Eubios Journal of Asian andInternational Bioethic
EJAIB Vol. 31 (1) January 2021
www.eubios.info

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

Official Journal of the Asian Bioethics Association (ABA)

Copyright ©2021 Eubios Ethics Institute(All rights reserved, for commercial reproductions).

page
Editorial: Ethics, Values and the Treaty to Prohibit
1
Nuclear Weapons - Darryl Macer
Ethical Values and Principles for Healing Society in Lightof the COVID-19 Crisis
2- Statement of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee
Re lections on the impact of COVID-19 pandemic on life
and the world8- Ravichandran Moorthy & Gabriel Tyoyila Akwen
Organized religion, spirituality and COVID-19
13- Darryl Macer
Belief in god vs. worship of a religion
18- Nader Ghotbi
Spiritual healthcare and mental health issues during
the COVID 19 pandemic
21- Dhastagir Sultan Sheriff
Healthy lifestyle is the key for a healthy society
24- Rogelio P. Bayod & Darwin Arnosa
Overcoming death: the state of man in the midst of a29
pandemic - Christopher Ryan Maboloc
A century with agony or death with comfort
32- Samreen Siraj, Zainish Hajani, Afsheen Hirani,
Shyrose Sultan, Nasreen Ra iq and Salima Siraj
Transgender Realities in the Context of COVID-19 in
35
Bangladesh - Nazneen Akhter
COVID-19 pandemic and its impact on the socio-economic 38
context of Bangladesh - Shamima Akter Rozy & Muhammad Ali
Banking against all odds: concerns of government bankworkers in the Philippines amid the COVID-19 crisis
43- Geroson C. Reginio, Randy A. Tudy, Rex B. Buac
COVID-19 and food security: The Eastern Visayas State
University experience in the municipality of Burauen
51- Sheldon Ives G. Agaton
Changes of health care practice in the ield of
ophthalmology during the COVID-19 pandemic
55- Sibel Inan
This includes many papers from the International Public HealthAmbassadors Conferences (Refer: www.eubios.info)

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Editorial address, and all correspondence to:Prof. Darryl Macer
Email: darryl@eubios.info

Editorial: Ethics, Values and theTreaty to Prohibit Nuclear Weapons
75 years after the irst explosions of nuclear weapons we haveseen today the rati ication of the UN Treaty to prohibit nuclear
weapons. There are a few other technologies that humankind
have made that are capable of destroying the whole planet.
Eubios Ethics Institute founded Youth Peace Ambassadors in2010 in Hiroshima with UNESCO. In 2014 we held a ield trip of
the 14th Asian Bioethics Conference to Nagasaki.
It is itting on 22 January 2021, this issue launches theStatement “Ethical Values and Principles for Healing Society inLight of the COVID-19 Crisis”, from the World Emergency
COVID19 Pandemic Ethics (WeCope) Committee, as the result of
dialogue between 50 persons from all around the world. One ofthe principle values is peace and nonviolence. It may have taken
the pandemic to bring home to people the fragility of life on thisplanet, which is still actively destroying the lives and hopes ofmany around the world. Thank God, it was not a nuclear winter,because the toll would have been 2 billion instead of 2 million.
The dozen papers include studies on the impact of COVID-19 on
different communities and the measures that people have taken
to try to control this pandemic. In the monthly IPHA conferencesthat we are hosting we see many papers as a result of numerous
research studies that are really opening up the ield of publichealth ethics in a manner which had not been explored in suchdetail before. It is not the mighty hydrogen bomb which has
shown us the fragility of human existence. Rather it is a little
virus, that has now started to mutate and naturally play an
evolutionary game with the lives of its host, us.
Surely it is also with a note of hope to see the inauguration of
U.S. President Biden, who immediately rejoined the USA to theParis Climate Accord, and the World Health Organization, and has
declared he will be part of COVAX, the effort to make the
COVID-19 vaccine accessible to people in every country in theworld. So, I think it’s quite reasonable at least for today thatbioethicists can be proud of what we’ve been doing to ight for
preservation of the environment for all living creatures and of
humanity itself. Let us double our efforts to work so that thosecountries which have nuclear weapons will never have a reason
to use them, and will eventually give up such as suicidal
technology.

sContents

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

Ethical Values and Principles for
Healing Society in Light of the
COVID-19 Crisis
Statement of the World Emergency COVID19 Pandemic
Ethics (WeCope) Committee (22 January 2021)

1. Preamble
As an independent, multidisciplinary, and cross-culturalcommittee, comprised of ethicists from cultures andnations across the world, in the context of our previous
statements, we offer the following statement andrecommendations on Ethical Values and Principles for
Healing Society in Light of the COVID-19 Crisis.1
We hope that this joint statement will widen the scopeof re lections both within and between communities andnations and will help share a mutual vision for a healing
society by elucidating ethical values and principles that can
assist in making better societies. The possibility of better
societies can be achieved through the participation of all
people to consider what would be “better”, and through thetransformative potential of what every person on theplanet has learned from COVID-19.
Areas of potential transformation include bothindividual and societal development, including but notlimited to public health, education pathways, economic
lows, institutional dynamism, hierarchical systems,
authoritative relationships and broader issues of social
conventions. In the context of earlier WeCope Statements
on Autonomy and Responsibility, State and Governance,
and the Environmental Implications of COVID-19, we needto broaden our conception of a healing society taking into
account bioethical consideration for all spheres of life.
Other potential transformation points relate to identifying
tensions and the dynamics of unsustainable or asymmetric
inputs and outputs, fragile structures, or contexts that
demonstrate imperatives that are counter to common
perceptions of morality such as non-bene icence,
male icence, unjustness, irresponsibility, or non-autonomy.
Ethical visions related to these themes may aid inincreasing awareness, and herein we discuss some of theapplicable principles and humbly issue recommendations.

2. Healing Society
The term “healing society” suggests that humanity is
injured which marks the cycle of evolution of all life forms
wherein injuries are perceived as new challenges and often
lead to paradigm shifts. This is precisely why global society
adopted the Millennium Development Goals (MDGs)
followed 15 years later by Sustainable Development Goals(SDGs). In this statement we add another new dimensionthat plays an important role in the healing of an injured
world which centers on the ethos of interrelationships
between living beings wherever and whoever they are.
To begin healing society, one may focus on its basic
component, the human person, upholding the individual’sdignity, rights, values, and humanity. Perhaps this would
manifest statecraft and social conventions built on trust,
rather than coercion backed by a monopoly on legal
violence. By social conventions we mean more than social
agreements or social contracts; the structuring of society
should be based on effective practices that allow theconstruction of a new ethic in which the rules and ideas
enable people to articulate their differences as individuals
and social beings. The common human good can withstanda reasonable asymmetry of ownership, of information, but
not privileges and rights, especially pertaining to the rightto use violence as a means.
To solve the challenges wrought by the past cycle ofdomination and inequality creating dynamics, those withthe most shall no longer be granted unfair privilege andrights to shape society through policy or brute force. Legalsystems should be secondary to other normative systems
such as those of morality or ethics. The curative society
invites us to forge our social relationships based on ethics,
rather than merely law.
It is not naïve utopianism to recognize that afoundational agreement of non-violence allows forcoexistence and cooperation to develop into universal coevolution. This co-evolution not only allows peaceful coexistence of peoples, cultures and nations, but also of
humans, non-humans and natural systems. Humanity has
so far survived the tension and balance of mutually assured
destruction (MAD), of a prolonged acceptance of inequality
enforced by systemic privilege, and the right to use
violence. By recognizing the violent path we have travelled(e.g., by acknowledging the resources spent on weapons
development, of pro it from suffering, and the verymechanisms of violence), we may integrate the knowledge
we learned into a broadening universal awareness of thedevastation such a path incurs.
We may heal, with awareness and loving compassion,
senseless suffering, and achieve the goal of preventing
future suffering or cycles of systemic violence. Policies ofdomination, forceful coercion, and extraction of common
resources should become dis-incentivized until they cease.
One should recognize that an absolutely broad de inition ofviolence, may become violent itself. Some attempts to solve
violence may lead to institutionally mandated structuresthat are accompanied by the blind force of law on citizens
and in that sense, the purpose of non-violence can be
distorted by itself. Our common humanity has become

1 The authorship of this statement reads as Andrew Bosworth, Darryl R.J. Macer, Nader Ghotbi, Nilza Maria Diniz, Manuel Lozano Rodríguez,

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Suma Parahakaran, Ayoub Abu Dayyeh, Abhik Gupta, Kayo Uejima, Sukran Sevimli, Thalia Arawi, Laura Victoria Puentes, and Marlon P.
Lofredo, and other members of the WeCope Committee (listed at the end of this Statement). This Statement draws on ideas and literaturefrom many sources and bene ited through comments from the full Committee members and other persons as well.
https://www.eubios.info/world_emergency_covid19_pandemic_ethics_committee

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
more evident because of living through a global pandemic,
where no nation is immune to the virus.
Recommendation 1:
Adopt the principle of non-violence (ahimsa). Achievethat principle while broadening the de inition, notweakening it. Attempt to move towards increasinglevels of universality of that broadening de inition.
This could be formalized in a universal agreement on
non-violent means to competition and dispute
resolution.

3. Education
Post-COVID educational opportunities should emphasize
inquiry-based learning, which in addition to othercurricula, integrates cross-cultural bioethical themes.
Education should develop the synthetic capabilities of thesenses, including observing, understanding and listening.
Adopting experiential and outcomes-based educational
methods and frameworks may build the knowledge,
attitudes, skills and ethical habits of learners,2 with anadditional focus on re lection, in order to develop criticalthinking and ethical capacity of students, and with the goalof increased participation and contribution towards
betterment of themselves and their communities.
Wherever possible, the components of the ive humanvalues of love, truth, peace, right conduct and non-violence
should be considered and implemented. To achieve thesevalues, teaching methodologies may adopt mindfulness
and awareness, as an integrated approach to learning.
Along with inspiration based upon modelled examples ofconcepts, it can provide students the support they need forthe integration of affective domains (feelings, attitude andbeliefs), and allows for a true love of life celebrating all
individuals and an integrated community.
Additionally, in terms of the implementation of
education by means of online technology, extra effort
should be made to demonstrate the principle of “education
for humanness” through critical thinking. Critical thought
has two aspects: one, the analytic function, which refers to
the competence of learners to examine the content oflearning and understand the concrete application ofconcepts in real life and context, and two, the integrative
function, which addresses the formative aspect of learningwith respect to human values, attitudes, and openness toreality.
Increasing the creative, adaptive resilience of students isparamount. Education opportunities should be abundantand have a clear aim to support individual and communal
wellbeing. Education should multiply opportunities, whileproviding support for those who choose to target speci ic
goals. Policy and research should also counter negative
effects of commercial advertising on students, especiallythose lacking the cognitive ability and/or bioethicalmaturity to understand the persuasive content of the

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2 WeCope Committee (2021), Implications of COVID-19 for Education.

3

material. Education should be consistent with the self andscienti ic evidence.
The curriculum should balance subjective force andobjective reality, the contradictions of which can be
replaced by the idea of intersubjectivity. The relativism of
the subjective in the face of doubts about objectivity insome philosophical conceptions such as contemporary
pragmatism, can be included in the concept ofintersubjectivity. This social concept highlights thearticulation between the individual reality of each subject
which can be understood as a social construction based on
language. What lies at the basis of communication is notnecessarily mutual agreement but mutual understanding.
Perhaps what is considered true is a shared world that the
speaker and the interpreter share.
Recommendation 2:
Society should strive to create an educational
experience consistent with not only a social or cultural
epistemology, but based on self-directed and scienti ic
evidence, which elicits intellectual leaps, matching
independent imagination and a strong creative power,with the best knowledge of the given facts.
Recommendation 3:
In order to foster solid ethical values, the curriculum
should equip students to:a) Appreciate the human and ecological conditions
around them and personally interpret theirexperiences through critical ethical re lection, andthink of innovative, ethical, and creative solutions toproblems they encounter.
b) Recognize the intersubjectivity that allows anincrease in the scope of consciousness, individuallyand collectively.
c) Balance subjective force and objective reality as
experienced by students towards an increase of theboundaries of awareness, both individually andcollectively.
d) Promote organic educational development
pathways, which support the mental and physicalwellbeing of learners.

4. Economics
It is possible to transition the economy using thechallenges of COVID-19, towards healthier and resilient
dynamics, which support the wellbeing of all members ofsociety.
The primary dynamic that must change is the coercive
and deceptive extraction of wealth from public resources(e.g., the “commons”), internally and externally. Current
power politics needs to be restructured to better represent
the people, and to provide more methods for consensus
building. It is not necessary to tax all inancial activities orredistribute private wealth. However, it is necessary to
acknowledge and correct the inappropriate loss of land,Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

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water and property as a result of colonization and otherinancial privileges that have led to severe inequality, as
well as a divergent decoupling of inancial markets fromreal economic facts. It does require drastically supporting
those with the least wealth, and limiting the moral hazard
perpetrated by those with the most, as well as somecreative ideas that are grounded in both fact and necessity.
The response by economic authorities to COVID-19
demonstrated the fragility of the economic structures atthe start of 2020. It was not a new or creative response,rather it was only different in the quantity of money
created and delivered. This situation is unprecedented
because it is clear that a repeat of past strategies (thatcoincidentally bene it an increasingly smaller andwealthier group), can no longer save the broader economic
system. If it continues like this, the inal break can bedramatic. It is not enough to simply save the smallest
percentage and expect the unproven trickle down toincrease to a rate that can revive the economic growth.
Because the system failed to reform until the very lastminute, a dilemma of ‘too little too late’ is overcome using
the dynamics of weekly or bi-weekly injections of publicfunds, to the public itself. This has saved lives and hasforestalled the nearly inevitable structural collapse. In
theory, gradually increasing the frequency and amplitudeof the handouts can synchronize economic activity andcreate a new rhythmic engine of growth, even in the midstof the economic chaos at present.
Those changes must be done soon and undertaken with
unparalleled commitment, and they should be directed atthose who are most vulnerable and in dire need of
economic help. This will subsidize the wellbeing of the
public as a whole. It must not be used as a tool of in lation
only, but irst as a source of protection for those worst
affected by COVID-19, and secondly as a tool of demand
creation for economic stimulation. It is also an opportunity
to re lect on the thesis of in lation as a source of extraction
and power. It is also a chance to build new economic
infrastructures, and rollback the extractive andunproductive forces that have thrived until now.
Novel redistributive dynamics may support bothresilient wellbeing and public health. Since inancial
markets have decoupled from real economics, there is lesshazard in adopting certain non-counterparty boundmechanisms, as the fallacious and ictitious nature of
wealth may allow for the directed altering of inancial
ratios and direct the low towards a common goal. The
same loopholes and mechanisms of extraction that wereonce realized without zero-sum linear constrictions caneasily be used as a source of funding for the public good.
This is a temporary ability, as the inancial markets mustalso eventually return to reality, but a great opportunity,
nonetheless. Such an action combined with simultaneously
increasing the distribution of ownership businesses via
various creative means can ultimately result in the recoupling of inancial and real economics circles; even if it
does not create equality in the rates of wealth increasing, it

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4

will create equality in direction. Some ships will rise fasterthan others, but we can support all ships.
A precursor to such a transition, as well as an inevitableby-product of attempts to make such change, will likely
involve vast debt restructuring and relief, and possible
debt jubilees, as well as eliminating individuals’ income
and purchase taxes. Economics should no longer be
structurally violent, via coercive or punitive paternal
models of authority. Relaxation of the forti ied gatekeepingof economic activity will allow micro-currents oftransactional economic energy to stimulate and reshapeeconomic processes. Allowing abundant economic activity
to take place and the wealth of pro it to sink throughdistribution helps free capitalism for all and securesocialism for those who need it.
Recommendation 4:
Develop an economy that structurally supports
vulnerable members of society and all others. Decree
and adopt for them the same monetary and inancial
mottos such as: ‘something from nothing’, ‘whatever ittakes’ and, central bank policy backing, which are
currently afforded only to the privileged few. This may
include a basic universal income, which should
increase in line with a global price in lation tracker
that follows rates of change in cost of living, including
food and energy, as well a basket of commodities tomaintain relative purchasing power.
Recommendation 5:
Embark on a public awareness program fortransparent formal and informal economic education,at all levels, that explains how universal basic income
works. Where it is not possible due to indebtedness or
iscal mismanagement, or lack of transparency orpolitical will, alternative schemes involving a
combination of redistributed public land andproductive resources, combined with conditional but
universal access to needed low interest loans may
suf ice.

5. Rights
International society is, in good measure, founded on
mutual respect and adoption of the Universal Declarationof Human Rights. The governing statutes of all countries
enshrine human rights in law, although it is true that not
everyone can celebrate their full human rights. A healing
society is one in which there is self-determination andrespect for human rights and responsibilities of all
persons.
During the quarantine and lockdowns, most directives
dictated as a response to COVID-19 have been coercive andforceful, and yet have been impossible to effectively
enforce. They have commonly been damaging to attempts
to self-organize by individuals, at grassroots, or to locallydecided community responses to the situation. The
absence of consistent scienti ic facts, and abundant
fearmongering, has made the situation more perverse andEubios Journal of Asian and International Bioethics 31(1) (January 2021)

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ritualistic. Healing from this mindless mentality will
require concerted effort of research-policy evaluation.
Human security means people must have what theyneed and have freedom from fear. It depends on resilienceand resilience depends on the freedom for individual moral
agents to make decisions that increase their wellbeing. The
re lexive lockdown response has ensured that the
pandemic’s health effects were not limited to the direct
effects of the virus but multiplied the suffering indirectly
and in more complex ways.
There was a wide range of styles of lockdowns and othermeasures that could be a simple approach but were often
mismanaged. Analysis of the impacts reveal the complexityof myriad other public health issues. Estimated deaths
related to a broad range of issues, from malnutrition inchildren, to missed treatments and diagnosis of nonCOVID-19 diseases, to long-term poverty, to breakdowns infood supplies, and rising prices, were some of directconsequences still being experienced.
Instead of choosing modulated or tempered democratic
responses, some policy makers over-reacted without
considering the long-term effects. By decimating social andeconomic systems, ‘the cure may be worse than the
disease’, collective resilience is lower as a result, should
there be a continued crisis.
Therefore, we refer readers to the recommendations of
our Autonomy and Responsibility Statement:
Recommendation 1: The concepts of autonomy and of
responsibility should be considered in their broad moral
meaning (and not in a narrow legal meaning), and in thecultural context to understand the different ways they can be
expressed and the speci ic meaning they can acquire. In thecurrent pandemic individual autonomy must be balancedwith social responsibility to control the spread of theinfection.
Recommendation 2: The exercise of autonomy and of
responsibility require some basic political, economic, social,and educational conditions to be truly and effectively
developed. Otherwise, people can neither be recognized as
autonomous, nor can they be held morally responsible. In thecurrent pandemic, basic conditions for the exercise of
autonomy and responsibility should be assured.
Recommendation 5: Moral legitimacy of individualautonomous decisions depends on their universal potential
to be adopted by all. Therefore, they ought to be altruistic,cooperative, and helping to strengthen solidarity andequality. These general requirements for moral behavior
become even more important in exceptionally vulnerable
and demanding situations such as the current pandemic.
And we refer readers to the recommendations of ourState and Governance Statement:
Recommendation 5: Human rights and fundamental
freedoms are not to be unwittingly and unnecessary
compromised by the State in its COVID-19 management.
Recommendation 1: State policies and regulations
promulgated for the prevention and control of COVID-19
need to be just, compassionate and humane, science-based,
and truly responsive, non-discriminatory and equitable. This

5time of global health emergency is an opportunity, as well asa challenge, for governments around the world to prove
themselves as resilient, cohesive, trustworthy, credible, andlegitimate institutions capable of creating and implementing
laws and policies that build resilient, cohesive, and trusting
communities.

6. Well-being
Well-being is being comfortable, healthy and happy. The
long-term damages of our responses to COVID-19 are still
unknown and have not fully realized but they have thepotential to cause the worst public health effects by anorder of magnitude. The devastating response to COVID-19
has failed by not recognizing the duality of security against
insecurity, and seeking total security against a speci ic
threat, which created the opposite in a multiplied fashion.
In re lection it is worth considering Karl Popper’s words, “...
only freedom can make security secure.”
Currently, there are different degrees of social chaos inmost countries' politics, as they respond to outbreaks andnew mutations of the virus. Healing from chaos is achieved
by way of synchronization and dampening of extreme
actions on all sides. The many facets of human security in a
new world order can only be addressed with the willing
participation of individuals who have the audacity to hopefor increasing their wellbeing, and to achieve that a betterbalance between freedom and security must be reached.
Traditional models of social contracts point out thedif iculty to fully balance equality and freedom because
state models choose to privilege one or the other. Social
justice starts from the deconstruction of the opposite
relationship between freedom and equality and therede inition of solidarity as a unifying element. Solidarity
allows the compatibility of individualism and private
freedom, with life in society, identifying the similarities ofthe people who are part of a group. Thus, solidarity is therecognition that differences with other people are lessimportant than the desire to avoid pain and suffering.
Utilitarianism can also achieve a connection between
freedom and equality, which has been taken advantage ofby the use of economic analysis in law, through the conceptof "prospective responsibility", which aims at ef iciency.
The most sustainably secure social systems are thosewhich are not paternalistically and coercively enforced bycentralized dictates of law or a top-down ideology, rather
security comes from the willing participation and mutualinterdependencies which arise from, and are inherent to,
healthy self-organization of moral agents. One half should
not dominate the other, nor can a select few effectively
dictate to the many. A thorough analysis of different
systems of government and democracy needs to be
conducted to examine the balance between the common
good and individual self-determination.
Recommendation 6:
We may promote well-being by:a) Enacting policies which recognize that security
requires mutual participation, and that pursuing a6Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
policy of an absolute form of security results in
insecurity of other forms.
b) Enacting policies which engage the public arenecessary to negotiating common security. This may beachieved by providing a range of options, andoutcomes, and recognizing the freedom individual
moral agents have to decide over the best outcome, as
well as developing new options based on feedback.
c) Developing channels to negotiate with the public ona case-by-case basis, to defuse tensions and dampen
any chaotic potentials, and to offer reasonableconditions to opt in or out of decrees.
d) All countries should transparently evaluate theimpacts of policies that include restricted movement,
mask mandates, and heightened surveillance, and thebene its and liabilities of individual agency. The
assessment may include analysis of the misery that
resulted from the policies, the lives saved, and theenhancements in the maturity of health-minded andloving citizens.

