dies every 5
seconds around the world. 18 September.Available at:https://www.who.int/news-room/detail/18-09-2018-achild-under-15-dies-every-5-secondsaround-the-world(accessed 22 January 2020).

- Carmela M. Roybal, MBGPH
Ph.D. candidate, Department of Sociology
Doctoral fellow, Robert Wood Johnson Center for Health
Policy, University of New Mexico, USA
Email: cmoral7@unm.edu
Abstract
Indigenous nations across the United States and the globe
are not strangers to epidemics and germ warfare. Overmultiple generations of humankind, U.S. tribal
populations have experienced one of the greatest
downsizing of numbers on the planet: from nearly 17
million (Thornton 1987) to their current population of
approximately 5.2 million (U.S. Census 2010) in the
United States alone. Biological warfare, smallpox, andgovernment policies have been used to reduce and wipeout entire nations. This article looks at the potential
impacts of COVID-19 on tribal populations in the UnitedStates today, including the potential loss of elders,knowledge keepers, and language speakers. America’s
indigenous communities today are aging communities,
and signiTicant portions of their populations are at risk ofdeath due to the current health status of tribal
populations, distance to medical resources, inadequate
resources, and extreme poverty. Using insight from tribesin the American Southwest, this presentation will offer
insight into sustainability for tribal nations, community
ties, cultural capital, and resiliency as buffers to the virus.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
them” (Deloria 1970). Hopkins (1983) illustrated how
colonists fostered the spread of the disease in order tobreak indigenous resistance and to facilitate land grabs by
European settlers. An estimated 90% of the North
American tribal population was reduced in the years
following the European invasion (Thornton 1987).

In more recent years, Native Americans have been
impacted by contemporary epidemics such as thoserelated to diabetes, suicide, and HIV, all of which haven e ga t ive ly i m p a c te d t r i b a l p o p u l a t i o n s . S u c hcontemporary epidemics illustrate the current state ofhealth among tribal peoples and residual effects ofcenturies of colonization. In 1955, the Indian HealthService (IHS) was established, and clinics and hospitals
were built to address the health of Native Americans.
Today, a total of only 26 hospitals, 59 health centers, and32 health stations exist in the United States to serve 573
tribes and more than 5 million people. Federal funding of
the IHS is discretionary, and spending is optional andvaries by administration. The program is historicallyunderfunded, making it difTicult to serve patients acrossthe country. In 2020, the U.S. Department of Interiorannounced a 14% cut in funding for tribal programs.
According to the IHS chief medical ofTicer, the entire IHS
system had only 625 hospital beds, only six ICU beds, andonly 10 ventilators (https://www.politico.com/news/
2020/03/20/coronavirus-american-indianhealth-138724). According to the Indian Health Board,
only 16% of tribal providers reported receiving any typeof federal resources, and only 4% received protective

119

equipment since the start of the epidemic. According to
the Center for Disease Control and Prevention (CDC 2020)
t h e C o ro n av i r u s P re p a re d n e s s a n d Re s p o n s e
Supplemental Appropriation Act, 2020 (P.L. 116-123) $8.3
billion in emergency funding for federal agencies to
respond to the COVID19 pandemic, $40 million which is tobe allocated to tribes, tribal organizations, and healthservice providers. Divided across 573 tribes, this amounts
to roughly $70,000 per tribe, barely enough to make ends
meet.
In the face of the COVID-19 pandemic, the IHS
system is not prepared and is not funded to support theneeds of everyday populations and offers little support. In
this paper, I make several arguments. First, the failure of
U.S. and state governments to address the social
determinants of health among tribal populations andminorities has placed tribal populations at an elevatedrisk during this pandemic. Second, the lack of engagement
and investment by national and state political leaders andpolicymakers have exacerbated health conditions acrosstribes, contributing to a shortage of investments in lifesaving resources such as education, healthcare, internet
access, and preventative care. Third, and mostimportantly, the indigenous peoples and tribal nations ofNorth America possess community cultural wealth (Yosso2005) that encompasses a multitude of strengths andmeasures that each tribe can call upon to ensure theprotection of their communities.
Elevated Risk and Underlying Health Conditions
The current health proTile for American Indians andAlaska Natives in the United States demonstrates deep
disparities compared to other racial and ethnic groups in
the United States. According to the CDC (2014), death
rates among Native Americans are 50% greater than thoseof non-Hispanic Whites. Death records for both Native
American men and women combined show that theleading cause of death in the United States is cancer,
followed by heart disease (CDC 2014). Heart disease is aleading cause of death in the United States among all
populations: Approximately 610,000 people die of heartdisease every year (CDC 2017). Heart disease is a leading
cause of death among Native Americans in the UnitedStates, with the CDC (2018) reporting 3,632 deaths
among Native populations between 1999 and 2016.
While other racial and ethnic groups have seen adecrease in mortality rates due to heart disease, Native
American populations have not seen a substantial
decrease in heart disease-related deaths since 1993 (CDC2016). Between 1993 and 2017, there was an average of
100.4 deaths of Native American males across the UnitedStates per 100,000 population (CDC 2016). Heart diseaseis the second leading cause of death among Native
American women (CDC 2017). The CDC (2015) reported
that 17% of all deaths among Native American women
were related to heart disease (CDC 2015). According to
the CDC (2014), Native American men are 20% more
likely to smoke cigarettes and are 30% more likely thannon-Hispanic Whites to have high blood pressure. Native
Americans died from heart disease at younger ages thanany other racial and ethnic groups in the United States(CDC 2004). According to the CDC (2004), 36% of heart