7. Lessons Learnt on Ethical Policy

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The essence of cross-cultural bioethics is to increase andserve the well-being of all beings, and to increase theirmaturity to discuss policies and to make informed
decisions. The pandemic has provided many opportunities
for re lection on the ef icacy of response towards bioethicalimperatives. It has not been easy to face the challenges.
From a dynamic perspective, one of the consistent aspectsof policy response has been the application of simple
responses to complex issues, as well as short-term
appearance versus long-term effects.
The hard truth is that many of the responses to the
COVID-19 pandemic exacerbated unhealthy conditions.
This may have been a result of misunderstanding, malintent, fear of the pandemic, and/or an opaque vision ofsociety. Together, it has resulted in dilemmas far beyond
the biological effects of the virus. Attempts to in luence
health and well-being are essentially futile, if applied
without holistic facts. There may be fractal logicalfractures, repeating at scales and causing more fracturesand fragility, rather than providing solutions. Simple
solutions, which ignore these facts, create dislocations thatdamage the whole.
There are plenty of negative situations arising frommisunderstanding, mal-intent, and/or opaque visions,
including foremost the discounting of myriad healthproblems other that COVID-19, discounting of social andpolitical grievances, and economic realities. These have all
been rolled up into the container labeled Sars-Cov-2, andsummarily made worse, rather than better for the mass
majority of humans.
The cumulative result is that unsustainable extremes
that will repeat ad-in initum, ad-nauseum must bereconciled. The failures of policy to this point can still be
remedied if the right lessons are learnt and responses
applied. The big challenges are economic, psychosocial,and structural, and may impact all facets of life.

Structurally, society must not simply be thought of as gears
and cogs moving in a direction, or its antithesis regarding
any opposition or resistance. Rather, we must integrate anunderstanding of energetic dynamism and non-directional
pathways, which balances the bene its of lower
dimensional chaos with the divergent risks of higher
dimensional chaos, with the caveat of quantum
absoluteness. Achieving this awareness in society will
require that past assumptions and expectations continually
face re-evaluation with evolving awareness.
Psychosocially, dissonance is prevalent as a result offractured order, best described as an independent
divergent localized perspective which is made worse as thecoercive dominant ill the narrative vacuum; it is a form ofchaotic dislocation. In some cases, dampening those voices
will be bene icial and in others, elevating the quiet will be
the best option. Discourse in the public sphere can be ahealing force. Tolerance of divergent views is where thesociety begins healing.
The challenge of holism is to acknowledge the repeating
fractal aspects of an ideology, for better and for worse. It iseasy to promote holism, but it is the most dif icult to enact
it. This is most true in the economic sphere of life. One
example for the need to correct simple responses tocomplex issues and the failure to do so can be found in tax
receipts. Governments knowingly or unknowingly createda Faustian dilemma once they arbitrarily judged somebusinesses as essential and others as non-essential, thus
placing themselves as the determiner of values beyond
their capability, morally or legally, to calculate. It is a newtwist on the classical dilemma whereby picking up the tool
forces them into an impossible role to play. It is
detrimental to the populace as they become dependent onsuch subject arbitrations that cannot meet the necessary
demands. Overall, it ensures entropic rei ication in a
dynamic whereby the lower path becomes the only path, ashigher-awareness and higher-complexity balances aretraded for overly simple energetic balances.
In each society, and at each lockdown, the de initions ofessential have shifted. Inadvertently the rule-makers usedtheir position to pick losers and winners in society. Thiseconomic suppression has and will continue to hurt the
governments and the citizens which trust them. Inclusive
capitalism it is not, it is the very de inition of exclusive
privilege, and it repeats at scales and function.
If we are to enact inclusive capitalism, which is notcorrupted from the inception, we must end the arti icially
imposed scarcity, and its counterpart of manipulated
demand. The goal becomes one of sustainable abundancy
that repeats at all scales, allowing for the bene icial
distribution of resources and the moral agency needed tosustain a higher complexity of homeostasis without thesuffering caused by disproportionate in lationary effects.
The creation of a re lective index that is a non-linear
calculation of connectivity and distribution ratios, andgrowth curves of local resources, will be helpful. The
diversity of homeostasis on a directionally non-binary
index, once achieved, will provide a dynamic map that willEubios Journal of Asian and International Bioethics 31(1) (January 2021)
correlate with in lationary and de lationary pressures
integration into classical accounting systems, with the
caveat of incentivizing the non-exploitation of nature.
Recommendation 7:
Create an index that in essence is an anti-misery index,
perhaps called the ‘Potential Abundancy Index’. It
should account for the connectivity, and potential foraccess of individuals to the totality of resources in thelocality of the measurement, the growth of resources,
and the score made relative to other localities, without
a singular point of reference, but a dynamic loatingscore, in a loating continuum. It should also
incorporate other factors of importance including thehurdles to connection, such as gatekeeping functions,and entropic costs as a score detractor.
Selected References
Board of Governors of the Federal Reserve System. (June2020). Monetary Policy Report – June 2020.
Department of Health and Social Care, Of ice for National
Statistics, Government Actuary’s Department and Home
Of ice. (April 8 2020). Initial estimates of Excess Deaths
from COVID-19. Retrieved from https://
assets.publishing.service.gov.uk/government/uploads/
system/uploads/attachment_data/ ile/892030/
S0120_Initial_estimates_of_Excess_Deaths_from_COVID-1
9.pdf
Headey, D. et. al. (2020). Impacts of COVID-19 on childhood
malnutrition and nutrition-related mortality. The Lancet,
396: 519-21. Retrieved from https://www.thelancet.com/article/S0140-6736(20)31647-0/
fulltext
Deutsche Bank Research. (May 8 2020). Honey, we shrank
our economy! Deutsche Bank AG/London.
Dieppe, A. (2020). Alistair Dieppe. Washington: World Bank
Group.
Joffe, A. (2020). COVID-19: Rethinking the Lockdown
Groupthink. Preprints, 2020100330 (doi: 10.20944/
preprints202010.0330.v2).
Macer, DRJ. (1998). Bioethics is the Love of Life. Eubios
Ethics Institute.
Raworth, K. (2017). Doughnut Economics. Business Books.
Rorty, R. (1989). Contingency, Irony and Solidarity.
Cambridge University Press.
UNESCO (2005). Universal Declaration of Bioethics andHuman Rights.
World Bank Group. (June 2020). Economic Prospects.
Washington: World Bank Group.

Members, World Emergency COVID19 Pandemic
Ethics (WeCope) Committee

h t t p s : / / w w w . e u b i o s . i n f o /world_emergency_covid19_pandemic_ethics_committ
ee

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Dr. Thalia Arawi (Lebanon)
Dr. Mouna Ben Azaiz (Tunisia)

7

Dr. Lian Bighorse (San Carlos Apache Nation, USA)
Dr. Andrew Bosworth (Canada)
Dr. Rhyddhi Chakraborty (India, UK)
Mr. Anthony Mark Cutter (U.K.)
Dr. Mireille D'Astous (Canada)
Dr. Ayoub Abu Dayyeh (Jordan)
Dr. Nilza Maria Diniz (Brazil)
Dr. Hasan Erbay (Turkey)
Prof. Nader Ghotbi (Japan)
Prof. Abhik Gupta (India)
Prof. Soraj Hongladarom (Thailand)Prof. Miwako Hosoda (Japan)
Prof. Dena Hsin-Chen Hsin (Taiwan)
Dr. Anower Hussain (Bangladesh)
Prof. Bang-Ook Jun (Republic of Korea)
Prof. Hassan Kaya (South Africa)
Dr. Sumaira Khowaja-Punjwani (Pakistan)
Prof. Julian Kinderlerer (South Africa)
Dr. Lana Al-Shareeda Le Blanc (Iraq)
Prof. Marlon Lofredo (the Philippines)
Prof. Manuel Lozano Rodríguez (Spain)
Prof. Darryl Macer (New Zealand)Prof. Raffaele Mantegazza (Italy)
Dr. Aziza Menouni (Morocco)
Dr. Endreya Marie McCabe (Delaware Nation, USA)
Dr. Ravichandran Moorthy (Malaysia)
Prof. Firuza Nasyrova (Tajikistan)
Dr. Suma Parahakaran (Malaysia)
Prof. Maria do Céu Patrão Neves (Portugal)
Prof. Deborah Kala Perkins (USA)Dr. Laura Victoria Puentes (Colombia)
Prof. Osama Rajkhan (Saudi Arabia)
Ms. Carmela Roybal (Tewa Nation, USA)
Prof. Mariodoss Selvanayagam (India)
Prof. Mihaela Serbulea (Romania)
Dr. Sukran Sevimli (Turkey)
Dr. Jasdev Rai Singh (England)
Dr. Raquel R. Smith (USA)Prof. Ananya Tritipthumrongchok (Thailand)
Dr. Kayo Uejima (Japan)
Prof. Erick Valdés Meza (Chile)
Dr. Lakshmi Vyas (UK)Prof. Yanguang Wang (China)
Prof. John Weckert (Australia)
Dr. Anke Weisheit (Uganda)

Inquiries to: Prof. Darryl Macer, Chair, WeCope
Committee; Email: darryl@eubios.info Tel.
+1-949-439-9307.
This statement is published in Eubios Journal of
Asian and International Bioethics 31: 2-7.

8Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

Reflections on the impact of
COVID-19 pandemic on life and theworld- Ravichandran Moorthy, PhD
President, Asian Bioethics Association
University Kebangsaan Malaysia- Gabriel Tyoyila Akwen
Department of Political Science
Federal University, Gashua Yobe State-Nigeria

Abstract
The COVID-19 pandemic has presented the world with anunprecedented global challenge that has impacted almost
everyone. The pandemic has caused major disruptions insystems of work, education, inance and in domestic affairs,
affecting nearly every aspect of people’s lives. Besides
health and safety, this pandemic also caused havoc in the
lives of people, in lockdowns, movement control, school
closures, high levels of emotional distress, higher risks ofviolence and increased food insecurity. Drawing fromexperiences of some countries around the world, thispaper re lects on the said impacts, challenges and futurescenarios of this pandemic to individuals, communities,
and nations.

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Introduction
The COVID-19 pandemic has presented us with anunprecedented global challenge, touching every
community in every nation of the world. The pandemic is
causing systems of work, education, inance and domestic
lives to grind to a halt, affecting nearly every aspect ofpeople’s lives. Besides the impact on health and safety, thispandemic also has caused havoc in the lives of people, in
lockdowns, movement control, school closures, high levelsof emotional distress, higher risks of violence andincreased food insecurity. The impact of the pandemic has
been estimated to double its adverse effect on the lives ofpeople. The socio-economic chaos caused by COVID-19 isindeed widespread and devastating – a large number ofpeople are already at risk of sinking into abject poverty,“while the number of undernourished people, currently
estimated at nearly 690 million, could increase by up to 132
million by the end of the year” (WHO, 2020).
Business entities and enterprises that support
workforce are facing great challenges to survive thisordeal; many had already crashed, leaving their workforce
jobless. Globally, it is estimated that almost half of the 3.3
billion workforces are in danger of losing their jobs. The
most vulnerable are workers in the informal sectors“because the majority lack social protection and access toquality health care and have lost access to productive assets”(WHO, 2020). Especially for daily wage earners, loss of
income translates into the inability to feed themselves andtheir families. Protracted movement control or lockdowns
in an extreme situation, will pose serious food security
issues, especially with the vulnerable segments of societies.

In this paper, the authors wish to re lect on some impacts,
challenges and future scenarios of this pandemic toindividuals, communities, and nations.

How the pandemic impacts lives?
Public health
The COVID-19 pandemic is the worst public health crisis
the world has faced in over a century. Initially, most
COVID-19 cases were con ined to the Wuhan province andwithin the Chinese borders, but the subsequent months
saw a steady rise in spread to other nearby regions andeventually to the whole world. Air travel and movement ofpeople across borders and regions have greatly intensi ied
the spread of this virus. As of 16 December 2020, there
have been 72,196,732 con irmed cases of COVID-19,
including 1,630,521 deaths, reported to WHO (WHO,2020).
The World Health Organisation (WHO) declared theoutbreak as a Public Health Emergency of International
Concern on March 11, 2020 (Sharma and Bhatta, 2020).
Despite the advice by WHO and actions taken by nations
worldwide, the spread of virus appeared unstoppable.
Many countries have experienced cycles of a spike of cases.
Malaysia, for example, had managed to bring down dailycases to single digit in mid-2020, only to see a subsequent
high spike. This pandemic has placed enormous stress on
the public health capacities of countries. Many countries
had to divert their resources from other sectors to publichealth. As the number of cases rises, health facilities needto cope with the increase in patients demanding
specialized care, placing enormous stress to the publichealth system. Many poorer countries with large and dense
population struggle to manage the crisis adequately. Many
countries struggle to provide adequate testing kits, medical
supplies, personal protective equipment (PPE) to its frontliners and patients, and its timely distribution to affected
centers. Front-liners such as doctors, nurses, paramedics
and irst responders and the overall public health system
may be ill-prepared to deal with the pandemic. To mobilize
resources and direct them to targeted areas of response
requires a robust crisis management system in place;
without it, there will be ineffective use of resources,
resulting in the frustration of the general public. For
example, “the hospitals in Nepal lack Intensive Care Unitfacilities, isolation wards and medicines to treat COVID-19.
Additionally, the implementation of infection prevention andcontrol mechanisms are not strictly followed” (Sharma andBhatta, 2020).
The measures taken to contain the pandemic, such as
lockdowns, stay-home curfews and movement control haveincreased the incidents of domestic violence and mental
health problems. This situation requires adequate healthinterventions in affected communities, as without suchinterventions, family and community institutions can be
impacted. Further, extended lockdowns can result in foodshortages, and may contribute to childhood malnutrition.
The longterm impact could well be a rise in the incidenceof chronic conditions attributable to the ack of physicalexercise and loss of income and livelihood. The resource
committed to deal with COVID-19 pandemic has
overstretched the capacity of many countries. In turn, this
scenario will reduce the capacity of many health systems tocope with existing disease burdens; cessation of routine
surgeries, health checks, and immunization programs may
cause outbreaks of preventable communicable diseases,
rising cancer rates, and increasing numbers of late-stage
complex medical conditions (Haw et al., 2015). It is alsofeared that the ensuing economic recession and job loss
may result in extreme stress to people, especially those
who are directly impacted with the scenario – which may
increase suicide rates in societies.

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Food insecurity
Before the advent of COVID-19 pandemic, many regions of
the world had already faced major food insecurity,
resulting from political con licts, rise in internallydisplaced peoples (IDP) and refugees, degrading socioeconomic conditions, disruption of food supply chains,impacts of natural disasters, climate change and fooddestroying pests. The increase in global food insecurity has
negatively impacted vulnerable communities in many
regions of the world. Although there is an adequate supplyof global primary food (grains) with relatively stableprices, many countries have experienced “high food pricein lation at the retail level, re lecting supply disruptions due
to COVID-19, currency devaluations and other factors”(World Bank 2020). Many countries have tried to control
the prices of their primary commodities, which enable less
luctuation of major food prices. However, the restrictive
nature of lockdowns inevitably pushes prices up. In suchsituations, countries with low and middle-income
communities will face more severe impacts, as a larger
portion of their income is spent on food compared to highincome communities. With reduced incomes, many
vulnerable communities may have to reduce the quantityand quality of the food they consume. It has been
forecasted that “an additional 137 million people could faceacute food insecurity by the end of 2020, an 82 percent
increase compared to the pre-COVID estimate of acutely foodinsecure people in the world” (World Bank, 2020; Anthem,2020).
The impacts of food insecurity during the pandemic arelikely to be diverse within and across countries. As alluded
earlier, people in the informal economic sectors andvulnerable groups, such as the unemployed, women andchildren are likely to be impacted severely. Poorer
communities are more likely to feel the pinch from a hikein food insecurity, because of their liquidity and cash- low
constraints and lower adaptive capabilities (Smith andWesselbaum, 2020). In addition to the pandemic,
agricultural and natural disasters such as extreme weather
events and pest problems can hurt food production andcreate further stress on the local, national, and regional
food systems (Haw et al., 2015). According to a UN report,
food insecurity and displacement are linked closely. “Nineout of ten of the world’s worst food crises are in countriesff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

9with the largest number of internally displaced persons,while the majority of displaced people are located incountries affected by acute food insecurity and malnutrition”(UN News, 2020). To add to this dilemma, COVID-19
mitigation efforts like border closures, trade restrictions
and movement control measures have made it dif icult forfood producers to access markets, subsequently disrupting
food supply chains. The sluggish economic environment
has also resulted in job loss and disrupted the livelihood of
millions of people around the globe (UN News, 2020;
Ejembi et al., 2020).
Education
Education is another sector that is badly hit by the
COVID-19 pandemic. In an attempt to stall the spread of
COVID-19, many governments around the globe have
momentarily shut schools and institutions of higher
learning. This was done to effectively enforce physicaldistancing. According to the UN Educational, Scienti ic andCultural Organisation (UNESCO) about 60% of students areaffected by the COVID-19 pandemic worldwide, and about
1.19 billion students are out of school in 150 countries of
the world (UNESCO Education 2020). COVID-19 led to theannulment of the 2020 examinations conducted byCambridge International Examinations (CIE). The affected
examinations include Cambridge IGCSE, Cambridge O
Level, Cambridge AICE Diploma, Cambridge International
A Level and AS, and Cambridge Pre-U examinations
scheduled for May/June 2020 throughout the world(Upoalkpajor & Upoalkpajor, 2020). The closure of schools
has not only reduced the enrolment percentage andlearning for now, it has the potential of increasing thenumbers of school dropouts in the long run. This cannegatively affect socioeconomic opportunities in the future.
The effects of COVID-19 as it relates to school closures
are projected to have an extremely negative impact on thevulnerable and risk intensifying the prevailing universal
inequalities. With the prolonged spread of COVID-19
pandemic, susceptible children will have insuf icientprospects to learn at home. Most of the children in thiscategory may not have access to internet facilities. Even to
the privileged students, the migration from the school
environment to home-based teaching may not produce thedesired result. This is because home-based teaching ismeant to augment the school-based teaching. For instance,
parents are supposed to complement children
mathematics lessons by practicing mathematics at home.
There is no doubt that many parents around the world will
be able to effectively school their children at home. Thiscannot be said of the general population. Certainly, there
are some signi icant disparities among families in theextent to which they can assist their children’s learning(Oreopoulos et al., 2006). Many parents may not have theluxury of time to commit to teaching their children. Again,
the non-cognitive abilities of the resources and thequantity of knowledge is an issue. Consequently, theseincidents would lead to an increase in the discrepancy inhuman capital growth for the affected partners.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
The serious short-term interruption of schools is felt by
many families around the world. Home-schooling is not
only a major shock to the productivity of parents but also
the learning and social life of children. Without testing,teaching has quickly moved online, alongside student
assessments. This spontaneous movement comes withuncertainty for all parties to the education sector, as
everyone is involved in one form of trial and error or theother. Numerous continuous assessments have beenhaphazardly graded or cancelled (Burgess and Sievertsen,2020). According to Marinoni et al. (2020), the African
continent has 77% of higher education institutions (HEIs)
closure, while Asia Paci ic and Europe have 55% apieceand that of Americas stood at 54%, even though at the timeof their survey Africa was not the worst hit by the
COVID-19 pandemic. This shows that the African leaders’precautionary measures led to a high percentage of HEIs
closure.
The percentage of HEIs has affected both the admissionof local and international students in all theaforementioned regions. This shortfall may snowball to
2021 because families and students are badly hit and are
yet to recover from the consequences of COVID-19
pandemic and may not have the wherewithal to pursue
higher education at the moment or the near future.
The suspension of in-person classes’ or school closureand the implementation of distance education canunhelpfully affect students’ education via four major ways:
less time devoted in learning, stress symptoms, change inthe manner of student’s interaction, and the dearth oflearning enthusiasm (Di Pietro et al., 2020).
Another impact of the COVID-19 pandemic on
education can be seen in the shrinking of the inancial
space to fund education, as a result of the shock on
government income and economic slump. In developing
states numerous items in the 2020 education sector budget
may not be executed due to the swinging inancial
shortage. Nevertheless, more funding is needed to preserve
the learning process as part of the state's palliative
procedures. The most pressing needs for governments
around the world at the moment is how to improveteachers' incentive, learners' readiness and stimulate local
digital and media enterprises (Upoalkpajor andUpoalkpajor, 2020).