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

disease-related deaths occurred before the victims were
65. Cancer is the No. 1 cause of death among Native
American women and the second leading cause of deathof men (American Indian Cancer Foundation 2014). Whilecancer rates decreased for non-Hispanic Whites over the
past 20 years, Native Americans have seen a substantial
increase (AICF 2014).
Disparities in health outcomes vary across tribal
nations. Some groups experienced elevated rates ofdiabetes, heart disease, and mortality rates compared toothers. For example, Native Americans in New Mexico
died at younger ages and have the highest percentage ofchildren who will not outlive their parents. Native
American toddlers between the ages of 1 and 4 have apremature death rate of 55.6 per 100,000, compared to
the non-Hispanic White counterparts (-0.5 per 100,000).
In South Dakota, the Pine Ridge reservation has one of thelowest life expectancies in the United States: 47 for men
and 55 for women, compared to the U.S. life expectancy of
78.69 years for men and 81 for women.

Aging Populations, Knowledge Keepers, andLanguage Speakers
COVID-19 is attacking--and could decimate --America’s
Native American populations in such a violent manner,killing vast numbers of men and women over the age of25, that the tribes could be at risk of never recovering.
More than just lives lost, the virus sweeping acrossAmerica could wipe out tribal cultural knowledge andheritage, tribal traditions, and tribal languages. All are at areal risk. Especially vulnerable to COVID-19 are tribes’
elders. According to the American Community Survey(ACS), in 2011-2013, there were close to half a million
Native American elders 65 and older. Some 35% of all
Native Americans were concentrated in Arizona, Texas,
New Mexico, Oklahoma, Florida, North Carolina, and New
York. Elders are integral to tribal communities. Protecting
the knowledge only they possess is at the forefront oftribal efforts everywhere. Ohkay Owingeh Pueblo of New
Mexico, along with several other pueblos, have closed
their borders and ordered tribal members to stay home.
Ohkay Owingeh tribal members are actively assisting thecommunity by distributing masks and cleaning products
to the homes of elders. Ensuring their safety and thesafety of the community is key. Protecting our elders isessential to sustaining traditions, language, and our
cultural knowledge.
At the pueblo where I live, Ohkay Owingeh, in New
Mexico, the tribal leadership has positioned over the pastfew days cement barricades and signs, blocking entrances
onto pueblo lands. No one from outside of the pueblo isallowed to enter. No one. Stay home, tribal members havebeen told. Only by self-isolation, tribal leaders believe, can
COVID-19 be defeated. Other pueblos have taken the sameor similar drastic and decisive measures. Michael
Chavarria, governor of Santa Clara Pueblo and chair of All
Pueblo Council of Governors describes “our mission is toprotect the life and health and safety of all our members
and employees of Santa Clara Pueblo, we had to close
down our casino, golf course, restaurants, and all ourentities” (KSFE, Santa Fe Public Radio 2020). He described
the Tinancial hardship that his tribe is going through andthe difTiculty of preparing for a threat that cannot be seen.
He urged tribal members to not take anything or anyone
for granted and reminded the community that no one isimmune. President Nez of the Navajo Nation argued inpublic commentary that tribes once again have beenforgotten. The Navajo Nation as of April 2, 2020, had 389
reported cases of COVID-19 (New Mexico Department of
Health 2020). The Navajo Nation has since closed its
borders and ordered a curfew for the nation. The Navajo
Nation is one of the largest tribes in the
United States with close to half a million
members.
Community Cultural Wealth andTribal CapitalIf decisive action does not take place,
COVID-19 has the potential to devastate
communities. Yet despite pre-existing
health conditions of many members ofvirtually every tribe, America’s tribes
have the potential to buffer the effects of
COVID-19 and to Tlatten the curve for their own
communities. Tribal populations in the United States are
no strangers to scarcity and life-altering pandemics. Tribal
peoples of North America possess community cultural
wealth. Community cultural wealth focuses on cultural
knowledge, skills, abilities, and networks withincommunities and across communities (Yosso 2005).
According to Yosso (2005), many of these skills go
unrecognized and unacknowledged. Yosso (2005)
described community wealth, an array of capital thatexists within marginalized groups, including resistancecapital, linguistic capital, navigational capital, and familial
capital. Resistance capital refers to knowledge and skills
that challenge inequality, where linguistic capital includes
the intellectual and social skills gained throughcommunication experience. Navigational capital refers to
the skills of maneuvering through social institutions
entrenched in structural inequalities. Familial capitalrefers to the cultural knowledge that’s nurtured amongfamily or kin and community history and to social capitalas networks and community resources. Tribal populations
possess community cultural wealth that dates backthousands of years--since the creation of the universe anddissention of the Tirst peoples on mother earth.
Building on Yosso’s (2005) forms of capital, I add
tribal capital. Tribal capital is the strengths and resourcesthat tribal nations possess in addition to other forms ofcapital that are speciTic to tribal populations that havegained federal recognition. Tribal capital includes but is
not limited to sovereignty and federal recognition. Federal

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
recognition signiTies that the U.S. government hasrecognized the right of an Indian tribe to exist as asovereign entity and that a government-to-government
relationship exists (www.ncsl.org). Tribal sovereignty
predates the formation of the United States and isrecognized through the U.S. Constitution and numerous
federal statutes and court cases. Tribal governments areon equal footing with state governments and have agovernment-to-government relationship with the federal
government (National Conference of State Legislatures).
In the case of the COVID-19 pandemic, sovereign nations
could request aid from other sovereign nations, including
countries such as Cuba, and from organizations such as
the World Health Organization. During the American
Indian Movement (AIM), members of that group received
aid and support from Cuba and built a platform ofsolidarity around the globe. Where the federal
government has failed tribes, tribal capital can be
exercised to bring aid and support to the sovereign
nations of the United States.