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Impact on cities and urban centers
In highly urbanized cities, the typical pathogen exchangemechanisms of COVID-19 transmission are exacerbated, so
it is no wonder that 95% of all COVID-19 cases worldwide
have occurred in cities and urban areas (UN-Habitat,2020). Therefore, disease prevention is a crucial concern inurban planning. Approximately one billion people globally
live and work in informal, under-serviced and insecureurban environments, and billions more depend on patchy
and inadequate piped water, power, and affordable
healthcare in cities with declining infrastructures.
Restraints of the precarious places in which individuals live
and work signify that it is practically impossible to

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segregate the people with symptoms. Apart from this, mostessential workers such as cleaners and waste collectors incities and urban places are prone to high-risk. This
category of workers is the lowest paid in most urban areasof the world. Therefore, lockdowns in cities and urban
areas have resulted in extensive economic dif iculty andjob losses, mostly for migrant employees and their families.
The above situation can also affect low-income states,
especially those in Africa that depend on inward
remittance. Up to 16% of the GDP of African state comesfrom remittances from Europe, America, and Asian
countries that experienced lockdown in most of the year
2020 (The Economist, 2020).
The COVID-19 pandemic showed that cities and urban
areas are extremely fragile; therefore, their inhabitants areunsafe. As of 1 June 2020, the global spread of COVID-19
stood at above six million identi ied cases and more than
371,000 deaths, predominantly amongst city/urban
residents (WHO, 2020). At the metropolitan level, thesocial distancing procedures, movement restrictions, andclosure of public restaurants put in place by governments
have obstructed food consumption behavior. This canimpact on diets. Also, some cities experienced panic
buying, leading to hoarding of goods by supermarket
owners (Pulighe and Lupia, 2020). The lockdown strategy
also extensively impacted on economic and societal costs
in urban areas. In many urban centers, mostly indeveloping countries, lockdowns in reaction to the spreadof COVID-19 have cast light on many economic and social
concerns, some of which include homelessness, healthcare,debt, and food insecurity (Björklund and Salvanes, 2011).
The situation is made worse by the fact that most of thecity dwellers in this context are daily wage earners. This
corroborated the position of Braimah (2020), which showsthat the lockdown measures in most African cities have led
to utter poverty, Job losses, family pressure, hunger, andincompetence to pay bills.
On a positive note, the outstanding lockdown
procedures to render our city streets empty with limited
vehicles have improved the quality of air in our cities at thetime of lockdown. This means that if we eradicate all
combustion automobiles from cities by permitting a few
public means of transport and the transport of essential
supplies, the quality of our air improves greatly. Thisinding wouldn’t have been possible without COVID-19.
Lockdown measures have resulted in the availability ofclean air in urban/city areas. During the lockdown period,
the news thrives with descriptions of extraordinarily blue
skies and improved visibility. Observers disclose a severe
decline in gas and particle smog over cities in situations of
con inement (IQAir, 2020). Cities of Delhi, London, Los
Angeles, Milan, Mumbai, New York, Rome, São Paulo, Seoul
and Wuhan have registered reductions ranging between−9% and −60% compared to 2019 data, and between +2%
and −55% compared with the prior four-year average(Baldasano, 2020:2). Limited economic activities during
the lockdown in most cities have also promoted cleaner
environments. There is a signi icant drop in air pollution

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
because COVID-19 has reduced all travel. “COVID-19
pandemic is shutting down countries across the world,
causing a signi icant decline in air pollution in major cities
as countries implement stricter quarantines and travel
restrictions” (Macer et al., 2020:406)

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Con lict zones, refugees and displacement
Before the advent of COVID-19 pandemic, con licts were acritical social determinant of health, yielding broad healthconcerns ranging from limitations on health systems tohitches in accessing and delivering health services.
COVID-19 increased governments’ capacity to use limitless
executive authorities that could exacerbate crises and havean overwhelming impact on con lict-affected populaces.
Even though the UN Security Council has called for aninternational truce in con lict areas to allow safe passage todefenseless populations for teaching them how to preventand respond to COVID-19, this call has not been followed.
Global treaties and peace agreements have also been
unheeded as the world concentrated on the COVID-19
pandemic. Also, as observed by the UN High Commissioner
for Human Rights, COVID-19 brought about an alarming
increase in security agents brutality and violation ofhuman rights under the pretext of emergency proceduresto curb the pandemic (Haw et al., 2015).
The dif iculties faced by the masses as a result of
COVID-19 prevention measures have triggered protest inparts of the world. In Africa, for instance, some countries
like Malawi, Nigeria, Rwanda, Kenya, Ivory Coast South
Africa and Zimbabwe experienced protests. These protests
met with police brutalities attempting to prevent themasses from violating the lockdown orders. In states like
Uganda, South Africa, Kenya, and Nigeria, there arereported cases of police confrontation and subsequent
death of poor citizens. In South Africa, security agents havebeen indicted for employing extreme force while executing
COVID-19 lockdown measures (Miller, 2020). They havearrested over 230,000 people and are accused of being
responsible for the death of 11 South Africans (Haffajee,2020). In Nigeria, police brutality was witnessed in states
like Ogun, Lagos, and the Federal Capital Territory. The
ruthlessness by the police negates some of the proceduresthat allow people to go out for essential reasons like thepurchase of foodstuff and medication. While there were
400 established cases and 12 deaths in Nigeria, the death
toll arising from extrajudicial execution by law
enforcement agents stood at 18 people (Aljazeera, 2020).
The lockdown strategy has also affected refugee andinternally displaced persons (IDPs). As for humanitariansituations, most governments have postponed receiving
new refugees and asylum seekers. For instance, in Uganda
from 25 March 2020, refugee response centers at theboundary points and the Department of Refugees (DOR)
of ices in Kampala were closed (Bukuluki et al., 2020).
While these measures were aimed at curtailing the spreadof COVID-19, they also had negative implications on the
refugees and other vulnerable groups (Mbiyozo, 2020).
This also negates the United Nations High Commissioner

11

for Refugees (UNHCR) policy on refugees, which states thatrefugees in all settings should be given access to safe,
cheap, enough and nonstop water to cover domestic andpersonal uses (UNHCR, 2019). This is goal number 6 of
Sustainable Development Goals (SDG), which is toguarantee availability and effective management of waterand hygiene for all people by the year 2030 (Bukuluki etal., 2020). In situations of lack of access to water, refugees
in cities will face challenges to stick to public healthprocedures, such as self-isolation, improved hygiene, andsocial distancing (Kluge et al., 2020).
Refugees are prone to the risk of poor healthconsequences when contracting COVID-19, aggravated bypoor living standards and hurdles in accessing healthcare.
This makes them the most vulnerable among all categoryof the population. The situation in Sweden can be used tobuttress this point. It was discovered that during 2020
period of the COVID-19 pandemic, refugees in Sweden who
were previously confronted by challenges such as
unemployment, crowded living conditions and strains in
obtaining health care were the worse hit (Mangrio et al.,2018). In Sweden, more migrants have died due to
COVID-19 compared to the rest of the population(Elisabeth et al., 2020). A good number of these refugees
who died in Sweden as a result of COVID-19 pandemic
were from Eritrea and Somalia. As usual, the refugees
dwelling places are overcrowded and socially destituteareas of Sweden (Valeriani et al., 2020). More so, Truelove
et al. (2020) substantiate the ongoing argument, when they
posit that the COVID-19 pandemic has more dreadfulconsequences in refugees’ camps than the overall
population in Bangladesh. Most of the con irmed COVID-19
cases are Rohingya refugees from Myanmar, with about
600,000 found in the Kutupalong-Balukhali Expansion Site
(Truelove et al., 2020)

Conclusion
The COVID-19 pandemic can be viewed from social
perspective, mainly from vulnerability and resilience
discourses (Moorthy, Benny & Gill, 2018). While thispandemic has impacted people across the globe, as
discussed earlier, the groups in the lower societal strata are
more severely impacted. Therefore, it is criticallyimportant to put in place robust systems and mechanismsthat can increase the resilience of these groups to face thispandemic. It is time for the international communities topull support and resources to assist the most vulnerable
segments in our societies. There should be concerted
global initiatives to soften the impacts of COVID-19,
especially in the health, economic and social sectors.
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The Economist (2020). COVID-19 might not change cities as muchas previous pandemics. Economist. https://www.economist .com/books-and-arts/2020/04/25/
covid-19-might-not-change-cities-as-much-as-previouspandemics. [20 December 2020]
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Organized religion, spirituality and
COVID-19- Darryl Macer, Ph.D.
President, American University of Sovereign Nations, New
Zealand/USA
Email: darryl@eubios.info
Abstract
There appears to be a signi icant difference between
organized religion and spirituality. In this paper I willcompare both and explore some impacts of thesedifferences in terms of the way that people of faith have
responded to the COVID-19 pandemic, how people havebeen exposed to the virus through religious sites andfestivals, and how religious institutions have responded to
the COVID-19 pandemic.

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The function of religion
There are a number of functions of organized religion forhuman lives. In terms of the worship of the Creator God,
many people have addressed a need for some form oforganization to provide order or a direction of our
spirituality through the establishment of various religious
practices. Spirituality is generally associated withimproved emotional health (Kowalczyk et al., 2020), as
well as with better outcomes from medical treatment (Bestet al., 2015).
There are a number of references in different faithsystems to the advantages of more than one person
praying together, or praying in large groups at the sametime, whether that be in the daily prayer services found in
temples, churches and mosques or sharing prayers at thesame ive times in the day among the followers of Islam. It
may also be in prayers to the rising sun in Shinto or Apachereligion. We also see ritualized prayers at certain times in
our lives such as birth, death, circumcision, or teenage
con irmation of faith or coming of age ceremonies. We also
see even some details in the placement of our hands inprayer that range across culture.
I have observed very religiously observant elderly ladies
in both Catholic countries and Buddhist countries, who
ind the religious rituals and organization in theirrespective places of worship a great comfort to them. They
may light candles or light incense, with the energy of ire,and the smell, as well as the symbolism of the burning of alame that will be temporary, as is life. These symbols that
remind us of our mortality may well be useful reminders ofseeking God and our need to pray. They also should remind
us that the faithful in their hearts will ind organization ofreligious services in their own village and circle to which
they are born and live in, a route to spirituality. That may
be because of their genes, their parents, and the spirit
living in their culture.
Religion has had mixed impacts on the environment.
Some particular animal species are seen messengers of
spirits and of God, so that particular birds may be seen as

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

13

messengers of God or evil, the presence of a black catmaybe an omen in some culture, and a wandering deer
from the forest may be seen as a messenger of spirits.
Many taboos on the hunting of animals or the picking ofplants, serve as important preservers of biodiversity(Bosworth et al., 2012). Before you ever belittle a custom
or a taboo, learn more about the wisdom it may represent.
The false dichotomy and spiritual snobs
Some critics of organized religion, strict adherence todenominations of faith, and religious rituals, may attack
what they see as a super iciality of organized chanting,using words of distant languages such as Latin masses inservices, priestly clothes and hats, and other symbols offaith, claim that these are somehow distinct from true faithof direct connection to God through spirituality. It’s
actually snobbery to believe that one’s own faith andspirituality is better than another person, just because of arejection of organized religion.
In the same spirit, however, there are those who had adistinctly negative impression of organized religion that
may well have good reason to reject it. Over time aroundthe world, we can clearly see religious authorities may
become instruments of earthly oppression and repressionof the free spirit of human beings. There are many modern
incarnations of the Spanish inquisition and the “HolyCrusades”, and inter-religious con licts are often still tied tonationalism and political regimes. As a Christian, I see thisindependence of thought enshrined in the Universal
Declaration of Human Rights as freedom of belief, implicitin the concept of “Imago Dei” (The image of God). Rather tore lect the wonderful human diversity, we can argue thatwhatever gets you through the night, as long as you do notharm others, can be embraced as it builds our relationshipwith the Spirit.
Actually “smells and bells” (the expression that incense,
gongs and chanting with music) are forms of sensory
stimulation that can make many of us closer to thespiritual. It’s probably no coincidence that we can see
incense has independently evolved as a facilitator of
spiritual experiences in a number of religious spaces,
whether we be Russian Orthodox or Buddhists. These canbe vehicles of spirituality, but as Ghotbi (2021) writes,“Worshipping your religion is just creating another form of
idolatry”.
Inside the English traditions we may also ind this
distinction between the “High Church and Low Church”,
and the high Church tends to be associated to moreorganized religion including incense and a ixed religious
liturgy (Order of Service), whereas a low church maybe
freer in terms of the way that it teaches. However, tradition
still sets up a pattern in each space of worship, whether it
be a familiar drum beat, an electric guitar, drums and folk
music, or a pipe organ. All can ful il certain urges forhuman re lection and worshiping of God and spirit(s). I
appreciate that in some places we can seamlessly move
between both in the same day, depending on meeting theneed for some modern or classical music, some hour-long14

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
academic exegesis of scripture, ablution of our body towash our hands, feet and mouth, and a simple hug or smile.
We need all. God bless all.
Separation of us and them
The monotheism and polytheism debate is anotherexample of a snobbish argument that was often used incolonization, basically to say that my gun is bigger thanyours (i.e. My god is bigger than yours). We can see
elements of polytheism in Judaism (meant to be thefounder monotheistic religion pathing the way to
Christianity and Islam), and elements of monotheism in
Hinduism (meant to be polytheistic). There are traditions
in all faith systems of a balance between knowing ourCreator God and knowing many spirits, and also prayers to
our ancestors.
The exclusive clauses of salvation have sadly been used
to separate the “enlightened” from the “pagan”, and areeven still used to kill some people, and to suppress culture.
It certainly seems a paradox that someone who looks at thegrains of sand in a beach or a desert could think that they
have an exclusive revelation of the Creator. For the
Christians, the words that only through faith in Christ Jesus
can you enter the Kingdom of heaven, need to be balancedwith the teaching that God is all loving and there will
always be religious and faithful people that have not seen a
Bible.
The evangelist zeal to convert the “pagans” to one’s
religion has a number of misadventures, as well as a lot of
genocidal blood. Anthropologists changed this evangelicalfocus to writing books and papers about “lost” people, as
elements of encyclopedias to celebrate the conquests ofknowledge. Ironically the same rituals that were
suppressed as songs of the devil by evangelists ofChristianity and Islam, and some other forms of humancreativity, were applauded by some anthropologists –sometimes even shipping a few token indigenous people
who were not massacred to be circus side shows.
At the same time religion has brought out the best insome people’s creativity. Church music is a common art
form that is appreciated in the wider community wellbeyond Christians, and we actually see some broader
celebration of Christmas carols and Easter masses. We also
see participatory songs and dances in many religious
festivals. Likewise, we can ind the melodious chanting of
Buddhist monks something which also brings about afeeling of spirituality. The drumbeats of Native Americanmusic songs and particular dancing rituals, and the call to
prayer from the minarets of mosques, are also expressionsof organized music that please the ears and hearts of manysouls. We can also see meditation and yoga as techniquesthat can be seen in all religions, yet their rediscovery as
secular health techniques was led by reference to Eastern
spirituality.

Religion and the Pandemic
Religious leaders have important responsibilities in public
policy and health (Barmania and Reiss, 2021). It is beyond
the scope of this article to make any judgment on how
effectively those roles are performed, but some religious
leaders have led by example promoting hand washing andphysical distancing, wearing masks, and promoting
equitable distribution of medical resources and vaccines.
Barmania and Reiss (2021) present how religion isimportant for COVID-19 health promotion by examining
how religion plays an important role in determining how
likely it is that someone will get infected with COVID-19,
they draw on both complexity theory and approaches todealing with religion in science education to suggest how
religious leaders can help in the efforts against COVID-19.
I refer readers to some ongoing projects to map the
responses of religious authorities to COVID-19.3 Various
academic associations also have provided
recommendations, such as the American Psychological
Association.4 Religious faith can increase resilience toquarantine and other stressful situations that have been afeature of 2020 in most countries.
In some theological discussions the explanation of thetiming of rains, sunshine, plagues, pandemics, disastrous
weather, volcanoes, earthquakes and winds can be seen as
directly attributable to God speaking to our community. We
have the expression that this attribution of the unexplainedis the “God of the Gaps”, and with modern technology andunderstanding of weather patterns or tectonic plates, wedon’t need to refer to God as a reason for natural disasters,
or for the patterns of rain. However, if God is the creator of
all the universe, it doesn’t really matter if God is using
tectonic plates or weather patterns or chaos theory or
zoonotic transfer of diseases, to bring about the occurrenceof natural events. The necessity of chance can explain theway that the Creator God can allow randomness and chaos
to lead the way of the world (Polkinghorne, 1989).
Rather the real issue is the more interesting and a deep
philosophical question of predestination versus free will,
which we really will not know the answer to, because it’s
not a scienti ic question. You cannot prove that you believe
in God because God came to speak to you through God’sintervention, or through the prayers of the faithful friend,or God came to answer to your prayers directly. And
conversely you cannot disprove that events didn’t occur
because of human sin or the absence or power of prayer.
It’s rather a personal journey that we take as to how weattribute different events with different causes. Perhaps acommon response of both organized religion andspirituality is to say that we should be thankful foreverything that we are given whether it came about bychance or by divine intervention or by someone’s blood,
sweat and tears (i.e. hard work). As scientists we can

3 https://berkleycenter.georgetown.edu/subprojects/religious-responses-to-covid-19

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4 https://www.apa.org/topics/covid-19/faith-crisis

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
explore how much the in luence of genes, nurture,
television, capitalism, communism, culture and so on is,
but we actually have to respond to a more importantquestion.

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Religion and COVID-19
This brings us to the question of what are the demands ofyour faith that shape your response to the COVID-19
pandemic. The response of religion should be to feed thehungry and take care of the sick, and we can see somesigni icant progress in the expression of practical religious
faith systems through the solidarity seen by governments,
businesses and religious organizations in 2020.
The central ethical principle underlying science isbene icence, the pursuit of understanding of themechanisms of the world is founded in understanding thescienti ic mechanisms. This is not only seen in major faithsystems that have been critical for the advancement of thescienti ic method, Christianity and Islam, but also in someindigenous epistemologies of knowledge (Macer, 2015).
The former Head of State and former Prime Minister of
Samoa, Tui Atua Tupua Tamasese Ta’isi E i (2009)
described the importance of the Samoan concepts of tapu
(the sacred) and tofa sa’ili (the search for wisdom) in
identifying ethical practices for application in research. He
argues that it is possible to ind a middle ground between
ideas and practices grounded in religion, the spiritual, thesacred and science. Against the background of an
exploration of different facets of the Samoan concept of
tapu, which encompasses the sacred-ness of the origins of
all things as well as the af inity between people, thecosmos, and animate and inanimate earthly phenomena, heenvisages a Paci ic bioethics that reaching out for wisdom.
As many people lost their employment, soup kitchensand food delivery from religious organizations, has been apositive opportunity to show love. Some existing systems,
such as mission soup kitchens and Sikh Gurdwaras, wereideally set up to rapidly expand, and they have risen to thechallenge. Religious festivals have also been opportunities
for practical solidarity, from Diwali (Vyas, 2021) toChristmas. 2021 will be another test of faith as we see thescramble for the vaccines.
There is a common religious focus on mobilizing urgent
direct assistance to meet the social and economic needs ofvulnerable communities, and advocacy that gives voice tothe voiceless by pressing for action on and support to thesecommunities at all levels (G20, 2020). Many local faithcommunities are mobilizing support for food, shelter, andlivelihoods, but “Despite notable mobilization of volunteers
and inancial resources, religious community efforts toprotect and support vulnerable communities suffer fromweak coordination with, and limited support from, publichealth and other efforts, so that efforts over- all are far
more fragmented and less effective than could readily bepossible.” (p. 46). One of the questions that has emerged in
the pandemic is how does each society de ine, “essential
religious services”? Although we can ind commonalities
where faith systems come together, there have also been

15

reports around the globe of religious discrimination
hindering the responses to the pandemic, especially when
this occurred among religious pilgrims (Sarkar, 2020).
Hopefully, epidemiology and mortality have proven thatthe pandemic is not what some extremists said – namelythat it is a message from God to kill off sinful people,
because despite early claims of some faithful people thatthey would be safe in their house of worship, some housesof worship have actually been seats of severe infection. For
example, some of the early outbreaks in Korea were linked
to religious places of worship. Including the Shincheonji
Church of Jesus. A number of cases in Iran and Turkey werereported among those who visited Iran’s Shia Muslim holysites of Qom and Mashhad in February 2020 (Al-Rousan
and Al-Najjar, 2020). A large delegation of Islamic TablighiJamaat in Kuala Lumpur was the cause of the second waveof the pandemic in Malaysia, with attendees from the event
travelling to Brunei, Cambodia and Indonesia (Che Mat etal., 2020).
With regards to the irst question, it doesn’t seem that“sinful” people are being targeted by COVID-19; rather we
see a higher mortality rate in older people and people withpre-existing conditions. The mortality is also higher in men
than women. Despite the ageism that elderly people ind in
the normal ethical dilemmas of rationing of healthcare,futility, and organ allocation, it is a breath of fresh air thatthe elderly are receiving their vaccines irst in many
countries.
This false argument that sinful people will be killed off
because they are especially targeted by a virus or disease
was seen a few decades ago with the humanimmunode iciency virus (HIV) and AIDS, where my 1993
research on attitudes to disease found that many people
differentiated between so-called sinful people who got it
through their behavior, and so-called innocent people —the people who caught it through blood transfusions, or
medical malpractice (Macer, 1994). After decades ofresearch, most people can be effectively treated with drugs
to manage HIV, and many people in developing countries
have access to these drugs.
Another group of people that has severe effects after
infection by the sars-cov2-virus are those with pre-existing
health conditions. We shouldn’t argue that people who areobese, became obese because of over-eating or gluttony orthat they are dying at higher rate because of their sin.
Similarly, while some diabetics are at high risk, and somediabetics are diabetic because they have consumed too
much soda drinks and sugar, it is the food culture thatin luences people to become addicts to sugar. In one sense,
the disease is not very different to a number of wideranging infectious diseases that kill many babies andinfants in the world today, and people living in poverty areat higher risk. The response of providing vaccines to these
at-risk persons earlier, is one based on love of others, theGolden Rule, a common religious command.
Religious prohibitions that are linked to healthpromotion in some religions, include avoidance of drinking
alcohol, drug taking, gluttony, sexual activity with multiple