In addition to sovereignty, tribal nations havetraditional forms of government. Although, many tribes
have one government, many have dual forms ofgovernment. Dual governments equate to traditional
forms of government that follow indigenous governing
bodies, separate from governing bodies that deal with thefederal government or state governments. Traditional
governing bodies can provide protection for communities
and have an in-depth knowledge of community members
and traditions and stand to protect the well-being andsurvival of communities. In-depth knowledge of thecommunity allows for the recognition of peoples that may
be at higher risk, including knowledge of any preexisting
health conditions that community members might have.
This allows for the isolation and immediate protection ofelders and members whose health may be compromised-and thus provides an added layer of protection,communication, and togetherness with nations. Since thecoronavirus pandemic was declared, many tribes haveclosed their borders and provide food and medicine toelders.
Tribal populations can close their borders to
nontribal members. Many have internal resources such as
hotels and casinos that could double as makeshift areas tohouse and protect elders. Others have access to foodservices that can deliver food and sustenance into tribal

121

areas without members leaving reservation borders. Food
services that normally serve tribal education, and adultservice centers, and casinos can provide food for tribal
members. Eliminating the need to enter crowded towns
and urban centers to shop for necessities. There are manyother resources available. It is time for tribal leaders tothink outside of the box, in an effort to protect theirnations at all costs.
Tribal Traditions and the Power to Survive
Tribal traditions and healing practices and aknowledge of medicines are an integral component oftribal nations. Understanding the COVID-19 pandemic
from a traditional perspective reduces anxiety andreinforces inner strength. Dr. Rodney Haring, a Seneca
tribal community member of New York, describes
COVID-19 as creating “a time when people of cultures
have an opportunity to reconnect and recreate. Reconnect
to identity, person-in-environment, and place and time. A
micro yet global self-evaluation. It’s also, perhaps, a sign
to slow down, let the Earth rebalance, “take a breath” fromthe everyday hustle and bustle of human impression.” Insome communities, art is being used to promote the use ofmasks and safety. One nonproTit, Dukes Up of
Albuquerque, N.M., placed billboards across the city topromote the use of masks and to direct people to practicesocial distancing. The intention was to remove the stigma
of wearing masks in tribal communities in an effort toprotect the health and well-being of family. Together, theindigenous of North America will continue to thrive. Many
are using their artistic skills to create awareness. Many
communities are using song and dance to create
uniTication and healing.
Other communities are organizing prayer groups.
Some are offering their art. As traditional people, we havethe power to resist and to hold strong to elements thathave provided mechanisms for survival for the past 2,000
years.

Conclusion
In summary, there is an urgent need to support andprotect tribal nations across United States and globally.
Indigenous people in the United States and throughout
the Americas are at great risk.
Centuries of tribal
downsizing efforts by the U.S. government andgovernments across the Americas have made indigenous
peoples some the most at risk populations in the world.
Until structural racism and the social determinants ofhealth are addressed among tribal peoples their existence
will be challenged.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

References
APCG Chair J. Michael Chavarria Discusses The Impact of
COVID-19 on Indian Country http://tinyurl.com/w75ew5v
Carlos, Ann M., and Frank D. Lewis. "Smallpox and Native
American mortality: The 1780s epidemic in the Hudson Bay
region." Explorations in Economic History 49, no. 3 (2012):
277-290.
Centers for Disease Control and Prevention, (January 2020).
Atlanta, GA: U.S. Department of Health and Human Services,Centers for Disease Control and Prevention.
Deloria, Vine. Custer Died for Your Sins. An Indian Manifesto .
(Sixth Printing.). Macmillan Company, 1970.
Fenner, Frank, Donald Ainslie Henderson, Isao Arita, Zdenek
Jezek, and Ivan D. Ladnyi. Smallpox and its eradication. Vol. 6.
Geneva: World Health Organization, 1988.Hopkins, Donald
R., and George I. Lythcott. Princes and peasants: smallpox in
history. Chicago: University of Chicago Press, 1983.
HufTington Post (President Nez, of the Navajo Nation). https://w w w. h u f f p o s t . c o m / e n t r y / n a v a j o - n a t i o n coronavirus_n_5e838c96c5b6871702a59ee8
National Indian Health Board https://www.nihb.org/
National Conference of State Legislatures: Legislative
Newshttps://www.ncsl.org
Portman, Tarrell A.A., and Michael T. Garrett. “Native American
healing traditions.” International Journal of Disability,
Development and Education 53, no. 4 (2006): 453-469.
https://www.politico.com/news/2020/03/20/coronavirusamerican-indian-health-138724
Thornton, Russell. American Indian holocaust and survival: A
population history since 1492. Vol. 186. University ofOklahoma Press, 1987. U.S. Department of the Interior, IndianAffairs https://www.bia.gov/bia
United States Census Bureau / 2010 Census.U.S. Census Bureau,
2010.Web. 1 April 2https://www.census.gov/topics/
families.html >.
Valencia-Weber, Gloria. "The Supreme Court's Indian Law
Decisions: Deviations from Constitutional Principles and the
Crafting of Judicial Smallpox Blankets." U. Pa. J. Const. L. 5
(2002): 405.
Yosso,* Tara J. “Whose culture has capital? A critical race theory
discussion of community cultural wealth.” Race ethnicity andeducation 8, no. 1 (2005): 69-91.