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
partners, and suicide. Conversely the Islamic and Sikh
recommendations to wash before a religious service, andexpressions such as “cleanliness is next to Godliness”, areimportant to reduce the spread of disease. This was aphrase popularized by the Methodist leader John Wesley inthe late eighteenth century (Callahan et al., 2010).
One of the central sacraments to the Christian faith isthat of holy communion, where people share bread andwine. In the irst lockdown in many countries all religious
services were prohibited including receiving holycommunion (Norman and Reiss, 2020). In a number ofcountries this communion service uses grape juice rather
than wine, and also uses individual cups rather than
drinking from the same container that is merely wiped by acloth between mouths. One could expect the global natureof COVID-19 and public health education will further pushcommunities towards the use of individual cups as amatter of hygiene. In some cultures where the climate
permits, religious services have shifted to outdoor settings
only.
Religious leaders have also taken important roles in
reducing the spread of disease through both the gatheringof large numbers of people at funerals, and also touching
the dead body. Jaja et al. (2020) described how funeralgatherings in South Africa were linked to some spreadingof COVID-19. There are reports that in some countries,
including Indonesia, families took their dead relatives
bodies from morgues to ensure that they received a proper
burial (Karmini and Milko, 2020). Although COVID-19 is
not so severe as Ebola, it is still a public health risk.
The centrality of intensive interactive rituals that are tied
to the communal bene its of religion (e.g., social support,
emotional catharsis, perceived healing) will result in acontinual tension between many religious groups’ desire
for in-person gatherings and the social distancing
requirements necessary to limit the spread of COVID-19
and other infectious diseases (Baker et al., 2020). For those
who research the sociology of religion, the impact of theshift to Internet based gatherings of worshippers is aninteresting research question, with overlaps to theconcepts of virtual meetings in all spheres of our human
co-existence.
Religious exceptionalism is something I have seen in the
United States, reinforced by interpretations by theSupreme Court that freedom of religion is more important
than following public health policies to avoid having
crowds of people gather together.5 This decision wascounter to public opinion where 4 in 5 persons opposed
separate standards for places of worship.6 Even we indthat some religious followers still reject masks, believingthat God will protect them.
Perry et al. (2020) found that “Analyzing panel datacollected in the thick of the COVID-19 crisis, we ind Christiannationalism was the leading predictor that Americans
engaged in incautious behavior like eating in restaurants,
visiting family/friends, or gathering with 10+ persons(though not attending church), and was the second strongest
predictor that Americans took fewer precautions likewearing a mask or sanitizing/washing one's hands.
Religiosity, in contrast, was the leading predictor that
Americans engaged in more frequent precautionary
behaviors.”
The issue of religious freedom is a sensitive one
everywhere, and a political issue in the United States,
which has the largest toll in human lives lost to COVID-19.
Better communication may have avoided the emergence ofa confrontation between a right to gather to worship andthe necessity of public health restrictions on gatherings ofmultiple people. One could predict that it is more likelythat the general public will criticize religious places that
promote an exceptionalism for religious services,
especially as more infections are spread. Evolution would
predict that the types of mutations to make the virus moretransmissible detected at the end of 2020 will become evenmore common.
There are a variety of approaches to deciding whether apractice is ethical or not. In the Western Abrahamic andpost-Enlightenment worldviews, there is a strong belief
that universal values can be realized through objective
criteria. Contrastingly, the Indic systems believe that while
universal values exist, they are not achievable, because
human beings apply their own subjective experiences andemotions to their knowledge of values (Singh Rai et al.,2010). Therefore, whereas the former ascribes a degree ofobjectivity as a prerequisite for legitimacy, the latter
considers subjectivity as a major in luencing factor speci ic
to individuals, groups, cultures, and so on. This world view
will tolerate many individual choices as long as they do not
do harm and will also tolerate belief in attempting to
improve ourselves.
End of life Care
There has been signi icant criticism of the decisions taken
by many medical authorities and hospitals, especially inthe early months of the pandemic, to refuse permission forthe loved ones of dying patients to be at the bedside of
persons dying from COVID-19. Although video telephone
calls were often provided, these are not a substitute forholding the hand of a spouse, parent or child, when the
person in dying.
There are also concerns that the loved ones may not beable to personally see the dead body of their loved one.
Religious and cultural values are violated by such practices,
and accommodations to the public heath rules need to beconsidered.

5 https://www.usatoday.com/story/news/politics/2020/12/15/churches-take-covid-19-supreme-court-sides-religious-freedom/

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Many of the ethical issues raised by COVID-19 are notunique to the disease. Decisions over the extent that life
sustaining treatment should be applied, and when it should
be removed have been explored in medical ethics. Hsin andMacer (2006) found that the Taoist idea to low withnature in the refusal of excessive life sustaining treatment
was shared among elderly Christians, Buddhists andfollowers of other religions in Japan, New Zealand andTaiwan.

Jayapaul Azariah, Helena Martin, Yeruham Frank Leavitt,
Farhat Said-Pervaiz, Joanna Hammonds, Ananya
Tritipthumrongchok, Lian Bighorse, Paul Hammonds, Tim
Forester, Sahin Aksoy, Minakshi Bhardwaj, Timothy Boyle,
Jasdev Rai Singh, Sang-yong Song, Nader Ghotbi, Mihaela
Serbulea and Wendsler Nosie, for the discussions on thispaper, prayers, support and joy of life.

Unity and solidarity
The year 2021 offers a chance for our world to showsolidarity. There is some rejection of those who don’t wear
masks, and I sometimes see the comments that someone
didn’t wear a mask and therefore they deserve to havecoronavirus. Sadly, some people are taken in by conspiracy
theories that deny the virus, even as they utter their lastwords before being intubated.
God will protect us through wearing a mask andfollowing the science of public health. It is a blessing if God
gave you an immune system that will protect you, but
asymptomatic people can still spread the virus to others
who are not so blessed.
If someone was not taught proper hygiene, then teach itto them; do not blame them. Particular groups of people
living in crowded rooms, slums, refugee camps, usually did
not enter these spaces because of their free will.
Fortunately, in the world today, most people see a disease
as more actively attacking those born with an unfortunate
genetic lottery, those living with poor nutrition and inpoverty as victims of the economic system, rather thanbecause of any moral fault of their own. There needs to behealth evangelism rather than a culture of the saved andthe unsaved – be the change in the world that you desire.
Religion and spirituality remind us of our membership ofthe community of living beings and souls (Macer, 1998).
Paul Tillich (1963) wrote in The Eternal Now, “One cannot
be strong without love. For love is not an irrelevant emotion;
it is the blood of life, the power of reunion of the separated.”
In the words of Erich Fromm (1963), “If I truly love one
person, I love all persons, I love the world, I love life. If I cansay to somebody else, ‘I love you’, I must be able to say: ‘I lovein you everybody, I love through you the world, I love in you
also myself’.

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www.g20interfaith.org
Hsin, Dena Hsin-Chen and Macer, D.R.J. (2006) “Comparisons ofLife Images and End-of-Life Attitudes Between the Elderly in
Taiwan and New Zealand”, The Journal of Nursing Research 14(3), 198-208. DOI: 10.1097/01.JNR.0000387578.58974.42
Jaja, I.F., Madubuike, U. and Jaja, I. (2020) Social distancing: how
religion, culture and burial ceremony undermine the effort tocurb COVID-19 in South Africa. Emerg Microbes Infec. 9: 1077–
1079.
Karmini, N. and Milko, V. (2020) Burial Traditions Clash withCoronavirus Safety in Indonesia [Internet]. Associated Press[cited 2020 July 9]. Available from: https://apnews.com/
22764fc02d1974e78c84 4605a5170df1
Kowalczyk, O, Roszkowski, K., Montane, X., Pawliszak, W.,ff

Acknowledgments and dedication
This is a work in progress, and I will add academic andscriptural references. Your comments are very welcome!
This describes a living work, and I wish to thank just a few
of the special people who have helped me on my journey (Ido not list their titles). I thank my father John Macer for his
passion and love of nature to get up early to walk aroundlakesides and rivers watching ish, enjoying birds, andlistening to the wind. I thank my mother Eileen Macer forthe eyes of an artist to see the beauty of both the real andthe symbolized in art, and in these the love of life. I thank
Heather Hammonds for her focused prayer which helped
bring me to faith. I thank John Bowker, Humitake Seki,

References
Al-Rousan N, Al-Najjar H.(2020) Is visiting Qom spread CoVID-19

Tylkowski, B. and Bajek, A. (2020) “Religion and Faith
Perception in a Pandemic of COVID-19”, Journal of Religion and
Health 59:2671–2677 https://doi.org/10.1007/
s10943-020-01088-3
Macer, Darryl R.J, Bioethics for the People by the People.
Christchurch, N.Z.: Eubios Ethics Institute, 1994.
Macer, Darryl R.J., Bioethics is Love of Life. Christchurch, N.Z.:
Eubios Ethics Institute, 1998.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
Macer, DRJ. (2015) “God, Life, Love, and Religions among
Indigenous Peoples of the World”, pp. 196-214 in E.E. Lemcio, A
Man of Many Parts. Eugene: Wipf and Stock Publishers.
Norman, Z. and Reiss, M. J. (2020) Risk and Sacrament: Being
Human in a COVID-19 World. Zygon 55(3), 577-590. DOI:
10.1111/zygo.12618.
Perry, S.L., Whitehead, A.L. and Grubbs, J.B. (2020) Culture Wars
and COVID-19 Conduct: Christian Nationalism, Religiosity, andAmericans’ Behavior During the Coronavirus Pandemic, Journal
for the Scienti ic Study of Religion 59(3); https://
onlinelibrary.wiley.com/doi/10.1111/jssr.12677
Polkinghorne, J.C. (1989). Science and Providence. Shambhala
Publications.
Sarkar, S. (2020) Religious discrimination is hindering thecovid-19 response. BMJ 2020;369:m2280 http://dx.doi.org/
10.1136/bmj.m2280
Singh Rai, Jasdev, Thorheim, Celia, Dorjderem, Amarbayasgalan
and Macer, D.R.J. (2010) Universalism and Ethical Values for theEnvironment. Bangkok: UNESCO.
Tillich, Paul (1963) Morality and Beyond. London: Routledge andKegan Paul.
Tui Atua Tupua Tamasese E i. “Bioethics and the Samoan
indigenous reference.” International Social Science Journal. 60(195, 2009), 115-124.
Vyas, Lakshmi (2021) “Diwali Festival and how the Hindu
communities providing Helping and Healing Services during
the Pandemic in UK & Europe”, in the WeCope Committee
report on Faith Systems and COVD-19.

Belief in god vs. worship of areligion- Nader Ghotbi, M.D., Ph.D.
Ritsumeikan Asia Paci ic University (APU) Beppu city, Oita,
Japan Email: nader@apu.ac.jp
Email: nader@apu.ac.jp

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Abstract
Religions are human interpretations of the meaning of life
and the position of the man in the world, and how humanactions and relations should be regulated to protect theirharmony; they are not direct words of a god(s). There issome wisdom in them as well as ideas that may need areconsideration, which is very human, and the only way to
ind the truth is to critically examine each teaching basedon the current knowledge and understanding andattending to the needs of a rapidly changing society andenvironment. Unfortunately, most organized religions
require a blind acceptance of certain pillars promoted as
fundamental ‘beliefs’, implying that critical evaluation is
not welcome. This cannot continue as the new generation
more and more inds some of these beliefs irrelevant to theissues of the time. Respecting equal rights for men andwomen, and autonomy over sexual and reproductive
choices are examples. Spirituality can be a way out of thisstate of con lict, and it can have bene its for all people fromany religious tradition.

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Introduction
A study over religion versus spirituality may start byreviewing the literature left by Albert Schweitzer (1875 1965), the recipient of the 1952 Nobel Peace Prize after his
work on the concept of “Reverence for Life” (Schweitzer,
1936). Schweitzer was a theologian, a medical doctor, ahumanitarian, and a pioneer bioethicist. Especially hiswork translated as “The Quest of the Historical Jesus”(1910) is worth mentioning in which he examined how theimage of Jesus had changed with the times. He concluded
that the life and thinking of Jesus must be interpreted
through convictions of "late Jewish eschatology" and later
attempts at understanding him by making parallels to adifferent way of thinking had been misleading. By dared to
critically examine his own beliefs as a Christian, Schweitzer
proved he was a man searching for the truth. One of his
signi icant convictions was that: “We are brothers andsisters to all living things and owe to all of them the samecare and respect that we wish for ourselves.” (Brabazon,
2000).
I was born to religious parents. They are used to theirreligious beliefs and are not interested in examining them.
However, I had many questions about those beliefs since
my childhood and I was looking for ‘better beliefs’ and kept
searching for other religious interpretations of the world. I
was essentially searching for a ‘substitute’ religion, after
disappointment over the of icial religion in my homeland,
thinking that everyone needs to be af iliated with somereligion. In other words, I was searching for a compatible
religious ‘identity’. However, nowadays, I see the younger
generation mostly in total disbelief over religion in general.
I see myself as belonging to a generation between two very
different generations, one before and one after. The
generation before is mostly resistant to change and thegenerations after are much less interested in following
religious traditions of the past. I have been trying to reduce
this generational gap by seeking the truth; if I can ind
pieces of it in the past and relate it to the present,connecting them with reason and facts, and get the courage
to express the indings truthfully. A recent survey in Iran
has surprised religious commentators by revealing thatover 50% of the population has lost its religion (Maleki etal., 2020). The overwhelming majority of college students
where I teach are non-religious, especially those fromJapan, China, Vietnam and other Asian countries, the main
exception being some students from Indonesia,
Bangladesh, Pakistan and the Philippines. One may evenobserve a revolt among some of the latter group against
the radical beliefs they left behind after moving to Japan.
An implication of organized religions is that they have aseries of ixed fundamental beliefs. Most organized
religions require their followers to abide by thesefundamental beliefs, to not question or critically debate
them, and stay committed to con irming them when asked.
As an example, the Twelver Shia Islam which is the of icial
religion in the Islamic Republic of Iran, requires allfollowers to believe that the Twelfth Imam is still alive,
albeit 1100 years have passed since his disappearance, andhe is coming to ight evil and win a war that will set theworld on its inal course before the end of times! My own
critical examination of the facts and the history around thisbelief has convinced me that it is an untruthful myth.
However, as an Iranian, my life would be in danger if I
expressed doubts about this story. In 2014, the Islamic
Republic of Iran executed a 37-year-old man after inding
him guilty of heresy for insulting prophet Jonah; Mohsen
Amir-Aslani who had doubted the story in Quran of Jonah
being swallowed by a large ish only to be returned alive
days later, was hanged for making “innovations in thereligion” and “spreading corruption on earth” (Kamali
Dehghan, 2014). That is so unfortunate when we learn thatthe story of Jonah in Judaism represents the teaching ofrepentance and being forgiven by god, and in Christianity
Jonah’s story is a model for resurrection and coming backto life. The story of Jonah demonstrates how a single story
may be interpreted differently by three related religions.
There are other radical differences in the teachings of
the Abrahamic religions, Judaism, Christianity and Islam.
For example, the historical fact that Jesus was cruci ied isprobably the most signi icant event in Christianity;
however, Quran says (verses 4:157-4:158) and Muslims
believe that Jesus was not cruci ied but was bodily raised
up to heaven by God (Lanier, 2016). Another majordifference is over the status of Jesus in Islam and themeaning of trinity. A fundamental belief in Christianity isthat Jesus was (son of) god. However, Quran says that Jesus
is a man, not god or his son, and trinity is understood torefer to the father, son and the mother (Mary) instead of
the holy spirit (Quran 5:116):“And when Allah said: O Jesus, son of Mary! Did you say
unto mankind: Take me and my mother for two gods beside
Allah? he said: Be glori ied! It was not mine to utter that towhich I had no right. If I said it, then you’d know.”
How is it possible that Abrahamic religions differ somuch on such fundamental beliefs? Can we suggest thatthese differences exist because the teachings do not havethe same (divine) origin but are interpretations of thefounders of these religions? But where is the source of theChristian beliefs? Aslan (2013) explains: “In 325 C.E.,
Emperor Constantine brought together bishops in the cityof Nicaea to permanently ix the Christian faith,commanding them to reach a consensus on the doctrine of
the religion. After months of negotiations, the council
handed to Constantine the Nicene Creed, outlining for theirst time the of icially sanctioned beliefs of the Christianchurch, that Jesus is the literal son of God, true God fromtrue God. This was a popular belief resulting from the
popularity of the letters of Paul as opposed to those ofJames, the brother and successor of Jesus who was
executed in 62 C.E. After the destruction of Jerusalem in 70
C.E., Christianity had become a gentile religion and neededa gentile theology; that is precisely what Paul provided.”

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Discussion
There are already various arguments to demonstrate that
religions are human interpretations of what god(s) wouldff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

19

want humans to believe and to do, including archeological,
historical, and logical examinations of the various religious
texts; there is a small bibliography at the end of this shortarticle for those who may be interested in reading further
on the subject. However, I present in here a mathematicalargument to support my claim! Let’s assume there are N
religions (R) in the world (N=the number of all religious
sects that exist). For any Ri (i =1, 2, 3, 4, …) that may be atrue re lection of the god, there are N-1 religions that holda different view of what god wants humans to believe or to
do. Assuming that god must have made up his mind overwhat is right and what is not, and there is one truthfulreligion out there, there should be N-1 religions withbeliefs and practices that are different from the righteous
word of god. In a situation like that, nobody can be surewhich religious sect is based on the truthful words of god.
That is basically how various sects formed! In other words,
if a religion is divided into sects with different ‘beliefs’, asin Christianity and Islam, one may accept that the differing
beliefs and practices follow the differences in humaninterpretations, not the divine. If the divinity was clear,
they would not disagree so much to need to form aseparate sect! Whenever various sects branch out of areligion each having string claims of self-righteousness
over the other sects, that is itself a proof to their nondivinity. This may be the reason why Emperor Constantine
needed the bishops to agree on Christian beliefs and thenban all others in 325 C.E. (Aslan, 2013).
If humans are prone to mistakes and sins, and religion
is supposed to stop them from that, how would that bepossible when the religion itself is based on humaninterpretations made at a point in time long in the past and‘ ixed’ for eternity? Isn’t it the task of a religious person toseek the truth? How can they do so if they stop themselvesfrom examining the beliefs that they have committed
themselves to, only because of being born to it, or being
assigned to it because that was the dominant religion
where they lived. The new Coronavirus pandemic provided
an opportunity to examine the religious claims all over theworld. In Iran, closing down the sacred tombs of Imams
and their sacred family members, and then using alcohol todisinfect the facilities, while alcohol is considered ‘unclean’,had its impact. These are just examples. I have studied andfollowed many religions and I have found similar issues
with each and every one. The basic issue is that religions
are human interpretations about creation, existence, andlife and what they really mean. These interpretations
cannot be complete and free from error, especially as they
suffer from being relatively old and relevant to a time whenhuman knowledge and information was much more
limited. Closing the door to a critical reexamination of
one’s beliefs, only serves to widen the gap with an evolving
knowledge and understanding of the world. As a Christianchoosing this tradition to express my spiritual beliefs, I
have a clear stance regarding certain claims: No, god did
not father a human child to have him cruci ied so that hecould forgive our sins if only we attested to that!