COVID19: Social Stigma and Public
Health Dilemma- Shahanaz Chowdhury MBBS (SSMC,DU), MPH(NIPSOM,DU), MBGPH (USA), PhD (USA)
Associate Professor & Head, Dept. of Community Medicine,
Faculty of Public Health, Bangladesh University of Health
Sciences (BUHS), Bangladesh
Email: dr.shahanazch@gmail.com
Introduction
The World Health Organization declared the outbreak apandemic. Coronavirus disease (COVID-19) is aninfectious disease caused by a newly discovered
coronavirus. Most people infected with the COVID-19
virus will experience mild to moderate respiratory illness
and recover without requiring special treatment. Older
people, and those with underlying medical problems likecardiovascular disease, diabetes, chronic respiratory
disease, and cancer are more likely to develop serious
illness. 1 The corona virus COVID-19 is affecting 196

countries and territories around the world and 1
international conveyance (the Diamond Princess Cruise
ship harbored in Yokohama, Japan). 2 Public healthemergencies, such as the outbreak of coronavirus disease2019 (COVID-19), are stressful times for people andcommunities.3 Social stigma in the context of health is thenegative association between a person or group of people
who share certain characteristics and a speciTic disease. Inan outbreak, this may mean people are labeled,stereotyped, discriminated against, treated separately,
and/or experience loss of status because of a perceived
link with a disease. Such treatment can negatively affectthose with the disease, as well as their caregivers, family,
friends and communities. People who don’t have thedisease but share other characteristics with this group
may also suffer from stigma. The current COVID-19
outbreak has provoked social stigma and discriminatory
behaviors against people of certain ethnic backgrounds aswell as anyone perceived to have been in contact with thevirus.4
Social Stigma and COVID19
The level of stigma associated with COVID-19 is based on
three main factors: 1) it is diseases that’s new and forwhich there are still many unknowns; 2) we are often
afraid of the unknown; and 3) it is easy to associate thatfear with ‘others’. It is understandable that there isconfusion, anxiety, and fear among the public.
Unfortunately, these factors are also fueling harmfulstereotypes.4 Fear and anxiety about a disease can lead tosocial stigma toward people, places, or things. For
example, stigma and discrimination can occur whenpeople associate a disease, such as COVID-19, with apopulation or nationality, even though not everyone inthat population or from that region is speciTically at risk
for the disease. Stigma can also occur after a person has
been released from COVID-19 quarantine even though
they are not considered a risk for spreading the virus toothers.3
Some groups of people who may be experiencing stigma
because of COVID-19 include:•
Persons of Asian descent•
People who have traveled•
Emergency responders or healthcare professionals
Social Stigma and its Impact
Stigma hurts everyone by creating fear or anger towards
other people. 3 Stigma can affect people, places, or things.
It occurs when people associate a risk with something
speciTic—like a minority population group—and there isno evidence that the risk is greater in that group than in
the general population. Stigmatization is especiallycommon in disease outbreaks.
Example: A 2002 outbreak of severe acute respiratory
syndrome (SARS) in China caused global concern.
Unfortunately, fear also led to a great deal of stigma.
Although there were no associated cases of SARS in
America, many citizens began to avoid Chinatowns andother Asian-American communities—including Japanese,
Korean, and Vietnamese peoples—throughout the UnitedStates because they believed those groups were at greaterrisk for spreading SARS.

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
Stigmatized groups may suffer psychologically andeconomically. They may be subjected to:•Social avoidance or rejection•
Denial of healthcare, education, housing, or
employment•
Physical violence 5•
Drive people to hide the illness to avoid
discrimination•
Prevent people from seeking health care
immediately•
Discourage them from adopting healthy behaviors 4
Stigmatizing minority groups may also distract people
from focusing on the real risks in a crisis situation. When
only part of a population is perceived as being affected,
others may incorrectly believe they are not at risk. By
assuming they are safe, majority population groups may
not take important public health precautions,
unintentionally compromising their own health and wellbeing.
Addressing Social Stigma and Public HealthC r i s i s c o m m u n i c a t o r s m u s t wo r k t o c o u n t e r
stigmatization during a disaster. Messages should
reinforce real risks through accurate information andawareness. Images should reTlect all people who aresusceptible to getting sick. Ideally, public health messages
will proactively address possible stigma before it begins.
However, prepared communicators should be ready tochallenge any negative stigmatizing behaviors that do
emerge. 5
Communicators and public health ofTicials can help
counter stigma during the COVID-19 response.
• Maintain privacy and conTidentiality of those seeking
healthcare and those who may be part of any contact
investigation.
• Quickly communicate the risk or lack of risk fromassociations with products, people, and places.
• Raise awareness about COVID-19 without increasingfear.
• Share accurate information about how the virus
spreads.
• Speak out against negative behaviors, including
negative statements on social media about groups ofpeople, or exclusion of people who pose no risk from
regular activities.
• Be cautious about the images that are shared. Make
sure they do not reinforce stereotypes.
• Engage with stigmatized groups in person andthrough media channels including news media andsocial media.
• Thank healthcare workers and responders. People
who have traveled to areas where the COVID-19
outbreak is happening to help have performed avaluable service to everyone by helping make sure
this disease does not spread further.
• Share the need for social support for people who havereturned from China or are worried about friends orrelatives in the affected region. 3• Journalistic reporting which overly focuses on
individual behavior and patients’ responsibility forhaving and “spreading COVID-19” can increase stigma•

123

of people who may have the disease. Some media
outlets have, for example, focused on speculating on
the source of COVID-19, trying to identify “patientzero” in each country. Emphasizing efforts to Tind a
vaccine and treatment can increase fear and give theimpression that we are powerless to halt infections
now. Instead, promote content around basic infection
prevention practices, symptoms of COVID-19 andwhen to seek health care.
All materials should show diverse communities being
impacted and working together to prevent the spreadof COVID-19. Ensure that typeface, symbols andformats are neutral and don’t suggest any particulargroup 4

Conclusion: Fight the COVID19, not the people
Disease related stigma could very well qualify as the mostdamaging form of social stigma. It poses, in some cases,
insurmountable barriers to what could be lifesaving
medical care. Disease related stigma has a deleterious
effect on its victim’s psycho emotional capacity. It
effectively hinders our neighbors from seeking treatment- placing the community as a whole at greater risk ofcontagion, and the effects of unrelenting panic. It is
powerful enough to incite violence, and malicious enoughto compromise and drive a wedge between amicablenations. 6 People who have conTirmed COVID-19 and are
in isolation, and people who may have been exposed to
COVID-19 and are self-monitoring, are doing the rightthing and helping to protect their communities.7
When talking about COVID-19 disease, certain words(i.e suspect case, isolation) and language may have anegative meaning for people and fuel stigmatizing
attitudes. They can perpetuate existing negative
stereotypes or assumptions, strengthen false associations
between the disease and other factors, create widespreadfear, or dehumanize those who have the disease. This candrive people away from getting screened, tested andquarantined. Words used in media are especially
important, because these will shape the popular language
and communication on the new corona virus (COVID-19).
Negative reporting has the potential to inTluence how
people suspected to have the new corona virus(COVID-19), patients and their families and affected
communities are perceived and treated. 4 They should
never be harassed and bullied, including through social
media. We should offer compassion, support via phone
and texts, and assistance as appropriate, but neverhostility or judgment. 7
References
1.https://www.who.int/health-topics/coronavirus#tab=tab_1
2.https://www.worldometers.info/coronavirus/
3.https://www.cdc.gov/coronavirus/2019-ncov/symptomstesting/reducing-stigma.html
4.h t t p s : / / w w w . u n i c e f . o r g / m e d i a / 6 5 9 3 1 / T i l e /Social%20stigma%20associated%20with%20the%20coronavir
us%20disease%202019%20(COVID-19).pdf
5.h t t p s : / / e m e r g e n c y . c d c . g o v / c e r c / c e r c c o r n e r /article_123016.asp
6.Joan Williams, Diego Gonzalez-Medina, Quan Le, 2011.
Infectious diseases and social stigma. ATI, 4 (1), 58-70

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

7.h t t p s : / / w w w. n c d h h s . g ov / d iv i s i o n s / p u b l i c - h e a l t h /coronavirus-disease-2019-covid-19-response-north-carolina/
covid-19-stigma

Maintenance of Physical Distanceto Prevent COVID-19: A Glimpse at
Bangladesh- Wardatul Akmam, MBGPH, PhD
Professor of Sociology, University of Rajshahi, Bangladesh
Email: akmamw@ru.ac.bd- Md. Fakrul Islam, MBGPH, PhD
Professor of Social Work and Dean, Faculty of Social
Science, University of Rajshahi, Bangladesh
Introduction
The world is now preoccupied with combating aformidable foe, i.e., COVID-19 (Corona Virus Disease2019). It is “an infectious disease caused by a newly
discovered coronavirus” with Tlu-like symptoms that does
not have any vaccine or a speciTic treatment. Even thoughbecoming infected with COVID-19 does not mean
conTirmed death, it brings fatal consequences to people
with co-morbidity like “cardiovascular disease, diabetes,
chronic respiratory disease, and cancer” (WHO 2020a).
The disease spreads very fast through droplets discharged
from coughs and sneezes of infected persons. In this shortpaper attempts have been made to reveal some facts on
the maintenance of physical distance in Bangladesh toprevent COVID-19 using secondary sources of
information.
Although coronavirus has reached Bangladesh after
invading 102 countries (Al-Jazeera 2020), the UN fears
that its easy transmission process and conditions in
Bangladesh may lead to death of 2 million people if proper
measures are not undertaken immediately (The
Australian 2020, March 29). In order to resist such asituation, washing hands frequently with soap or using
hand sanitizers and maintaining a physical distance of atleast three feet between two people (the authors prefer to
use the term ‘physical distance’ rather than ‘social
distance’ as they believe the latter has a different
connotation) are essential (WHO 2020b).
Measures undertaken to prevent COVID-19
To prevent spreading of the disease the government has
taken various actions including closure of all primary,secondary and tertiary level schools/colleges/universities
from March 18, 2020 to April 11, 2020 and declaration ofa general holiday from March 26, 2020 to April 11, 2020
so that people stay home and are able to maintainphysical distance. Public transports (on land/water/air)have stopped running and the army has been deployed toprevent people gathering on the streets. National
programmes, e.g. Inauguration of the year-longcelebration the Birth Centennial of the Father of the
Nation was observed in a limited scope on the 17th ofMarch and other national programmes to celebrate theIndependence Day (26th March) and the Bangla New Year