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

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To be ethical requires one to express what may be
truthful, and to seek the courage to do that. To simply saythese are faith systems and all are true, may be a politicallyeasy tactic but is confusing, untruthful and therefore
unethical. One should not blindly allow any belief system,
whether ideological such as communism, or religious andfatalistic such as the Twelver Shia Islam, especially when
there has been evidence of harm to the lives of millions ofpeople. I often told my Muslim friends: “Remember yourduty to not stray from the path of god. Worshipping yourreligion is just creating another form of idolatry.” This isespecially important in Islam, because the most importantpillar of Islam was to believe in one god and to pursue only
the god, not anything else including the religion or a sect init or a person associated with it.
Searching for God has been a human endeavor for
thousands of years (Aslan, 2017). The search is not over;nobody has the inal answers; nobody knows the god in
full; maybe humans will never will, but it doesn’t mean
they can claim the search to be over and dig their old
religious records to ind directions for now and the future.
The next generations will look back at us with pity, like wewere the fans of a mythical story of fantasy and magic
similar to Harry Potter, but only too boring and frequently
irrelevant. A good example is when the public healthsystem wanted to promote the use of condoms to slow
down the spread of HIV and there was opposition fromcertain religious groups that god would not allow that!
How did they know god would oppose the use of condoms
to prevent HIV? Was it a genuine divine command, or just ahuman interpretation based on digging in old humaninterpretations?
The Center for American Progress released a report in2019 to warn the U.S. public of exploitation of religious
liberty to deny access to healthcare, to discriminate against
foster and adoptive parents, to form dark money channels,
and to deny this liberty from some religious traditions
while providing it to a select few (London & Siddiqi, 2019).
They also recommended policies and practices to reinstatea balanced and inclusive vision of religious liberty, toensure that religious exemptions do not undermine patient
health, to prohibit for-pro it businesses from claiming
exemptions from anti-discrimination laws, and to extend
nondiscrimination laws at the federal level. Some say the
problems that existed in medieval times, such as thecondemnation of Galileo for reporting his scienti ic
observations, do not exist anymore. However, the last four
years in the U.S. provide a strong counterargument. As
Roose (2020) has documented:“A Pew Research Centre report from 2016 showed 81% ofwhite evangelical Christians voted for Trump compared to
16% for his Democratic challenger, Hillary Clinton. White
Protestants (58%) and white Catholics (60%) also voted for
Trump over Clinton in a campaign de ined by Trump’s racist
and insensitive comments toward Mexicans and Muslims, aswell as his poor treatment of women. Despite four years of apresidency de ined by Trump’s unprincipled behavior, not tomention over 228,000 deaths from the COVID pandemic,

white religious support for Trump has slipped only slightly.
The latest Pew Research Centre report shows Trump isfavored over his current Democratic opponent, Joe Biden,among white evangelicals (78%), non-evangelical whiteProtestants (53%) and white Catholics (52%).”An anonymous commentator in social media wrote:“America! It is time to take responsibility for your theology.”
On the other hand, a spiritual person who inds some truthin every religion, as well as some falsehood, can share
beliefs with any of all those religious sects. This isimportant because it helps avoid religious discriminationand opens the way to an examination of one’s beliefs in thecontext of an advancing body of knowledge and a better
understanding of the world. The time to spread magicalstories of religious miracles is over.
For me and an increasing number of people in mygeneration, spirituality is the answer to most issues withorganized religion. An example is the increasing interest in
the work of liberal theologians like John Shelby Spong, aretired American bishop of the Episcopal Church, who has
called for a fundamental rethinking of Christian belief awayfrom theism and traditional doctrines. Currently, he has
tens of thousands of supporters who like to hear that hedoes not know who the real god is, what it is like, and thatit may be a mystery never to be totally understood. So, heasks for all religions and their followers to respect one
another and asserts the only reason he is a Christian is that
he was born to that tradition and it is possible for him toapproach the mystery of god from that tradition.
Spirituality helps with mental health, known
speci ically as spiritual health, helps people from different
religions come together, is lexible to individual
perceptions of the mystery of god(s), and ills theemotional void that humans need to ill in order to ind
purpose in life and meaning in existence (Baynes, 2019).
One can follow cultural traditions of the religion he is born
to if he/she chooses to, as this is commonly a matter ofidentity formation. However, a big mistake would be to rely
only on religious beliefs for policymaking, which could leadto disaster. Some examples are the policy issues related to
the right to have an abortion, marriage and divorce, LGBT
rights, and religious discrimination.
References
Aslan, Reza. (2013). Zealot: The Life and Times of Jesus ofNazareth. Random House.
Aslan, Reza. (2017). God, a human history. Random House.
Baynes, Robert. (2019). Spiritual Health: Understanding the Key toSpiritual Growth and the Function of Religion. Tellwell Talent.
Brabazon, James. (2000). Albert Schweitzer: A Biography (2ndedition). Syrcause University Press.
Kamali Dehghan, Saeed. (2014). Iran executes man for heresy. The
Guardian. Sep 29. At: https://www.theguardian.com/world/
2014/sep/29/iran-executes-man-heresy-mohsen-amir-aslani
Lanier, Gregory R. (2016). “It Was Made to Appear Like that to
Them:" Islam's Denial of Jesus' Cruci ixion". Reformed Faith &Practice: The Journal of Reformed Theological Seminary. Orlando,
Florida: Reformed Theological Seminary. 1 (1): 39-55.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
London, Emily & Siddiqi, Maggie. (2019). Religious liberty should
do no harm. Center for American Progress. April 11, at url:
https://www.americanprogress.org/issues/religion/reports/
2019/04/11/468041/religious-liberty-no-harm/
Maleki, Ammar and Pooyan Tamimi Arab. 2020. Iranians’
attitudes toward religion: A 2020 survey report. Published
online, gamaan.org: GAMAAN. At: https://gamaan.org/wpc o n te n t / u p l o a d s / 2 0 2 0 / 0 9 / GA M A A N - I ra n - Re l i g i o n Survey-2020-English.pdf
Roose, Josh. (2020). Trump still enjoys huge support amongevangelical voters — and it’s not only because of abortion.
October 30, at url: https://theconversation.com/trump-stillenjoys-huge-support-among-evangelical-voters-and-its-notonly-because-of-abortion-148174
Schweitzer, Albert. (1936). The Ethic of Reverence for Life.
Excerpted from Civilization and Ethics (Part II of the Philosophyof Civilization), translated by John Naish. Available at URL:
h t t p : / / w w w. a n i m a l - r i g h t s - l i b r a r y. c o m / t e x t s - c /schweitzer01.pdf

Bibliography
Armstrong, Karen. (2004). A Short History of Myth. Canongate
Books.
Armstrong, Karen. (2011). A History of God: The 4,000-Year Questof Judaism, Christianity and Islam. Ballantine Books.
Ehrman, Bart. (2009). Jesus, Interrupted: Revealing the Hidden
Contradictions in the Bible (And Why We Don't Know About
Them). HarperOne.
Ehrman, Bart. (2016). Jesus Before the Gospels: How the Earliest
Christians Remembered, Changed, and Invented Their Stories of
the Savior. HarperOne.
Spong, John Shelby. (2009). A New Christianity for a New World:
Why Traditional Faith is Dying & How a New Faith is Being Born.
HarperOne.
Spong, John Shelby. (2011). Re-Claiming the Bible for a NonReligious World. HarperOne.

Spiritual healthcare and mental
health issues during the COVID 19
pandemic- Dr. Dhastagir Sultan Sheriff,
Faculty of Medicine, Benghazi University, Benghazi, Libya
Email: drdsheriff@gmail.com

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The coronavirus disease 2019 (COVID-19) pandemic isstressful for people. Fear and anxiety of getting infected,
social distancing and stigma due to infection during the
COVID-19 pandemic can all lead to mental health issues
that warrant speci ic coping measures, resources andcounter methods. The COVID-19 infection is associatedwith delirium/encephalopathy, agitation, stroke, insomnia,
loss of sense of taste and smell, anxiety and depression(Benjamin et al., 2020; Ling et al., 2020).
Anxiety is a generalized response to an unknown threat
or internal con lict, whereas fear is focused on a known
external danger. Emotions are de ined as “passions of a21

short duration.” Emotions are intimately linked withorganic life that may lead to “abnormal excitation of thenervous network,” inducing changes in heart rate andsecretions, or interrupt “the normal relationship between
the peripheral nervous system and the brain.” The fear ofgetting infected or being infected along with the anxiety ofuncertainty due to lack of speci ic therapy for COVID-19
remains a risk factor for mental health issues. These
mental health issues require specialized but holistic care.
Palliative care is specialized medical care focused onproviding relief from the symptoms and stress of terminal
illness. The goal is to improve quality of life for both thepatient and the family. Palliative care is provided by aspecially trained team of doctors, nurses and otherspecialists who work together with a patient’s otherdoctors to provide an extra layer of support. Palliative careis based on the needs of the patient, not on the patient’s
prognosis. It is appropriate at any age and at any stage in aserious illness, and it can be provided along with curative
treatment.
During such anxious moments of the disease many seek
spiritual guidance and healing. It is said that “spirituality isuniversal, deeply personal and individual; it goes beyond
formal notions of ritual or religious practice to encompass
the unique capacity of each individual. It is at the core andessence of who we are, that spark which permeates theentire fabric of the person and demands that we are all
worthy of dignity and respect. It transcends intellectual
capability, elevating the status of all of humanity.” (McSherry and Smith, 2012)
According to Florence Nightingale's philosophy of care,spirituality is inherent in humans and is the deepest andstrongest source of healing. The nursing community needs
to learn more about spiritual needs of the patients as well
as receive training on how to impart spiritual therapy to
the willing but needy patients.
An observational study of nurses regarding spiritual
dimensions of nursing care reported that 84% of nurses
identi ied patients with spiritual needs, buy only 40% feltthat they were able to meet their patients’ spiritual needs.
54% of the quali ied nurses stated that they had notreceived any instruction into the spiritual dimension and
73% felt that they did not receive suf icient training into
this aspect of care (van Meurs et al., 2018).
The spiritual dimension of human personality is closely
linked to one’s religious beliefs. It is stated that: “Thespiritual dimension tries to be in harmony with the universe,and strives for answers about the in inite, and comes into
focus when the person faces emotional stress, physical illness,or death.” (Murray & Zenter, 1979). Religion is an organizedand public belief system of worship and practices thatgenerally has a focus on a god or supernatural power. It
generally offers an arrangement of symbols and rituals thatare meaningful and understood by its followers. The majorreligions practiced in India are Hinduism, Islam,
Christianity, Sikhism, Buddhism and Jainism. Religion andspirituality are not the same thing, nor are they entirely
distinct from one another. Spirituality may incorporate

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
certain elements of religion as it is generally a broader
concept.
The practice of being compassionate and practicing
compassionate presence, i.e., being fully present andattentive to patients and being supportive to them in all of
their suffering including physical, emotional, and spiritual
are ways to improve the mindset of affected patients. The
various aspects of spiritual care include: “Listening topatients' fears, hopes, pain, and dream, obtaining a spiritual
history, being attentive to all dimensions of patients andtheir families: body, mind, and spirit, incorporating spiritual
practices as appropriate, involving Spiritual Counselor as
members of the interdisciplinary health care team”(MacLean et al., 2003; Selby et al., 2017).
The basic spiritual needs of a person could include ameaningful philosophy of life (values, love, peace,positivity, acceptance), comfort, forgiveness, hope, etc. andmoral sense), a sense of the transcendent (outside of self,view of God and something beyond the immediate life), a
trusting relationship with God (faith), a relatedness tonature and people (friendship), experiencing love andforgiveness and a sense of life meaning. The person may
not verbalize their spiritual pain, so it’s important to beaware of their behavior and actions too. For example, they
may seem afraid of being alone or refuse help when they
appear to need it. Some of the methods for obtaining
spiritual history are:
1. FICA model talks about faith and belief, importanceof faith or belief in one’s life, support systems in the formof communities (churches, temple, mosque or likemindedpeople), and how to address these issues in a patient’s
healthcare.
2. HOPE questions are used by physicians for formal
spiritual assessments. H of the mnemonic HOPE refers to apatient's basic spiritual resources, such as sources of hope,
without immediately focusing on religion or spirituality. It
leads to meaningful dialogues with a variety of patients
whose spirituality lies outside the tenets of religion orwithin the religion (Anandarajah & Hight, 2001).
3. SPIRIT model provides a framework for recording thespiritual insights of a patient or a path to assess spirituality(Maugan (1997):
S—Spiritual Do you have a formal religious af iliation? Canb e l i e f you describe this? Do you have a spiritual lifethat is important to you? What is your clearest
systemsense of the meaning of your life at this time?

P—Personal Describe the beliefs and practices of yourreligion that you personally accept. Describe
spirituality

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those beliefs and practices that you do not
accept or follow. In what ways is yourspirituality/religion meaningful for you? How
is your spirituality/religion important to you
in daily life?

I—
Integration
withaspiritualcommunity

Do you belong to any religious or spiritualgroups or communities? How do you
participate in this group/community? What isyour role? What importance does this group
have for you? In what ways is this group asource of support for you? What types of
support and help does or could this groupprovide for you in dealing with health issues?

R—
Ritualizedpracticesandrestrictions

What speci ic practices do you carry out aspart of your religious and spiritual life (e.g.
prayer, meditation, services, etc.) What
lifestyle activities or practices do your religion
encourage discourage or forbid? Whatmeaning do these practices and restrictions
have for you? To what extent have you
followed these guidelines?

I—
Implications
for medicalcare

Are there speci ic elements of medical carethat your religion discourages or forbids? To
what extent have you followed theseguidelines? What aspects of your religion/
spirituality would you like to keep in mind as I
care for you? What knowledge orunderstanding would strengthen our
relationship as physician and patient? Are
there barriers to our relationship based upon
religious or spiritual issues? Would you like todiscuss religious or spiritual implications ofhealth care?

T—Terminal Are there particular aspects of medical caree v e n t s that you wish to forgo or have withheld
because of your religion/spirituality? Are
planning

there religious or spiritual practices or rituals
that you would like to have available in thehospital or at home? Are there religious or
spiritual practices that you wish to plan for at
the time of death, or following death? From
what sources do you draw strength in order tocope with this illness? For what in your life doyou still feel gratitude even though ill? When
you are afraid or in pain, how do you ind
comfort? As we plan for your medical carenear the end of life, in what ways will yourreligion and spirituality in luence yourdecisions?

4. FACT: The FACT tool helps to take spiritual histories
in a clinical setting. It is said that a spiritual history tool
depends upon ive criteria: brevity, memorability,
appropriateness, patient-centeredness, and credibility. The
chaplain-developed FACT stands for: F-Faith (and/or
Belief); A-Active (and/or Available, Accessible, Applicable);
C-Coping (and/or Comfort)/Con lict (and/or Concern);
and T-Treatment (Larocca-Pitts, 2008).

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
Questionnaire to take spiritual case history of apatient:
RELIGIOUS BACKGROUND AND BELIEFS
What religion did your family practice when you weregrowing up? How religious were your parents? Do youpractice a religion currently? Do you believe in God or ahigher power? What have been important experiences
and thoughts about God/higher Power? How would you
describe God/higher Power?
SPIRITUAL MEANING AND VALUES
Do you follow any spiritual path or practice (e.g.,
meditation, yoga, chanting)? What signi icant spiritualexperiences have you had (e.g., mystical experience,near-death experience, drug-induced dreams)?
PRAYER EXPERIENCES
Do you pray? When? In what way(s)? How has prayer
worked in your life?
Some of the methods suggested for spiritual careinclude meditation, peaceful prayer practices, support
groups and reading scriptures. Meditation is acontemplative practice, engaged in across various religious
and spiritual traditions as a means of quieting, focusing
and transforming the mind. Meditation cultivates selfawareness and provides the optimum conditions forpracticing the skill of mindfulness. Generally, the goal of
meditation is to intensify personal and spiritual growth, in
addition to calming the mind and body.
Of the different types of meditation, mindfulness
meditation has been shown helpful for people withdepression and anxiety, cancer, ibromyalgia, chronic pain,
rheumatoid arthritis, type 2 diabetes, chronic fatigue
syndrome, and cardiovascular disease.
Prayer may elicit the relaxation response, along withfeelings of hope, gratitude, and compassion—all of whichhave a positive effect on overall wellbeing. There areseveral types of prayer, many of which are rooted in the
belief that there is a higher power that has some level ofin luence over your life. This belief can provide a sense of
comfort and support in dif icult believe.
Yoga is a centuries-old spiritual practice that aims tocreate a sense of union within the practitioner throughphysical postures, ethical behaviors, and breathe
expansion. The systematic practice of yoga has been found
to reduce in lammation and stress, decrease depression
and anxiety, lower blood pressure, and increase feelings ofwellbeing.

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Barriers to providing spiritual needs
1. The lack of Universal language of spirituality makes it
a dif icult concept to discuss.
2. Patient & families may not understand the concept ofspirituality or know to how to respond to questions ofspirituality.

3.

23

Nurses, Doctors and other staff caring for patient may
not feel comfortable or competent to discuss spiritualmatters.

Conclusion
If care is shown with compassion and spiritual guidance, it
may prove helpful in tackling the mental health issues ofpatients with COVID-19 infection, the physicians,
associated health professionals along with the public kept
under long lock down period.
References
Ambuel, B., Ed. 1999. Improving End-of-Life Care: A Resource
Guide for Physician Education, 2nd Edition. Milwaukee, WI:
Medical College of Wisconsin.
Anandarajah, G. and Ellen Hight. 2001. Spirituality and Medical
Practice: Using the HOPE Questions as a Practical Tool for
Spiritual Assessment. Am Fam Physician. Jan 1;63(1):81-89.
Benjamin L, Singh B, Lant S, Michael BD, Easton A et al. 2020.
Neurological associations of COVID-19. Rapid review. Lancet
Neurol.;19(9):767–83. At https://www.thelancet.com/
journals/laneur/article/PIIS1474-4422(20)30221-0/fulltext
Selby D, Dori S, Jim H, Kristin K, Margaret F. (2017). Patient versus
health care provider perspectives on spirituality and spiritualcare: the potential to miss the moment. Ann Palliat Med 6(2):143-152.
Grif ith, JL, Grif ith, ME. 1997. Hope in suffering/pain in health:
Talking with patients about spiritual issues. Presented at the18th Forum for the Behavioral Sciences in Family Medicine,
Chicago, Illinois.
Larocca-Pitts MA. 2008. FACT: taking a spiritual history in aclinical setting. J Health Care Chaplain.;15(1):1-12. doi:
10.1080/08854720802698350. PMID: 19424909
Liang L, Ren H, Cao R, Hu Y, Qin Z, Li C et al. 2020. The effect of
COVID-19 on youth mental health. Psychiatr Q. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173777/, accessed
2 October 2020).
MacLean CD, Susi B, Phifer N, et al. (2003). Patient preference forphysician discussion and practice of spirituality. J Gen Intern
Med. 18(1):38-43.
Maugans, TA. The Spiritual History. 1997. Arch Fam Med, 5:11-16.
McSherry, W. Smith, J. (2012) Spiritual Care in McSherry, W.,
McSherry, R., Watson, R. (Eds) (2012) Care in Nursing
Principles values and skills Oxford University Press.
Murray, Ruth B & Zentner, J Proctor.1979. Nursing concepts forhealth promotion (2d ed). Englewood Cliffs, N.J Prentice-Hal,
van Meurs, Jacqueline; Smeets, Wim; Vissers, Kris C.P., FIPP;
Groot, Marieke; Engels, Yvonne. 2018. Nurses Exploring theSpirituality of Their Patients With Cancer, Cancer Nursing:
7/8 41 (4), E39-E45. doi: 10.1097/NCC.0000000000000526

24

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

Healthy lifestyle is the key for ahealthy society- Rogelio P. Bayod, PhD
roger.bayod@gmail.com- Darwin Arnosadarwinarnosa@gmail.com
Cor Jesu College, the Philippines
Abstract
Healthy citizens are important for a healthy society. Whenpeople are healthy, they can not only enhance theircapability to ight different virus outbreaks but also
participate in the building of better and healthier societies.
However, different forms of sickness as a result of people’s
lifestyle are appearing in many countries. Ironically, in adeveloping country like the Philippines, policies for healthenhancing activities have gained minimal support. This
paper will argue that promoting a healthy lifestyle thatinvolves ive essential elements – feet, fork, ingers, sleep,and heart – is necessary for a healthy society. This meansthat people must be physically active, eat pre-dominantly
plant-based food, avoid vices such as smoking and too
much alcohol, get enough sleep, and establish deep
connectivity and reciprocity with their fellow humanbeings and the rest of creation as exempli ied by many
indigenous peoples. While some people choose to stayhealthy through their conscious choices, many carelessly
behave unhealthily. This is where government policies andprograms for proactive health and wellness must be
crafted and implemented. Instead of focusing much onprescriptive medicine, government should support thepromotion of healthy lifestyle as an important modality toensure that citizens are healthy and have a strong immune
system not only to ight a pandemic but more so in
preparing them in their vital role to build better andhealthier families and communities necessary for a morereliable and healthier society.

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Introduction
People are predisposed to various diseases based on their
way of living and occupational habits (Sharma &Majumdar, 2009). The way we live our lives today may leadto chronic diseases, which are products of how we design
our daily activities, from the movements we do, the food
we eat, and the quality of sleep we take. Sickness due tounhealthy lifestyle results in deaths and additional healthexpenditures. According to the World Economic Forum
Report, 60% of all deaths worldwide in 2005 (35 million)
resulted from noncommunicable diseases and accounted
for 44% of premature deaths. What's worse, around 80%of these deaths occur in low and middle-income countries
like India which are also crippled by an increasing burdenof infectious diseases, poor maternal and perinatal
conditions and nutritional de iciencies (World Economic
Forum, 2008). The report also points to countries like
Brazil, China, Russia and India which currently lose morethan 20 million productive life-years annually to chronic
diseases and the number is expected to grow by 65% by2030 (World Economic Forum, 2008). In 2007, nearly 3.1
billion people were economically active, and the igure isestimated to exceed 3.6 billion in 2020 (Sharma &Majumdar, 2009). Workplaces should make possible
healthy food choices and encourage healthy lifestyle.
Unhealthy diets and excessive energy intake, physicalinactivity and tobacco use are major risk factors for noncommunicable diseases, the report said (World Economic
Forum, 2008).
Globally, lifestyle diseases lead to mortality. Almost twothirds of the 57 the million deaths in 2008 occurred in low
and middle-income countries (WHO, 2010). But the goodthing is, they are preventable, and can be lowered withchanges in diet, lifestyle, and environment (Sharma &Majumdar, 2009). Lifestyle diseases which are primarily
caused by bad habits of people as well as their
inappropriate relationship with other beings and with
their environment are rising over time. While the onset oflifestyle diseases is gradual and may take years to develop,
once encountered do not lend themselves easily to cure
(Sharma & Majumdar, 2009). Medicine for this chronic
disease would have been unnecessary if the lifestyle ofpeople meets the human body's essential needs. Improving
our diet and lifestyle can prevent 80% of noncommunicable diseases (heart disease, stroke, type2
diabetes) and 40% of cancer (WHO, 2019).
Medicines cure diseases. However, shreds of evidence on
the different adverse effect of drugs in our body haveswarmed health journals (Pijl & Meinders, 1996; Keene &Davies, 1999; McGregor, Callaghan & Hunt, 2008).
Seemingly, one medicine cures a speci ic illness but causes
another ailment due to side effects. Medicine treats a bodyin emergency cases. Pharmaceuticals may manufacturedrugs and convince the people that these are preventive
measures to disease. Thus, the irony - medicine is notmeant to prevent; it is supposed to cure.
In recent years, the Philippines has experienced rapid
economic growth, but it has caused more damage to its
populace than good. There may be an increase inpurchasing power for most people, but this consumption
has not had a substantial impact on people's healthy
lifestyle. Vigorous economic activity certainly does notequate to quality of life. Most often than not, people arebuying because it offers convenience and instantgrati ication. One of the consequences of thisconsumeristic attitude of people is the proliferation ofdifferent lifestyle disorders.
The healthcare system of the country was tested as the
COVID pandemic struck. The "tip of the iceberg" speaks ofa fragile foundation. The system works to cure, but not toprevent. Health program and initiatives of the Department
of Health vaguely support the healthy lifestyle of thepeople. No known program from the department explicitly
helps Filipinos avoid non-communicable diseases. What is
striking to know is that Non-Communicable Diseases(NCD) mostly affect people in their productive years, from

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
45-60. What then is the government priority at this stageof development? This paper will argue that there should bea shift of paradigm on its policies and programs.
The Philippine constitution provides for education of
every Filipino. According to this constitution, education isfree for all regardless of economic, social status, religion,and ethnicity. Its fundamental objective is to provide aworkforce for national development, produce a profession
to take the lead for the nation's advancement of knowledge
to improve the quality of life of Filipinos, establishing,
maintaining, and supporting a wholly adequate andintegrated system of education relevant to the needs of thepeople and society. Every individual has the right to claim
this from the government. There is no judgment on thegovernment. However, the failure of the state to actualize
this mandate is revealed in its failure to educate
individuals to become productive citizens and use
knowledge to acquire a good quality of life.
The quality of life varies from individual to individual. To
put this into context, quality of life in the 21st century ismostly dependent on the individual's health. “Health iswealth” is an adage, suggesting that the quality of life isbased on the health status. The health status of anindividual is an integrated system. It’s not only the absenceof disease. It also means enhancement of other factors suchas peace, freedom and capabilities to be able to face life’s
different challenges and take advantage from its
opportunities. The indicators of the quality of life include
nutrition, health, education, social, and leisure/recreation(Papageorgiou et al., 1970). These factors are highly
individualized; this operates from the individual level. As
human beings, our freedom to choose for ourselves isinnate in us. Our ability to select actions using the stimulus
outside us is ef icient.
We may have the capacity to decide, but our decision is
also sometimes affected by how we interact with thenatural and social environment. Thus, this paper discusses
how individuals are sometimes reduced to just following
instead of deciding. This attitude is detrimental to ourcapacity to be at our best human form, that is to determine
deliberately, especially when it comes to health andwellness.