(14th April) have been cancelled to maintain physicaldistance.
As COVID-19 did not originate in Bangladesh, it
could enter this country only through infected people whocame to this country from a country already affected by
the virus. The Tirst case of COVID-19 diagnosed in
Bangladesh had its source in a Bangladeshi who returned
from Italy—a country severely affected by COVID-19. All
the people who came to Bangladesh from corona affected
countries have been requested to remain in homequarantine for the Tirst14 days since their arrival whichmeant that they must live in an isolated room within theirhouses with preferably a separate washroom, having no
physical contact with anyone, even family members.
However, in a densely populated country like
Bangladesh, it often becomes very difTicult to maintainphysical distance at home, where three or more people
often sleep in one room. Sparing a room with a separate
washroom for one person may become impossible for afamily to manage.
Response from the people
Reports say that although 298,000 people returned to
Bangladesh from other countries between January 21 andMarch 23 only 17,834 people ensured quarantine. To thecontrary, “these returnees have been roaming aroundtheir localities, going to markets and even holding
marriage ceremonies, instead of being in the 14-day
quarantine” (The Daily Star, March 25, 2020). When asked
by the media, some of them said that they did notunderstand what quarantine meant.
People usually do not accept uncomfortable
practices like being conTined in their homes until thedanger arrives at their doorstep (Costa-Font, 2020). They
do not believe that they, along with their loved ones may
face death if they do not comply with the government
appeal to stay home. Evidence of such disbelief wasobserved when people rush from Dhaka to their village
homes in over-crowded buses, trains and ferries after ageneral holiday was declared from 26th March to 4th April(before the orders on closure of public transport wasannounced). They did not realize that they themselves
and their relatives in the villages would become more
vulnerable through such acts. As people are facing asituation that they did not experience before, they cannot
make decisions regarding what they should believe andnot believe; what they should do and not do.
During such periods, rumors spread very easily. We
have seen news of people being busy collecting andThankuni leaf (Centella asiatica) all night in Gopalgonj,
believing that if one eats (by chewing) three Thankuni
leaves with salt, they will not be infected with COVID-19(Dhaka Tribune March 18, 2020). Such rumors leadpeople to gather outside their houses in the middle of thenight with lanterns in search of the herb. Such rumors arevery much likely to aggravate the situation.
If people are convinced that their full participationin the physical distancing efforts is the key for them andfor their near and dear ones to be safe from COVID-19,
they are likely to go through the ordeal, albeit may be a
difTicult task. Celebrities who are idols to the people may
play a very good role in convincing people and to place

Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)
them on the right track. We have seen Shakib Al-Hasan (afamous cricketer of Bangladesh) going into quarantine
after he reached the US (Timesnownews.com 2020).
Meher Afroz Shaon, Tahsan Khan and some other singers/
actors have gone into quarantine after they returned
home from abroad (Campuslive.com, March 17, 2020,
Dhaka Tribune, March 18, 2020). These instances help
people in making their choices. Video messages fromother celebrities are shown in the media to inspire people
to accept the unusual practice of remaining within theirhouses for days together.
In Kaukhali Upazila of Pirozpur District, the Upazila
Nirbahi (Executive) OfTicer set rather an exceptional
example. She went to the homes of the people who were
under self-quarantine and gave them some books to help
them pass their time, appreciating their sacriTice for thegreater good (Prothom Alo 2020, March 24).
Realizing that it would be very difTicult for humans
to win against COVID-19 without divine blessings, somepeople have circulated in the social media, some hadith(sayings of the Prophet Muhammad (peace be up on him)announcing that people who stay at home and rely on
Allah during epidemics will be highly rewarded in thehereafter. Some prayers (dua) have been circulated in thesocial media to seek blessings of Allah. Some big
companies (like Grameenphone and BRAC are airing
commercials of their goods/services with messages
requesting people to wash their hands and remain athome for the greater cause of the country. A few have
prepared commercials with jingles and songs sung by
popular artists with appealing lyrics to attract people’s
attention and convince them to remain in their homes.
The most vulnerable in maintaining physical distanceAccording to Amnesty International (2020), daily wage
earners, Rohingya refugees, health workers and prisoners
are the most vulnerable to COVID-19 as they cannot
maintain safe distance away from other people. Daily
wage earners like rickshaw pullers and the homeless canhardly maintain the distance they are being asked tomaintain between two persons. They must stay on thestreets to earn their living. Prisoners also are compelled tostay in crowded rooms and hence are very vulnerable tobecoming infected. The prison authorities and thegovernment are checking out possibilities of releasing
3000 prisoners who are under trial for bailable offences
on bail. However, the Tinal decision will be made by the
judiciary (The Financial Express, April 1, 2020).
According to Seigfried (2020), aid workers are facing
a lot of difTiculty in educating the Rohingyas regarding
COVID-19, as there is a ban on use of mobile phones in thecamps, which are “more densely populated than the most
crowded cities”. A TV news report on Cox’s Bazar, aired on
March 30 depicted that physical distancing was not
maintained at all in market places and people’s activities
were almost as if it were a normal day. After six days ofstaying home, on April 1 people of Dhaka also started
coming out into the streets gathering in small groups,
saying that they could no longer remain locked in theirhouses, and many private vehicles were the main roads
and highways. Observing such situation the deployedarmy is going to play a tougher action against those who

125

fail to follow instructions regarding physical distancing
and quarantine from April 2, 2020. Till April 1, the army
and the police tried to keep people off the streets politely.
The Prime Minister of Bangladesh, Sheikh Hasina in
her address to the nation on March 25, 2020, and later on
several other occasions has explained the measures thather government has taken, including efforts to provide
salary to the garments workers for the period they remain
at home and provide shelter to the homeless. The districtlevel administrations have been instructed to help the
disadvantaged people by providing them with the basic
necessities. People belonging to different religions havebeen requested to pray at home, rather than gathering inmosques and other places of religious congregation. Dates
for paying utility bills (like electricity and gas) have been
extended, so that people do not gather in crowds in banks
for such payments. Bangladesh Bank has issued a sixmonth moratorium so that those who have taken bankloans including microcredit holders do not have to pay
installments during the lockdown periods.
The Prime Minister also urged the afTluent people tocome forward in helping the low-income people. The
national cricket team members have declared that they
will donate half of their salary. Many others have alsocome forward to help the needy amid this global crisis.
Some organizations are distributing daily essentials anddisinfecting items. It has been observed in TV news thatphysical distancing is often not being observed while
distributing these goods. Experts are calling for
coordinated efforts so that all the needy receive relief
more or less in proportion to their need, maintaining
physical distance.
Doctors, nurses and other health workers are themost vulnerable to COVID-19 in any part of the world.
Initially, there was a shortage of personal protective
equipments for doctors in different parts of Bangladesh,which hampered delivery of health services. The
government is trying to make arrangements for special
hospitals for treating COVID-19 patients. Till April 1,
2020, 54 patients tested positive for coronavirus andamong them 6 have died, 26 have been cured and others
are under treatment. Among the infected 2 were doctors
and 2 were nurses.
Conclusion
In the above attempts have been made to portray a
glimpse of Bangladesh regarding maintenance of physicaldistance to prevent COVID-19. In conclusion it may be said
that maintenance of physical distance has to be ensured inthis country by convincing people regarding urgency ofthis measure as well as by creating an environment andsocial conditions in which it can be practiced. Otherwise,
in a densely populated country like Bangladesh, it would
be very difTicult to manage outbreak of the virus.
References
Al-Jazeera (2020). Coronavirus: Which countries have conTirmed
cases? Accessed on March 29, 2020 at https://www.aljazeera.com/news/2020/01/countries-conTirmedcases-coronavirus-200125070959786.html?
utm_source=website&utm_medium=article_page&utm_camp
aign=read_more_links.

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Eubios Journal of Asian and International Bioethics 30 (3) (April 2020)