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Healthy lifestyle as the medicine
A lifestyle of physical inactivity is frequently associatedwith chronic diseases. In sociology, the word lifestyle
re lects an individual's way of life, how he expresses andtranslates his values, and forges a sense of self. A lifestyle isformed by a group of people or a society where patterns of
behavior, in luences, resource spending attitude, work, andactivity describe how they use their time and money.
Therefore, lifestyle is mainly dependent on the structure ofsociety (Mora Ripoll, 2012).
In the 20th century, humanity faced a signi icant
lifestyle shift. Our society has settled in the nest of comfort.
The industrial revolution was regarded as one of theconsiderable accomplishments of humans. While we enjoy
this comfort, it subtly destroys our values and our

25

worldviews about the interrelatedness of life – that our life
is a SONG: our relationship with Self, Others, Nature andGod. This concept of interconnectedness of different
myriads of life forms was destroyed during the modern
period. In the 21st century, the automation of almost
everything has declined the naturalness of life. The lifestylethat we create leads us to self-destruction. For Huntington(1996), it is culture rather than what is truth that dictates
people’s activities in the societies today. The capitalist
culture that promotes endless consumption of goods,
unlimited entertainment and too much focus on individual
achievements has destroyed not only our relationships
with others, nature and God but also our relationship with
self. This has resulted in the occurrence of many diseases
in human beings.
The rising cases of chronic diseases around the world
have also created concerns in the medical and allied ields.
Countless researches were done on how to combat these
diseases. They are creating formulation medicines toelevate the quality of life for those who are affected bythese diseases. Lifestyle was pointed out as the culprit ofthese diseases. Chronic disease is regarded as a lifestyledisease.
Lifestyle as a medicine is the idea that the way one
lives can promote inner peace, harmony and well-being aswell as prevention and cure to health problems feared bymost. The growing number of medical professionals
prescribing a lifestyle shift is remarkable. Doctors arestarting to recommend a lifestyle shift, starting on the food
we take, followed by physical movements, sleep andvarious relationships that we nurture. This shift ofparadigm gets back to how each individual is empowered
to choose a lifestyle that is most favorable to him as well as
to others.
Although lifestyle is affected by society and culture,humans have the freedom to design their lifestyle bybecoming informed and using this information for better
food choices, activities, and rest. Living a way of life that
relies mostly on a plant-based diet, regular physicalmovement and good rest, managing stress ef iciently, andavoiding substances that alter the natural interaction of the
body as well as living in peace and harmony with the restof creation may be challenging, but it is not impossible. In
fact, many indigenous peoples who were considered bymodern people as primitive, have shown that they are
more advanced in terms of attitude and life values ascompared to many “educated” persons. While the society
may judge them as lazy persons who are just content on
what they have, Bayod (2018) argues that this is so
because they are not so concerned with accumulating
wealth for the future. They generally live in the present
moment. Since they are not capitalists but are“communists” by principle and by practice (Bayod, 2018),
they are not into chasing wealth for their own advantage.
They work to be able to help the community. Since their life
is intricately interwoven to their land or ancestral domain,
they not only develop a reciprocal relationship with theirland, but also treat their land as a sacred being. Thus, they

26

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
practice deep communion with their land. In addition,
since they are living with trust to God’s providence, they
have less stress in terms of exerting more effort to chasewealth – an attitude that puts so much stress to a lot of
people in the urban centers.
In a country like the Philippines, a plant-based diet isstill possible, considering that it's an agricultural country.
There is a climate that favors the growth of food the whole
year-round. Regular physical activity is highly likely for all
walks of life. A lifestyle shift is possible for every Filipino.
However, there is a prevailing mindset among many
Filipinos that eating meat is a symbol of high social status.
Driven by technological advances, many of the food they
consume today is easy to grab food, energy-dense food,high in sugar or fat but low in nutrients. Many of thesefoods are available in almost every corner, convenient to
get and commonly costing less. Hence consumers
mindlessly bring this to their table. People also eat more
but move less. The food environment takes a new form
these days. Food establishments that offer high sugar
content are sprouting, and many young adults take it as ahabit. For them, it's a fashion, a fad to get in regularly,
affecting the lifestyle by promoting a high-calorie, lownutrient diet.
Highly effective advertisements on food and otherproducts promote these items and deceive consumers forpro it purposes spreading in all media forms for all ages.
Media exposure of the populace also has gone higher,
especially in urban areas where connection to the internet
is faster and more robust. This reality has continued for
decades, hence the rise of lifestyle diseases.
Ultimately, food consumption and movement
engagement are highly dependent on individual choices.
However, behavior changes occur only in a supportive
environment. In this time, affordable healthy food must
replace food shelves in grocery stores and food stalls, andopportunities for regular physical activity must be createdor organized for maximum participation.

I do a 30-minute exercise (walking,jogging, cycling) every day

12%

88%

I prefer to eat ish and vegetables
rather than meat products likepork, beef and chicken

25%

75%

I do not usually eat junk andprocessed foods

31%

69%

On the average, I sleep more thansix hours every night

31%

69%

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Questions & Responses (%)

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Survey of the lifestyle of Filipino college students
We conducted a simple on-line survey to college students.
There were 250 college students who answered the simple
survey questionnaire. Their answers are shown below:

Most often I am facing screen(computer, laptops and cellphones)

96%

4%

I have my regular prayer schedule

45%

55%

I have very good relationship withmy families and friends

79%

21%

I spend time going out in my houseto inhale fresh air

36%

64%

I think I am more stressed now than
before46%

54%

I smoke cigarettes

16%

84%

I drink alcoholic drinks

57%

43%

I have enough time to rest

39%

61%

I believe I have a healthy lifestyle

39%

61%

I believe I have the power to change
my current lifestyle

74%

26%

The results show that a lot of Filipino students areliving an unhealthy lifestyle. Most of them think that they
are more stressed now with the “new normal” mode ofeducation. However, a lot of them still have regular prayer
and a good relationship with their families as a source ofstrength during this pandemic. This was also con irmed in
the study of Arnado & Bayod (2020) on the help-seeking
behavior of young Filipino students. They found out thatspirituality and the presence of their family members are
the major sources of strength of the students. Because of
these, they become resilient in the midst of challenges
brought about by the COVID-19 pandemic.
But what is striking in the result is that many young
Filipino students are really living an unhealthy lifestyle
starting from the food they eat, their lack of regularexercise and the activities they indulge in. What is affecting
Filipinos over living a healthy lifestyle is the policies andsupport of the government. As pointed out, lifestyle isaffected by the structure of society. People's activity andconsumption behavior can be in luenced by policies orgovernance to support the lifestyle shift proposed in thispaper.

Role of government in promotion of healthy lifestyle
The government must consider the evidence that a healthy
populace is an asset to progress and development. As
pointed out earlier, lifestyle choices are largely dependent
on each person; however, the ecological frameworksuggests that there are multiple in luences affecting
individuals' behavior, such as social circumstances, thesurrounding physical environment, and wider sociopolitical forces (Biddle, 2015). This approachacknowledges that social and environmental factors
impact individuals' behavior, especially when information
in social media can travel in split-seconds around theEubios Journal of Asian and International Bioethics 31(1) (January 2021)
world. Gone are the days that people con ined themselvesin their immediate natural habitat. The world has becomea "small village". We are not only in luenced as a memberof a small community but also of the whole world. Without
the government supporting policies and innovations forthe health and wellness of the people, citizens will follow
an unhealthy lifestyle. In terms of programs and policies,
the government must promote and support healthy
lifestyle of its citizens through the following:
1. Encourage the use of bicycles for healthy citizens and ahealthy planet by constructing bicycle lanes.
2. Require Local Government Units (LGU) to have “ecoparks” where people can have space for exercise,meditation, to breathe fresh air and to commune withothers and with nature.
3. Encourage a vegetable diet by creating a system toensure that vegetables are free from pesticides and otherchemicals. There are technologies that can detect thelevel of pesticides and formalin that are present in thevegetables and even ish. They can use such technology
and make it mandatory that all vegetables and ish thatenter into the market will be subjected to testing.
4. Require work establishments to have health andwellness programs for their employees. Included in the
program (among others) must be bicycle parking spaceand shower room for the employees who use bicycles.
5. Allocate a budget for promotion of healthy lifestylerather than spending billions in buying synthetic
medicines from pharmaceutical companies. Only thosethat are very important should be purchased.
The problem is that the government is reactionary orreactive in its programs and policies especially in mattersof people’s health and also public health. This is moremanifest during the COVID-19 pandemic. The country has
no explicit program to proactively promote the health andwell-being of its citizens. Thus, when COVID-19 strikes, thecountry is facing dif iculty in terms of ensuring the healthand wellness of its citizens. Instead, it spends billions to
help those who have been contaminated by the virus andto provide inancial support to those who are affected by
the imposed lockdowns. These expenses could have been
avoided if the government had a functional health andwellness program to ensure healthy lifestyle of its citizens.

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Physical activity environment
Physical activity is a way for prevention of lifestylediseases. Systematic analysis has revealed its compelling
effect on the human body. The neighborhood design should
facilitate walking and bicycling for transportation. Publicparks, playgrounds, school vicinity, and recreation centersshould be well designed to invite users. The government
sectors, including transportation, city planning, and private
enterprise must create an environment that promotes
physical activity as a consolidated effort of the healthsectors and all essential government units. Crafting oflegislation and ordinances to compel individuals to adhere
and develop their habit of physical activity follows theclaim that social, cultural, physical environment and27

policies are essential factors in luencing a person's
behavior (Carlson, Dean & Sallis, 2017). Ordinances that
promote physical exercise of people must be accompaniedwith concrete social and infrastructure supports.
Moreover, interventions in the rising number of lifestyledisease cases should be done in multi-levels. For instance,
the transportation sector can help improve walkways androad intersections close to schools (environmental level),support school transports and require speed limits (social
level) and convey instruction projects to encourage
walking and bicycling to class (individual level). Schools
and of ices must provide parking areas for bicycles that aresafe and secure and o shower room for people who may
want to take a bath before attending to their daily work inof ices and schools. A variety of measures are expected toassess the ecological, social, and personal changes createdby this intervention (González, Fuentes & Márquez, 2017).
The role of the government is very critical in designingphysical activity environment. Its features must hold thepromise of increasing physical activity. Governing bodies
such as the Center for Disease Control, American Heart
Association, World Health Organization all recommended
these environmental changes to reduce the impact ofchronic disease on society (Carlson, Dean & Sallis, 2017).

Role of schools in the promotion of healthy lifestyle
Despite the support of research proving the bene its ofphysical activity to school children, the Philippines has notdone reforms to respond positively to these indings. The
inability of educational leaders to prioritize changes
favoring the increase of children's physical activity isevident in multiple ways. One is the time allotment ofphysical education in the curriculum. Physical education isa subject area wherein school children learn andexperience physical movement necessary for their fulldevelopment (Fairclough & Stratton, 2004). Aside fromother liberal arts subjects such as philosophy, psychology,
humanities and religious studies, physical education is asubject where students must understand the unity of the
body and mind. They gain a heap of bene its aside from thefun they encounter in the class by moving. The curriculumfor physical education in the Philippine allots only 45-60
minutes per week, instead of at least 240 per week
recommended by the World Health Organization (WHO)and the Center for Disease and Control (CDC).
Next is training suf icient number of teachers forphysical activity, especially grade schoolteachers, grades
1-6. The stage of development where these children belong
is crucial in attaining their maximum growth anddevelopment. Teachers' professional training to enhance
the physical activity level of students has not increased in
number and substance (Figueroa, Lim & Lee, 2016).
Another issue is the school culture that prohibits young
children from physical activity. In many schools in thePhilippines today, teachers are discouraged to ask students
to help in the cleaning of the school surroundings. Mostoften, public schools ask the parents to help in the “Brigada
Skwela”, a yearly program of the Department of Education

28

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
to clean and beautify schools for opening of classes.
Throughout the year, they hire janitors to do the cleaning.
While young children should focus on their studies, giving
them at least 30 minutes in the morning and 30 minutes in
the afternoon a chance to clean their room and beautify
their school surroundings through gardening and tree
growing activities will not only provide opportunities forphysical activity and exercise but also an opportunity todevelop friendship and camaraderie among their fellow
students. In addition, it will also help them become
responsible citizens and nature lovers in the future.
The next issue is insuf icient facilities and equipment.
Almost all schools in the country have a standard facility,
providing at least a gymnasium type of building. Some havea sophisticated design, but many are just a standard open
court type gymnasium and, most of the time, are venues forother activities and school programs.
These problems in schools need support from thegovernment and the constitution to take the lead for thenation's advancement of knowledge and improving thequality of life of Filipinos. Reforming the educational
system by providing quality physical education is vital in
support of healthy citizens in the country. The leading
expert in obesity Dr. John Foreyt, stressed that developing
healthy lifestyle habits should start with the young toprevent obesity. The habit of physical activity by the young
can start in physical education classes.

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Food choices
A policy that addresses the environment that improves
food choices is an effective preventive solution. In part, aperson's failure to choose healthy food and activity can beblamed on the environment when it is not conducive tofood choices. The changes in this environment needpolicies and practices necessary for effective obesity
prevention (Booth et al., 2001). Around the shelves in thegrocery stores, they display highly processed food packed
with energy and preservatives. 75% of the display contains
high calorie but is low in nutrients. With its colorful
packages and low prices, they lure the costumers to grab
and bring it home, some of them are even mindless about
the nutritional value these foods contain.
The role of the environment in promoting healthyeating is essential; although food choices are profoundly an
individual matter, the facilitation of these choices is greatly
affected by the environment. This is where policy
determinants of eating behavior can come in. There is a
growing literature on the in luence over food choices byfamily peers, social networks, the physical environment,socioeconomic status, cultural norms, and values examined
as determinants of food choices (Larson, 2009).
The department of health should get access these data
to respond appropriately to the concern over food choicesof Filipinos, especially the school children. School children
are not capable of defending themselves from thepersuasion of advertisements and cheap food commodities
from grocery stores and convenience stores. Most often
than not, they choose food with the price as the irst

consideration; second is the convenience and third isnutritional value. This way of choosing is an inverted wayof choosing. Food stalls along the school vicinity haveincreased in number, displaying high fat and sugar content
foods. While we encourage entrepreneurship from thepeople, there should also be regulations of the food choices
they offer to their consumers. The Ecological Systems
Theory possesses a strong model for this regulation.

Health as connectivity to the source
I would like to advance our thesis that health is alsoenhanced when we are always connected to an ultimate
source. This is where, mediation, yoga, mindfulness
exercise and prayers, are important resources inestablishing inner peace and harmony, and therefore,
health and well-being of people. But with the advancementof secular culture, spiritual and religious aspects in the
lives of people are put into the sideline. Instead ofconnecting to the source through meditation and prayer, a
lot of people go to entertainment activities when theyexperience boredom, anxiety or problems. Instead oftalking to their families or spiritual directors or quali ied
professionals or even trusted friends, many of them go tobars and parties to enjoy and drink hoping that theiranxiety will vanish. However, they forget that anxiety or
problems are part of being human. In fact, Joyce Rupp saysthat anxieties, problems and griefs are part and parcel ofexistence as human beings (Rupp, 1988). Since we are not
only composed of body but also spirit, our inal home is nothere on earth bus somewhere beyond this physical reality(Bayod, 2020). Thus, there is always something within us
that is yearning for something beyond our physicalrealities. Prayer as connectivity to the source will help us toachieve peace and serenity in the time of distress.
Conclusion
Health and economy have a vital relationship. The risingincidence of chronic disease places great pressure on the
country's healthcare system. Healthy lifestyle as medicine
needs to be promoted by the government as a paradigm. If
this happens, there will be a trickle-down effect tocommunities, families and individuals. Investing in anenvironment that promotes health as not only an absenceof disease but also enhancement of capabilities is timely
and relevant during this pandemic and as we move into theso-called new normal. Today's generation should be
prepared to thrive in a seemingly fast-paced world,
sublimed in a sedentary lifestyle of the people. The impactof health on the economy should not be underestimated.
The government must prioritize health over pro it (Frank,
2004).
Healthy lifestyle as a medicine is a more cost-effective
strategy compared to the current approaches of prevention
and treatment. Practical application of lifestyle medicine
enables health care professionals to show their concern tothe ailing population. They will be directed to what mattersmost in the healthcare system, which is health instead ofEubios Journal of Asian and International Bioethics 31(1) (January 2021)
pro it. Notably, lifestyle medicine reduces total costs andincreases the quality of life

References

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Arnado, J. & Bayod, R. (2020). Help Seeking Behavior of Young
Filipinos Amidst Pandemic: The Case of Cor Jesu College
Students. Eubios Journal of Asian and International Bioethics
30(8) (October 2020), pp. 463-466.
Bayod, R. (2018). The Future of the Environment and theIndigenous Peoples of the Philippines under the Duterte
Administration, Social Ethics Society Journal of Applied
Philosophy Special Issue, December 2018, pp.229-253.
Bayod, R. (2020). “COVID-19 Age: Spirituality and Meaning
Making in the Face of Trauma, Grief and Deaths.” Eubios
Journal of International and Asian Bioethics, 30, 5, June 2020.
237-242.
Biddle, S. (2015). Psychology of Physical Activity. In Psychology ofPhysical Activity. https://doi.org/10.4324/9780203123492
Carlson, J., Dean, K., & Sallis, J. (2017). Measures registry user
guide: physical activity environment. 60.
Cuellar J., Jones D.J., Sterrett E. Examining Parenting in the
Neighbourhood Context: A Review. J. Child Fam. Stud. 2015;
24: 195–219. doi: 10.1007/s10826-013-9826-y.
Figueroa, L.L., Lim, S. , Lee, J, (2016) Investigating the relationshipbetween school facilities and academic achievements throughgeographically weighted regression. Annals of GIS 22:4, pages
273-285.
Fairclough, S., & Stratton, G. (2004). 'Physical education makes
you it and healthy'. Physical education's contribution toyoung people's physical activity levels. Health Education
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Frank, J, 2004, Health and the economy: A vital relationship,r e t r i e v e d f r o m h t t p s : / / o e c d o b s e r v e r. o r g / n e w s /a r c h i v e s t o r y . p h p / a i d / 1 2 4 1 /Health_and_the_economy:_A_vital_relationship_.html
González, K., Fuentes, J., & Márquez, J. L. (2017). Physical
Inactivity, Sedentary Behavior and Chronic Diseases. Korean
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10.4082/ kjfm.2017.38.3.111
Huntington, S. (1996). The Clash of Civilizations and the Remakingof World Order. New York: Touchstone.
Jamie Montague Fischer, Mshadoni Smith, Adjo Amekudzi
Kennedy. (2014) Why and How to Use Customer Opinions: A
Quality-of-Life and Customer Satisfaction-Oriented
Foundation for Performance-Based Decision-Making.
Transport Reviews 34:1, pages 86-101.
Keene, LC., & Davies, P.H. (1999). Drug-related erectile
dysfunction. Adverse Drug Reactions and Toxicological
Reviews. 1999 Mar;18(1):5-24.
Larson N, Story M. A review of environmental in luences on foodchoices. Ann Behav Med. 2009;38 Suppl 1:S56-S73.
doi:10.1007/s12160-009-9120-9
McGregor, I.S.; Callaghan, P.D.; & Hunt, G.E. (2008). Fromultrasocial to antisocial: a role for oxytocin in the acutereinforcing effects and long-term adverse consequences ofdrug use? British Pharmacological Society Journals, 154, (2),pp.358-368, https://doi.org/10.1038/bjp.2008.132
Mora Ripoll, R. (2012). Lifestyle medicine: The importance ofconsidering all the causes of disease. Revista de Psiquiatria y
Salud Mental, 5(1), 48–52. https://doi.org/10.1016/
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Hohenberg, P. M. (1970). No Title. Ekistics, null(null). https://doi.org/10.1080/ 00207237608737626
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nu10060706

Overcoming death: the state ofman in the midst of a pandemic- Christopher Ryan Maboloc, PhD
Ateneo de Davao University, the Philippines
Visiting Professor for Global Justice, AUSN
Email: ryanmaboloc75@yahoo.com
Abstract
This paper is a philosophical inquiry about the state ofman during the pandemic. By philosophy, I mean a rational
investigation of profound and critical questions that seeks
to address fundamental issues pertaining to the meaning oflife. This study attempts to understand how the sovereign
rule of the state is controlling the population in the midstof the coronavirus crisis. It argues that political power,
through fear, has isolated human beings away from eachother in the name of public health protocols. State powerplays on the vulnerabilities of the people to take advantageof the situation. The state apparatus is exercising full andunprecedented disciplinary measures as an extreme formof bio-power purportedly meant to mitigate the crisis.
However, what is not seen is the reality that unjust
structures and the unequal situations of individuals inhuman society have resulted to more hardships on the partof the poor, thereby diminishing their sense of self-worth.
The most profound question when it comes to thepandemic, this paper argues, is existential – the reality ofdeath.

The will to live
In the midst of death, the poor have no other choice but toaccept the possibility of losing everything. The reality ofliving during the pandemic is de ined by fear, control, andanxiety. But the above-mentioned are not always borne outof the terrible consequences from a natural disaster. Michel
Foucault (2007) reminds us that “such a spectacle isinduced by the power of the state apparatus who possess
absolute control over the physical, social, and economic lifeof the population.” During this COVID-19 pandemic, every
human being is forced to separate himself from others in
the name of public health. It is an extreme form of biopower, according to Daniel Mishori (2020), which reveals

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

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an “unprecedented authoritarian control.” The pandemic is
telling people that human freedom cannot be absolute.
The new normal seeks the re-organization of society.
But going back into our old ways and practices is not justabout comfort or convenience. People also need to makecruel choices if society must erase inequalities and unjust
practices that undermine the dignity of the powerless. The
priority of rich countries is the re-establishment ofneoliberal policies that reinforce the socio-economic dividein the world. Big corporations are more concerned about areturn to their rent-seeking ways and pro itmaking
activities. The inancial muscle of powerful companies
allows them to continue to make money while small
businesses fail. It short, only those who are in the
peripheries of society are truly affected by the impact of
the coronavirus.
What can philosophy teach us in the midst of this lack ofreasonability in society? How can one truly live in a postpandemic world? Philosophy has something to do with theway we put our experiences into question. It is not justabout explaining reality and accepting things for what theyare. Wisdom, Aristotle (1958) reminds us, has something
to do with praxis. Philosophy, in this way, seeks to address
something that is more fundamental. While the pandemic
has put us in a position to see naked life as primordial,critical re lection opens up that aspect of our lives in which
we realize the need to put an end to our negative
prejudices and ultimately, dismantle unjust structures that
undermine the lives of others.
Hartsell et al. (2020) tells us that every philosophicalinquiry takes “a presumptive position and an optimisticsocial view about what political and social arrangements
will be created due to the COVID-19 pandemic.” This study
is aware of the tendency of philosophy to be eccentric. As
such, we must be wary of the “dominant discourses ofmorality, especially the kind of ethics that are associatedwith the Western and European modernity” (Mansueto,2020). In this sense, it matters to look into the conditions
on the ground or peripheries. The ordinary man can tell us
stories that reveal the state of being in the midst of thisemergency.
For example, the latest typhoon to hit the Philippines,
Ulysses, has worsened the already dif icult situation of theFilipino people due to the pandemic. But an issue has
emerged. Some non-government organizations (NGOs)
have attempted to question the resilience of the Filipino
people. By questioning the idea of resilience, some armchair analysts forget that they are making a frontal attack
against the Filipino spirit of “bayanihan”, which can beloosely translated in English as a form of heroic deed for
one’s fellowmen. It is a type of solidarity in which people
see the meaning and value of one’s community.
The ultimate concern of every man out there is his
survival. But what is the meaning of survival? Is survival
about escaping from an imminent physical danger? The
meaning of survival in this public health emergency is not amatter that is purely biological or economic. Common
sense tells us that there is an existential meaning to all our

problems. The “will to live” is rooted in the way we put real
meaning into our lives and the courage to pursue things
despite all. Life can mean nothing without the courage to
be. Precisely, even in the midst of a great disaster, theability to overcome every hardship, including death,depends on the human will.

The apparatus of power
The pandemic makes manifest the paralysis of humansociety. This paralysis is not natural but man-made.
Globalization is one of the culprits as to why we are in thissituation. (Tanabe, 2020; Maboloc, 2020; Sable, 2020) The
world is interconnected by way of trade and migration. Yet,the real thread that holds everything together is thehegemonic political order in the world. Powerful andaf luent nations control international trade rules andpolicies. For this reason, the poor in the Deep South haveno means but to live in accordance with the unjust realities
that they are forced into. What this results in is the realityof poverty, diseases, and violence.
Global inequality has been exacerbated by the
pandemic. While lockdowns have been imposed in North
America and Europe, at least the citizens of af luent
nations have received a considerable sum of money assubsidy from their governments. In contrast, the poor incountries such as the Philippines have to endure long lines,
missing lists, and exposure to the virus just to receive thesmall subsidy that the government doles out to the poor or
those who have lost their jobs (Bayod, 2020). But thequestion of accountability when it comes to the terrible
impact of the pandemic should be global in scope. Unjust
global structures have contributed to the dif icult lives ofthe people in the Third World before, during, and even so
after this pandemic.
According to Thomas Nagel (2005), “we do not live in ajust world.” But while citizenship is the basis of justice inthe domestic affairs of every state, it should be noted thatthe greater tragedy happens elsewhere. The consequencesof policies like “America First” show that migrant workers
are the least in terms of government priorities. It alsomeans that the poor in the Third World have to continue
living their miserable lives. When the global economy cameto a halt, the top 10% in the economic ladder have notbeen affected by the cataclysmic nature of the present
COVID-19 pandemic.
It is not nature but bio-politics that has separated
individuals from each other. Local experiences have beenwell-documented (Tudy, 2020). Strict measures are irstly
in the name of public health, which is the goal of the state.
The rules imposed by the state are meant to be followed,
like military orders. They come in the form of curfews,
street lockdowns, and general restrictions to travel. To
ensure that this strict discipline is observed, the militarymight of the state is made visible to the public eye. Ardent
political critics are calling out governments for stiff policies
since in democratic countries such as South Korea andJapan, the people have not been stripped of their capacity
to make autonomous decisions.

A background may be needed to understand the role ofthe state as an apparatus of power. For Foucault (1977),
the spectacle has been transformed from the visible
torture of the human body to the invisible reality of
discipline in society. Institutions systematically take awayfrom the people their freedoms, reducing human persons
into docile bodies that are manipulated by the powerful.
The state of emergency due to the coronavirus gives
politicians the opportunity to take advantage of the public.
The fear and anxiety induced into the minds of people
force them to believe that the dif icult sacri ices that they
have to endure every day are all worth it.

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The abolition of man
The coronavirus pandemic abolished the human being.
Man has ceased to become a fellow to the other man. The
worst enemy in a disaster is hopelessness. This
hopelessness is exacerbated by the prejudice of people
against each other. For Karl Gaspar (2020), what has
happened is that populist regimes have dictated how
people are supposed to behave. Echoing Giorgio Agamben,
the eminent anthropologist from Mindanao thinks thatillegitimate political power now disguises itself as a form ofscienti ic expertise. Gaspar believes that what is happening
is lockdowns serve as a pretext for the withdrawal of therights of citizens.
Surveillance determines how people in the society mustmove. Some rules hinder people from cooperating witheach other in a spontaneous way. Health experts prevent
people from seeing each other because of the health threat
but bureaucrats often forget the fact that people actually
draw strength from each other, not from some government
rule or policy. People who are suffering due to the virus aredying without even seeing their family, deprived of the care
and attention from the presence of one’s family, denied ofthe love and attention as one faces the ultimate reality ofdeath. Raymundo Pavo (2020) explores this point when heasks: “is it possible for people to remain indifferent, or
eventually slip into indifference?”
What worries Gaspar (2020) is the lack of resistancefrom the people. He is not questioning the role of experts
or the power of any government to manage the crisis
situation that the population is into. Rather, he is simply
making that observation as to the utter lack of voice of the
public. It is not a political form of resistance but a moral
one, grounded in the respect for the dignity of humanbeings. People have continued to go on with theirmonotonous lives under the threat of mental fatigue due tothe lack of meaningful activities. Millions of ordinary
people are living in the dark pit of life’s absurdity due tothe uncertainty of the times.
Governments are sometimes making the lives of thepeople more dif icult. Whole families are in a dif icult
situation with the loss of a permanent source of income.
The lack of safety nets is a result of government neglect
and irresponsibility. The problem is the culture ofcorruption in some governments. What people complain
about when their movement is being restricted is notff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

31

something physical. It also has something to do with thevalue of human freedom. Lockdowns imprison people
inside their heads. Therein, it is no longer the virus thatthey will fear. They will fear losing the meaning of theirlives.
Human life cannot be reduced into a biological thing.
The biggest threat out there is the lack of hope of people.
The pandemic, as an existential issue, puts to task themeaning of being human. People have nothing to dependon except the strength of their will. According to Martin
Heidegger (1996), man’s being is a “being-in-the-world.”
What this means is that the being of man is about his
power to be in the world (Dy 1986). This potential isrevealed in man as a being-towards-death. Man, in thisway, is an “un inished project” (Sartre 2007). We are in theprocess of a constant unfolding. For Heidegger (1996),
death is the inality of this unfolding.
Conclusion
In conclusion, the most important question about the
pandemic is something that cannot be answered solely
from the perspective of the health expert. There is anexistential question that ultimately each person must
confront himself if he wants to overcome these trying
times. People have to appeal to philosophical re lection toind the light. Overcoming death, in this respect, is a matterof putting meaning into our lives. People do not see thereality of dying. They will choose comfort over wisdom,money over peace of mind, and pleasure over realhappiness. They see human suffering or death assomething that is “not mine” (Dy 1986). But death, as the
pandemic reveals, is the inality of human existence.

References
Aristotle. 1958. Nichomachean Ethics. New York: Washington
Square Press.
Bayod, R. 2020. “Ethics of Care and Philippine Politics during the
COVID-19 Outbreak.” In Eubios Journal of Asian andInternational Bioethics, 30 (3): 69-75.
Dy, M. 1986. Philosophy of the Human Person. Manila: Goodwill
Book Store.
Foucault, M. 1977. Discipline and Punish. New York: Vintage
Books.
Foucault, M. 2007. Security, Territory, Population. Translated byGraham Burchell. London: Palgrave Macmillan.
Gaspar, K. 2020. “Extractive Industries.” In Ethics in Contemporary
Philippine Society. Edited by CRB Maboloc. Davao City: SMKC
Publishing.
Hartsell, L. Krabbe, A. & Pastreich, E. 2020. “COVID-19, Global
Justice, and a New Biopolitics of the Anthropocene” In Social
Ethics Society Journal of Applied Philosophy. Volume 6 (2):
1-31.
Heidegger, M. 1996. Being and Time. Translated by Joan
Stambaugh. New York: SUNY Press.
Maboloc, C.R.. 2020. “Globalization and Consumer Culture: Social
Costs and Political Implications of the COVID-19 Pandemic,” In
Eubios Journal of Asian and International Bioethics, 30 (3):77-80.
Mansueto, M. 2020. “Enrique Dussel’s Philosophy of Liberation:
Philosophical Re lections at the Time of the COVID-19

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Pandemic.” In Social Ethics Society Journal of Applied
Philosophy, 6 (2): 173-208.
Mishori, D. 2020. “Medical Technocracy, Extreme Bio-power, andHuman Rights.” In Social Ethics Society Journal of Applied
Philosophy, 6 (2): 230-266.
Nagel, T. 2005. “The Problem of Global Justice.” In Philosophy andPublic Affairs, 33 (2): 113-147.
Pavo, R. 2020. “Camus’ The Plague and COVID-19: Some
Philosophical Re lections.” In Social Ethics Society Journal ofApplied Philosophy,6 (2): 209-229.
Sable, S. 2020. “The Ethical Flaws of Globalization.” In Ethics inContemporary Philippine Society. Edited by CRB Maboloc.
Davao City: SMKC Publishing.
Sartre, J.P. 2007. Existentialism is a Humanism. New Haven,
Connecticut: Yale University Press.
Tanabe, J. 2020. “Exploring a Post-COVID-19 Sustainable Peace
Model.” In Social Ethics Society Journal of Applied Philosophy, 6(2): 73-103.
Tudy, R. 2020. “The ethical dilemma among healthcare
professionals in the midst of COVID-19 pandemic.” In Eubios
Journal of Asian and International Bioethics, 30 (5): 259-264.

A century with agony or death with
comfort- Samreen Siraj (Corresponding author)
Email: samreen.verasiya@aku.edu- Zainish Hajani (Email: zainish.hajani@aku.edu)- Afsheen Hirani (Email: afsheen.hirani@aku.edu)- Shyrose Sultan (Email: shyrose.sultan@aku.edu)- Nasreen Ra iq (Email: nasreen.ra iq@aku.edu)- Salima Siraj (Email: salima.siraj@aku.edu)
Aga khan University Hospital Pakistan

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Abstract
The elderly population is increasing worldwide. Autonomy
is an abstract concept and when it comes to the autonomy
of an elderly patient, it becomes more complex. Moreover,there are some cultural traits in some communities thatin luence the provision of autonomy in older patients. The
signi icance of familial clout in decision making usually
overrides the geriatric person’s autonomy. Elderly people
mostly prefer the quality of life (QOL) versus prolonging
life, so it is essential to give special consideration to the
QOL rather than mortality. However, there are somesociocultural factors which can oblige healthcare providers
to give futile medical treatments despite knowing its
ineffectiveness. As the medical technology advances, therank of old increases which leads to more intensecompetition for scarce resources. Despite scanty resource,
the usage of resources on the elderly can in luence the careof the other members of the population. Financial scarcity
in healthcare organization calls for setting limits on
healthcare resources and instituting priorities among
healthcare services. However, the concept of age-based
rationing may promote inequality towards basic goods andservices for the geriatric population. The following
strategies: fostering patient empowerment, providing

patient care partnership, care counselling, cost-effective
analysis (CEA), advance directives, and raising awarenesscan help in promoting high quality and ethical based carein the geriatic population.

Introduction
A 99-year-old female patient with a language barrier camefrom Chitral; she was about to complete the century of herlife when diagnosed with a sarcoma in the right upper
limb. The family members admitted the patient to thehospital where the only option with some hope for survival
given by the doctors to the family was amputation of theright arm. The family member didn’t tell the patient but
consented to this and asked the doctors to proceed. Arm
amputation was done. The patient was depressed when
she discovered this and said that the suffering of cancer
treatment was making her feel worse rather than the
disease itself. She got discharged and readmitted again
after one week with complaints of fever and purulent
discharge from the wound, was diagnosed with sepsis andshifted to the special care unit. The family member asked
the healthcare provider to use aggressive treatment to savethe life of the patient despite the fact that she herself
complained of miserable existence and continuous
suffering.
There will be two billion people aged sixty and over by
2050, out of which 75% will live in the developing world(Lunenfeld and Stratton, 2013). As medical technology
advances, the rank of old increases, which makes thecompetition more intense for scarce resources. This
scenario leads to so many questions that need to beanalyzed through the lens of ethics.
1. Do older patients have any right to choose theirtreatment options?
2. Does medical futility actually impair patient’s quality oflife?
3. Why did doctors give only options that are aggressive innature?
4. In Pakistani culture can only children decide about
their parents’ health in old age?
5. In attempting to provide bene icence, to what degree isthe family violating the elderly’s right to autonomy?
6. To what degree is coercion present in this situation?
7. Is coercion towards the elderly population acceptable?
8. To what extent the harm imposed by surgery outweighs
the bene it?
9. Does the patient’s autonomy decrease as age increases?
10. If resources are scarce, which group of people should be
privileged?
11. Is healthcare a right or a privilege?
12. Should age be the criteria for rationing allocation?
13. Does rationing by age violate the concept of justice?
This paper will re lect on this scenario based on
different ethical principles and theories.

Our position versus counter-arguments
Autonomy versus deontology“I want to go when I want. It is tasteless to prolong life
arti icially. I have done my share; it is time to go. I want togo elegantly”. (Albert Einstein)
For several decades, respect for personal autonomy has
been a cornerstone in bioethics. The term autonomy iswidely used in the healthcare profession. It is actually avery abstract concept and when it comes to the autonomy
of an elderly patient, it somewhat becomes more complex.
Autonomy actually implies that every person irrespectiveof their age, gender, race, and colour has a right to makedecisions about one’s life. There are some external andinternal factors that may desecrate the autonomy of thepatient; examples are age, gender, and culture. Older
people are mostly the victims of ageism. Due tostereotypical thinking, like less cognitive thinking andphysical deterioration, so many geriatric populations haveto struggle with family members and healthcare providers
regarding their autonomy in healthcare decisions. Indeed,older age may carry physical instability and cognitive
impairment, but it is not the dependency, instability, andvulnerability that threaten the autonomy of an older
patient, but the sociocultural context and institution that
restrict their exercise of autonomy. The concept ofadaptation from an independent life to dependence is mostchallenging for older people. Moreover, there are some
cultural traits in some communities that in luence theprovision of autonomy in older patients. Families play a
protuberant role in the life of geriatric population
particularly in Asian culture because of the concept of theextended family system. The signi icance of familial clout indecision making usually overrides the patient’s autonomy.
The family's decision for the aggressive treatment was
based on the attachment with the person. Most of thefamily members think in term of bene icence and do all
possible ways to keep that person alive. In Asian culture
and mostly in Islamic perspective it is the duty of the childto take care of their parents in older age. Sometimes thisconcept of bene icence overrides patient’s autonomy andcauses paternalism. Moreover, when an individual lacks
capacity especially in the elderly and has no concept ofadvance directive, healthcare providers usually seek asubstituted judgment from the surrogate decision maker.
Literature reveals that surrogate decision makers (family
members) are the best to understand and decide regarding
patient treatment (Blackler, 2016). However, some otherstudies divulge that surrogate decision making is based on
false assumptions regarding patient’s values. Moreover, it
is challenging for the surrogate to make their own beliefs
and interest distinct from those of the patient.

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Quality of life versus futile treatment“I hate persons who would prolong their lives
perverting nature's course to keep off death” (Euripides,
500 B.C.). The progress of current technologies andtreatment approaches has prolonged the life or thefunctioning of the physical being, but it has provoked theff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

33

necessity of dealing with some essential ethical issues. Oneof the major dilemmas in this concept is “whether physicalexistence is synonymous with living” (Burkhardt andNathaniel, 2008, p.232). Quality of life (QOL) is a subjective
and individual construct. Nobody can judge the quality of
another’s life based on their own values. Elderly people
mostly prefer the quality of life versus prolonging life, so it
is essential to give special consideration to the QOL rather
than mortality. (Bornet, Truchard & Rochat et al., 2017). In
addition, advancement in treatment approach has given
the opportunity to sustain life but without meaningful
existence in the geriatric population (Karnik & Kanekar,2016). Furthermore, futile medical treatments are uselessas they produce no positive results, increase pain andsuffering, upsurge inancial burden on the family and lastly
prolong the process of death with suffering. Moreover,
Hippocratic Oath proclaims to evade aggressively or
nihilistically treating patients whose recovery isquestionable.
However, some school of thought believe that thephysician is obligated to elude male icence and endeavour
for bene icence; consequently, physician authority is moreessential than the patient's autonomy. Nevertheless, somebelieve that providing futile medical treatment infringe on
the ethical principles of non-male icence. However, there
are sociocultural factors which oblige healthcare providers
to give futile medical treatments despite knowing its
ineffectiveness. Due to some religious and cultural beliefs,
most Asian families may request for continuity oftreatment, expecting a miracle from God. According toIslamic perspective, life is a divine mercy and humans haveno right to decide about death. Moreover, families also are
ighting with their conscience and consider
discontinuation of treatment as a sense of negligence for
their loved one. Thus, a continuation of futile treatment
sometimes helps the families to cope effectively andprovide an opportunity to be with their loved one during
the last hours.
Nevertheless, sometimes families do opt for these futile
treatments because they consider “cure is equal to care”
which means they think that cessation of treatment causes
suspension of care. Therefore, the persistence on futile
treatment is essentially a request for getting care, not cure.
(Aghabarary & Nayeri, 2017)

Age-based rationing versus fair opportunity rule
“When they no longer can serve the land, they ought to quit
this life, and clear the way for the youth” (Euripides, 500
B.C.). Higher mortality rates increase the length of stay andupsurge the cost of care in the elderly as compared to theyoung. The elderly consumes a large number of resources
due to having the most complex illnesses. Allocation of
resources in a developing country like Pakistan is the mostchallenging task. Despite scanty resources, the usage ofresources on the elderly can in luence the care of the otherpopulation. Financial scarcity in healthcare organizations
calls for setting limits on healthcare resources andinstituting priorities among healthcare services.