Amnesty International (2020). South Asia: As COVID-19 spreads,
fears rise for people at higher risk. Accessed on March 29,
2020 at https://www.amnesty.org/en/latest/news/
2020/03/south-asia-as-covid19-spreads-fears-rise-forpeople-at-higher-risk/
Campuslive24 (2020, March, 17). Actress Shaon in homequarantine to remain safe. Accessed on March 30, 2020 athttps://eng.campuslive24.com/entertainment/article/
1293/Actress-Shaon-in-home-quarantine-to-remain-safe.
Costa-Font (2020). Behavior Changed, Yes, but Only after COVID
was at Doorstep. Accessed on March 24, 2020 at https://www.socialsciencespace.com/2020/03/behavior-changedyes-but-only-after-covid-was-at-doorstep/.
Dhaka Tribune Bangla (2020, March 18). Coronavirus Gujob:‘Swopne Pawa Oshudhe’ Gopalgonj tolpar. (Coronavirus
Rumour: A Fuss in Gopalgonj relating to Medicine Found inDream). Accessed on March 29, 2020 athttps://
bangla.dhakatribune.com/bangladesh/
2020/03/18/21262/%E0%A6%95%E0%A6%B0%E0%A7%8B%E0%A6%A8%E0%A6%BE%E0%A6%AD%E0%A6%
BE%E0%A6%87%E0%A6%B0%E0%A6%BE%E0%A6%B8%E0%A6%97%E0%A7%81%E0%A6%9C%E0%A6%AC:-'%E0%A6%9A%E0%A6%B0%E0%A6%AE%E0%A7%8B%
E0%A6%A8%E0%A6%BE%E0%A6%87%E0%A6%AA%E0%A7%80%E0%A6%B0%E0%A7%87%E
0
%
A
6
%
B
0
%E0%A6%B8%E0%A7%8D%E0%A6%AC%E0%A6%AA%
E0%A7%8D%E0%A6%A8%E0%A7%87%E0%A6%A6%E0%A7%87%E0%A6%96%E0%A6%BE%E0%A6%93%E0%A6%B7%E0%A7%81%E0%A6%A7%E
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%E0%A6%97%E0%A7%8B%E0%A6%AA%E0%A6%BE%
E0%A6%B2%E0%A6%97%E0%A6%9E%E0%A7%8D%E0% A 6 % 9 C % E 0 % A 7 % 8 7 %E0%A6%A4%E0%A7%8B%E0%A6%B2%E0%A6%AA%
E0%A6%BE%E0%A7%9C.
Prothom Alo (2020, March 24). UNOr srijonshil uddog:
Pirozpurer drishtanto sobkhane onusoron kora hok (Creative
Initiative of an UNO: Let the instance created by Pirozpur befollowed by all) Editorial of a Bangla newspaper.
Siegfried, Kristie (2020, March 30). The Refugee Brief – 30
March 2020, UNHCR. Accessed on April 2, 2020 at https://www.unhcr.org/refugeebrief/the-refugee-brief-30march-2020/.
The Australian (2020, March 29). Coronavirus: two million could
die in Bangladesh, UN warns. Accessed on March 31, 2020 athttps://www.theaustralian.com.au/world/coronavirus-twomillion-could-die-in-bangladesh-un-warns/newsstory/
c9e9bb748c3f54ca26e9cca90a4c9ca2?
Tbclid=IwAR0qZTita2yNHxKaKcANUHhV6_GFJ_goZOJAoLu8i
pWBet76-08uoqOR-y4.
The Business Standard (2020). Borrowers get breather on loan
payment: Loans not to be classiTied if installments not paid
until June 30. Accessed on March 30, 2020 https://
tbsnews.net/economy/banking/businesses-get-6-monthmoratorium-loan-repayments-58384.
The Daily Star (2020, March 25). Cops clueless about most of the
returnees. Accessed on March 30, 2020 at https://www.thedailystar.net/frontpage/news/cops-clueless-aboutmost-the-returnees-1885462.
The Financial Express (2020, April 2). Govt plans to release
3,000 prisoners amid mounting virus fears. Accessed on
April 2, 2020 at https://theTinancialexpress.com.bd/
national/govt-plans-to-release-3000-prisoners-amidmounting-virus-fears-1585734223.

Timesnownews.com (2020, March 24). Painful that I can't see
my daughter: Shakib Al Hasan, in self-isolation, on reaching
USA. Accessed on March 30, 2020 athttps://www.timesnownews.com/sports/cricket/article/
painful-that-i-cant-see-my-daughter-shakib-al-hasan-in-selfisolation-on-reaching-usa/568636.
UNB News (2020, April 1). Coronavirus: Army warns of toughaction from Thursday. Accessed on April 2 at http://
unb.com.bd/category/Bangladesh/coronavirus-army-warnsof-tough-action-from-thursday/48493.
WHO (2020a). Coronavirus. Accessed on March 29, 2020 athttps://www.who.int/health-topics/coronavirus#tab=tab_1.
WHO (2020b). Basic protective measures against the newcoronavirus. Accessed on March 29, 2020 at https://w w w. w h o . i n t / e m e r g e n c i e s / d i s e a s e s / n o v e l coronavirus-2019/advice-for-public.

Editorial address, and all correspondence to:Prof. Darryl Macer, Ph.D., Hon.D.
President, American University of Sovereign Nations(AUSN), https://www.ausovereignnations.org
Email: darryl@eubios.info
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All potential authors should have read these guidelines
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For forthcoming conferences see: www.eubios.info
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Email to Darryl@eubios.info.
EJAIB Editor:
Darryl Macer (Chair, Accredited Universities of Sovereign
Nations)
Associate Editor:
Nader Ghotbi (Ritsumeikan Asia PaciTic University, APU))
Editorial Board: Akira Akabayashi (Japan), Sahin Aksoy(Turkey), Martha Marcela Rodriguez-Alanis (Mexico), Angeles
Tan Alora (Philippines), Atsushi Asai (Japan), Alireza Bagheri(Iran), Gerhold Becker (Germany), Rhyddhi Chakraborty (India/UK), Shamima Lasker (Bangladesh), Minakshi Bhardwaj (UK),
Christian Byk (IALES; France), Ken Daniels (New Zealand), Ole
Doering (Germany), Amarbayasgalan Dorjderem (Mongolia),
Hasan Erbay (Turkey), Soraj Hongladarom (Thailand), Dena Hsin
(Taiwan), Rihito Kimura (Japan), Abby Lippman (Canada), Umar
Jenie (Indonesia), Nobuko Yasuhara Macer (Japan), Masahiro
Morioka (Japan), Anwar Nasim (Pakistan), Jing-Bao Nie (China,
New Zealand), Pinit Ratanakul (Thailand), Qiu Ren Zong (China),
Hyakudai Sakamoto (Japan), Sang-yong Song (Republic ofKorea), Takao Takahashi (Japan), Noritoshi Tanida (Japan),
Ananya Tritipthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon (Republic of Korea).
.

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