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
According to Beauchamp and Childress (2013),
distributive justice plays an essential role in countries
where resources are limited. Distributive justice is de inedas the fair and equitable distribution of bene its andburdens because of inadequate resources; it is impossible
to divide the resources equally. Now the question arisesthat which population group should be given a priority? In
the above scenario loads of human and material resourceswere spent which gave nothing but a death with suffering
to a 99-year-old patient. Age could be used as a criterion
for rationing in prioritizing healthcare. On the basis ofquality-adjusted life years criteria, the young will farebetter than the older in allocation (Beauchamp andChildress, 2013). Besides, the utilitarian view also favorsthat the distribution of healthcare resources should be in amanner that maximizes the overall bene it. The social
utility of resources to the young population can be
maximized by denying access to healthcare to some of thevulnerable population, particularly the elderly. Daniels’
prudential lifespan also argues that age rationing is
judicious and suggests that the unbiased person would
choose to shift resources that prolong the lives of theelderly to the treatment of the younger person(Beauchamp & Childress, 2013; Brauer, 2009).
The concept of age-based rationing perpetuates theconcept of injustice by stereotyping the elderly anddevalues the status of older people. The anti-ageism
counter-argue against the use of age-based criteria for thedecision of life-prolonging treatments. The fair opportunity
rule from Rawls asserts that individuals should not receive
bene its on the basis of unjusti iable advantages anddisadvantages (Beauchamp and Childress, 2013). The
lotteries of biopsychosocial life do not provide a loor formorally acceptable discrimination in resource allocation.
Moreover, the egalitarian view also promotes the idea of
equal distribution of resources as a right to healthcare.

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Justi ication for our positions and its consequences
Our perspective is in favor of giving patient autonomy apriority at all stages of life. We believe that the involvementof the patient in a treatment approach enhances
determination towards health-seeking behaviors.
Moreover, in order to provide patient-centred care, it isessential to preserve the dignity of the person throughmaintaining autonomy. Besides, violating the autonomy
may lead to forced choices that are inconsistent withpersonal wishes and cause depression as evident in ourcase. In addition, autonomy cherishes the sense of
independence among the elderly which further improves
their quality of life. Furthermore, promoting individuality
increases the chance of successful ageing. Likewise, theimpact of decrease in autonomy can cause increase
vulnerability for futile medical treatment.
However, in order to provide equitable distribution of
resources, the principle of autonomy and justice may be in
con lict in the case of the elderly. But spending adisproportionate amount of money at this age isimprudent. Rationing by age is a non-discriminating

strategy and morally acceptable because each person will
receive some share at some point in time (everyone isyoung and later gets old). So, it is logical to spend theresources based on anticipatory life expectancy and to
avoid deliberate prolongation of life at all cost. Allocationof resources which are not cost-effective and produce
fewer bene its in elderly would have been used in adifferent population. Saving the life of the young will
provide more quality-adjusted life years (QALYs) as
compared to saving the life of an older person. So, age canbe used as a clinical indicator for making a decision
regarding aggressive treatment. Moreover, society alsobene its from the increase in economic productivity bhy
diverting the healthcare resources from an elderly withcomplex illnesses to the younger population who can work
to uplift the society.
The negative consequences at our position would be thedenial or guilt of family members that they could havedone something differently. Moreover, the concept of agebased rationing may promote inequality even towards
basic goods and services. Furthermore, it may cause
patient dumping and demarketing of services. It is the
hospital practice of relocating or repudiating to treat apatient who is uninsured, impecunious and undesirable toadmit. Elderly would become more often the victim ofpatient dumping. Moreover, promoting quality of life might
ignore the interest and claims of the elderly. Furthermore,they will be more victimized by ageism and will have tosacri ice for the bene it of others.

Conclusion and recommendations
Elderly people are the most vulnerable group of people interms of practicing autonomy. In eastern cultures, thefamily mostly overrides the autonomy of the elderly
person. So, it is essential for the healthcare provider toadvocate on behalf of the patient especially nurses as they
are the frontline in providing care to the patient. Moreover,
it is essential for the society to confront the issue of
healthcare rationing especially when resources are limited.
Moreover, some strategies need to be developed in order tobalance the need of the changing population. The following
recommendation can be implemented in order to promotea positive change at every level:
Fostering patient empowerment: It is an interactive
process between healthcare providers and the patient inorder to enhance his capacity for decision making.
Healthcare providers especially nurses can advocate andthe family needs to resign power and embrace the patientas an equivalent partner.
Provide patient care partnership: The hospitalmanagement may provide a brochure which includes therights of the patient and the things they could expect
during their hospital stay. This should be in different
languages. This also includes information regarding patientcare and treatment modalities.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

35

Care counselling: The concept of care counselling should
be included in the hospital policy especially in the care of
the geriatric population. This team should include thepatient, physician, geriatrics nurse’s practitioner, family
and the hospital ethics committee.

Transgender Realities in theContext of COVID-19 In
Bangladesh

Cost-effective analysis (CEA): Cost-effective analysis
should be done for rationing allocation. In this, the relative
cost and the outcome (bene it) of a different course ofaction need to be analyzed effectively.

- Nazneen Akhter, MBBS, MPH, DLSHTM, MSc
Fellow Uppsala University , Sweden, Good enough College ,London, Asian Health Institute (AHI), Japan,.
Founder & Managing Director, VAALO avant-garde Ltd,
Bangladesh [https://vaalo-avgl.com/)
Email: nazakhter705@gmail.com

Advance directives: The concept of advance directive
needs to be introduced especially in the geriatricpopulation. The nurses need to explore patient personalvalues, understand their disease process and signi icant
cultural traits that can in luence their decision-making
capacity.
Raising awareness: Moreover, as a healthcare provider, it
is essential to increase public awareness regarding theconcept of advance directives, elderly rights and autonomy
through community education, research and througheducation of nurses and other healthcare providers.
References
Aghabarary, M., & Nayeri, N. D. (2017). Reasons behind providing
futile medical treatments in Iran: A qualitative study. Nursing
Ethics, 24(1), 33-45.
Beauchamp, T., & Childress, J. (2013). Principles of Biomedical
Ethics (10th ed). NY: Oxford University Press.
Blackler, L. (2016). Compromised autonomy: When families
pressure patients to change their wishes. Journal of Hospice &Palliative Nursing, 18(4), 184-191.
Bornet, M. A., Truchard, E. R., Rochat, E., Pasquier, J., & Monod, S.
(2017). Factors associated with quality of life in elderly
hospitalized patients undergoing post-acute rehabilitation: across-sectional analytical study in Switzerland. BMJ
Open, 7(10), e018600.
Brauer, S. (2009). Age rationing and prudential lifespan accountin Norman Daniels’ Just health. Journal of Medical
Ethics, 35(1), 27-31. https://en.ppt-online.org/105100
Burkhardt, M. A., & Nathaniel, A. (2008). Ethics and issues incontemporary nursing. (3rd ed). Nelson Education.
Karnik, S., & Kanekar, A. (2016, May). Ethical issues surrounding
end-of-life care: A narrative review. In Healthcare 4(2), 24.
Multidisciplinary Digital Publishing Institute.
Lunenfeld, B., & Stratton, P. (2013). The clinical consequences ofan ageing world and preventive strategies. Best Practice &Research Clinical Obstetrics & Gynecology, 27(5), 643-659.

Abstract“Transgender” is the historically adopted appellation as“hijra” in Bangladesh. From the ancient period till the
1980s their identity remained a great question mark andthey were a forgotten cohort ofthe society often
discriminated and marginalized. Many years of dedicatedwork, research and advocacy efforts from different actors
like NGO, CBOs, Human Rights & Advocacy Networks andother national and international public and private sectors
active engagement to ight for the rights of transgenderultimately brought some changes in their societal and legal
identity as humans. Government of Bangladesh allowed
and approved the proposal from the Ministry of Social
Welfare to give transgender a social identity and status quo
as “Third Gender” in Government issued documents.
However, when this COVID-19 global pandemic appearedin the country their existence became more challenging
and vulnerable too. The livelihood of this community toearn their living became more dif icult, the lockdown madethem homebound which was dif icult for them for longer
when they are used to staying outside most of the timeeither on the streets or in the park, garden, market, or
railway and bus station. They were unable to go for theirhealth care needs, testing and diagnosis of STI, otherdisease including COVID-19 which was supported earlier
by the NGO and community organization who also stopped
their ieldwork activities during this high-risk lockdown
period. It is high time to investigate and ind out the facts
and indings of the transgender community to reveal andadvocate for their access to humanely important basic
needs like health care and hygiene, testing facility, food,social safety net and other needs to be ensured andsecured during this essential social distancing andlockdown period, so that they don’t become the victim of
this COVID-19 exposure and vulnerability. There healthcare, hygiene, social safety are essentially and equallyimportant like all other citizens of society to keep themsafe, well-fed and infection free in this COVID-19
distressing reality.
Key Words: Transgender, COVID-19, Third Gender, Hygiene,
Social safety, Social amenities. Marginalized, Discriminated,
Hijira.

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Introduction and Background
In Bangladesh, “transgender” is the historically adopted
appellation as “hijra” which is often translated to mean this36

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
transgender, which is basically the persons whose gender
identity and expression differ from their sex identity atbirth, the lexicon of “transgender” more known word in theSouth Asian context for portraying the hijra community( both male & female). 1,2 In the country according to the
Ministry of Social Welfare (MSW) of icial statistics accountfor 10,000 transgender persons but the total number
exceeds half a million, and they were mostly a forgotten
cohort of community in the early 1980s. Their existence inthe society is always viewed upon, as if they are born tolive with an isolated communal existence under a guru
(leadership) who tend to be always more connected,
powerful, and strong also set the rules for that communityand encourage them to follow a kinship and hierarchicalexistence. 3,4
From an ancient legacy to follow through ages, thetransgender community is portrayed to play anentertaining role either on the street in various form, or at
the house where a newborn baby is blessed get snatchedby them from the mother’s lap to ask for money.
Sometimes they even go for further uncivil engagement for
their earning and livelihood management either by selling
sex or snatching things or begging on the street.

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Discussion
A researcher explained to Human Rights Watch that suchinteractions can escalate if individuals refuse to give hijras
any money: Collecting money is not always a pleasantinteraction as it can become abusive. Hijras often use
abusive words, or the colloquial to express anger andfrustration or the body language they use while asking
money from people, the person gets easily offended or
irritated and tend to avoid them and their presence
nearby.5,6 Ditiya, a hijra in Dhaka, told Human Rights
Watch: “The public thinks that hijras are awful. ‘The way
hijras speak is disgusting. They don’t know how to be polite.
They’ll take off their clothes for no reason.’ How is this[perception] entirely my fault? 5,6
Over the years continued efforts and advocacy action by
the national and international Transgender (TG)community actors network and the development agencies
and the human right group who are the spine to support
the transgender self-help community and also gradually
succeeded to some extent in the solidarity claim on thevery realization of the rights and realities of thesemarginalized communities.
In reality, the transgender are a marginalized people who
are often discriminated and devoid of their basic social
amenities especially health, housing, and education as wellas in areas such as employment and immigration becauseof their transgender identity.7, 8,9, 10
Rupa, a 34-year-old hijra expressed, “Once I went to thedoctor in the hospital, I saw people hesitate to sit near to me.
Everyone was staring at me. I was kept waiting for a longtime to see a doctor. All the other people in the waiting room
had already been seen. Is this not discrimination?” 11
Kanta, a 42 year old Hijra who lives from the sex
business, said, 11 “In my passport, bank account and voter

ID, everywhere I am mentioned as a woman, so what is themeaning of recognition to me? However, I will keep ighting
for the rights of the hijra community.”
Pinky a 32 year old Hijra shared, “I am grateful to ourgovernment for making space for us. However, we have along journey to go.”11
One big milestone was when the Government of
Bangladesh approved and allowed the proposal from the
Ministry of Social Welfare to give transgender a social
identity and status quo as “Third Gender” in government.
documents including passport, national voter identity, land
registration document, and bank applications, including
other relevant of icial and legal identity as a citizen of
Bangladesh. Also, the Bangladeshi constitution provides aguarantee of equality before the law on the basis of
citizenship, not on the basis of sexual identity. Pakhi, a 38year-old hijra mentioned: I was so happy to hear about
the recognition! At least now we have an identity in thissociety. Nevertheless, the situation remained the same.
11, 12, 13, 14

Subsequently in 2014-15 budget the government also
expanded transgender relevant programs in 35 districts
and also created provision of employment for only 18
persons. Some NGOs and private sector organizations offer
a non-discriminatory job, an offer like Ready Made
garments (RMG) industry but here the main complexity isthat they can work at the garment factory but recruiters
only keep the option of male and female in their job
application offer, so if they join by hiding status, once itgets disclosed they are discriminated and quite often haveto quit the job.11, 12, 13, 14 Also these job opportunities seemvery nominal in comparison to a large number oftransgender people who still remain outside the formal
labor sector and they tend to continue their same practiceof livelihood management as was in the past. The earningknow-how and skillsets of the community is very limited
to, mostly selling sex, which even morally blamed andoften they are heavily discriminated and stigmatized in thesociety, thus live in an unstable economic situation.
To state more loudly, in this 21st century modernizedworld their fate is still entrapped into their ancestors
inherited basic unskillful engagement for instance on thestreet showbiz, selling sex, and stealing newborn to earn
lives or entertaining people in any cultural occasion.
Because of this they often become the victim of many
violent activities by the people in public spaces, in thepolice station and inside the prison , sometimes by otheradministration, also by hooligan/gangster, or even at homeby the family members too. These have become an
acceptable practice since the society and the law adopted
this since this third gender the community does notcomply with the hetero normative structure of Bangladesh
society 4, 7, 8, 9
Pinky a leadership of Badhan Hijra Sangha (self-help
Group) stated in one of the study interview 1 “Sometimes wewant to visit a specialist because of a critical medical
situation, but we cannot. We are often informed that thedoctors are not present. Therefore, we often have no choiceEubios Journal of Asian and International Bioethics 31(1) (January 2021)

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but to take care of our medical issues ourselves, even if weare in critical medical need.”
To measure the economic impact of COVID-19 crisis on
the Third Gender community in Bangladesh, an impact
study was done by Innovision consulting Bangaldesh on 51
Transgender. 82% of the respondents did not earn a single
penny in the last two weeks and only 18% of the
respondents earned an average amount of BDT 1,444 in
the last 14 days.7, 9, 15,
A total of the respondents who used to send money totheir home have stopped sending money due to the crisis,
59% of the respondents did not get any kind of support
during the crisis period. 86.36% need to defer their loan
payment due to low income during the crisis period, 9%will borrow money to repay the loan, 5 % will sell theirassets to pay back loans.7, 9, 15
Among the total of 51 persons, 41% respondents
received support during the last two weeks of an averageamount of BDT 940 from the Government and from private
individual and initiatives. Among them, 81% do not think
the support will continue. Respondents are counting on
reliefs for the upcoming days. Some will try to look for jobs
and some will start begging, All of the respondents wanted
food and monetary assistance for the remaining crisis
period.7, 9, 15During the lockdown and social distancing period all thetransgender persons urgently need food, cleaning supplies,
medicine, safe housing, and general economic support.
Although Social distancing is one of the proven scienti ic
options of preventing COVID-19 by stopping the rapid
spread of COVID-19 but for many of the poor in
Bangladesh’s cities and towns, living and working
conditions make distancing impossible and the word
remains more as jargon to them rather a practice.
Bangladesh Prime Minister Sheikh Hasina in her 31-point
directive on Bangladesh’s response to COVID-19, called for“special attention” and relief for “the most disadvantaged
people” including the hijra community.8, 10, 15.
Also according to the UN High Commissioner on Human
Rights statement, lesbian, gay, bisexual, trans and intersex(LGBTI) people may be particularly vulnerable during the
COVID-19 pandemic. It even appears more severely when
the people have co-morbidity or compromised immunity
especially the People living with HIV/AIDS, tuberculosis or
any other communicable and non-communicable illness
like diabetes, Blood Pressure or cardiac illness. In many
instances the homeless people, the population that
includes many LGTBI people, are less able to protect
themselves through physical distancing and safe hygiene
practices, increasing their exposure to contagion, access tohealth services, de-prioritization of required healthservices, Stigmatization, discrimination, hate speech andattacks on the LGBTI community, domestic violence, andabuse, access to work and livelihood, are the major issues
to look into in this COVID-19 realities since manytransgender communities are of a great disadvantageoussituation with COVID-19. Lockdown, social distancing andalso with other prescriptive health and lifestyle37

maintaining issues where these days they have on a single
penny to live on, little food to feed themselves, and even asafe space to stay safe and healthy 16, 17
I will have to go to the street and start begging. I don’t see
any other way. - Lara (27); Jatrabari
We are all looking towards the Government. How will wesurvive without any relief? -Ghuji (26); Rayer Bazar. 11, 15,
Very recently, through the apex foundation MJF( Manusher Jonno Foundation) the socially excluded andmarginalized community were supported by a cluster ofNGO and community organizations, namely: Bangladesh
Yo u t h L e a d e r s h i p C e n t e r, L E D A R S , B a n d h uSocialWelfareSociety, VAFWSD, BGS, ESDO, JSKS, BASA,
Ghashful, IED, FIVDB and GUK who have distributed soaps,
sanitizers, and masks disinfectants kits among 12000
marginalized individuals including food support (rice,lentil, potatoes and oil) among 5328 households of whomthere were a certain number of transgender communities
who were also inclusive in this support list .9, 10, 11, 18

Conclusions
Here it very important and pertinent to pay attention onthese special community who are already positioned asm a rg i n a l i z e d a n d i s o l a te d d u e to s t i g m a a n d
discrimination, while this COVID-19 invaded the country
their existence became more at stake and vulnerable too.
Since these people cannot earn their livelihood any more,
the lockdown made them home bounded since they cannot
be at home for longer rather they spend most of their timeoutside either on the street, or in the park, garden, market,
or railway and bus station. Now in this homeboundenvironment which is much taxing for this community
since they cannot go for their health care, testing, anddiagnosis of STI, other disease including COVID-19 while
they used to be supported earlier by the NGO andcommunity organization who are also remained stopped
from their ieldwork activities during this lockdown
period.
It is high time to pay due attention to the government
development partners, and NGO, CBO and private sector
agencies including Human rights activists and networks tothis special community person along with the other poor
community whom the Govt is already trying their best
efforts to keep them safe, well-fed and infection free in this
COVID-19 distressing reality.
References
1. Kalra, G. & Shah, N. (2014). The Cultural, Psychiatric, andSexuality Aspects of Hijras inIndia, International Journal ofTransgenderism,
14:4,
171-181,DOI:10.1080/15532739.2013.876378
2. Nanda, S. (1999). Neither Men nor Women: The Hijras ofIndia.London: Wadsworth
3. Khan, S. I., S. Islam, M. I. Hussain, S.Parveen, M. I. Bhuiyan,
G.Gourab, G. F. Sarker, S. M.Arafat, and J. Sikder. (2009). Living on
the Extreme Margin: Social Exclusion of the TransgenderPopulation (Hijra) in
Bangladesh. Journal of Health, Population and Nutrition 27(4):441–451

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

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4. Sharful Islam Khan, Mohammed Iftekher Hussain, Shaila
Parveen,et.al Living on the Extreme Margin: Social Exclusion of
the Transgender Population (Hijra) in Bangladesh : J HEALTHPOPUL NUTR 2009 Aug;27(4):441-451ISSN 1606-0997 | $5.00+0.20
5. Human Rights Watch Interview with expert, [location withheld],
April [date withheld], 2016.
6. Human Rights Watch interview with Ditiya, Dhaka, April 2,
2015.
7. “I Want to Live With My Head Held High”Abuses in Bangladesh’s
Legal Recognition of Hijras HUMAN RIGHTS WATCH |DECEMBER 2016: ISBN: 978-1-6231-34341
8. Godwin, J. (2010). Legal environments, human rights and HIV
responses among men who have sex with men and transgenderpeople in Asia and the Paci ic: An agenda for action. Bangkok:
United Nations Development Programme.
9. Khan, S. I., et al. (2009). Living on the Extreme Margin: Social
Exclusion of the Transgender Population (Hijra) in Bangladesh.
Journal of Health, Population and Nutrition, 27(4), 441-451.
www. ncbi.nlm.nih.gov/pmc/articles/PMC2928103/
10.Stenqvist, T. (2015). The social struggle of being HIJRA in
Bangladesh - cultural aspiration between inclusion andillegitimacy. https://dspace.mah.se/bitstream/ handle/
2043/18568/Stenqvist-T-DP15%20 inal.pdf?sequence=2
11.Abdul Aziz and Sameena Azhar, 2019 Social Exclusion andOf icial Recognition of Hijra in Bangladesh Journal of Researchon Women and Gender, Volume 9, Pages 3-19
12.Ahsan, F., & Al Amin, Z. (2015, 1 September). Celebration of thethird gender. Daily Star. www.thedailystar.net/op-ed/politics/
celebration-the-third-gender-135667 third gender
13.. www.bandhu-bd.org/third-gender-is-not-a-word-it-is-a-gender
14.THE “THIRD GENDER” IN BANGLADESH: Global Information
Society Watch 2015, Sexual rights and the internet, Association
for Progressive Communications (APC)and Humanist Institutefor Cooperation with Developing Countries (Hivos)
15.Kyle Knight May 2020 Senior Researcher, Lesbian, Gay, Bisexual,and Transgender Rights Program, Bangladesh Should Support
Hijra, Trans Under COVID-19, Published in The Advocate https://w w w. a dvo c a t e . c o m / c o m m e n t a r y / 2 0 2 0 / 5 / 0 7 / m o s t vulnerable-people-world-right-now
16.TOPICS IN FOCUS COVID-19 AND THE HUMAN RIGHTS OF
LGBTI PEOPLE 17 April 2020, See open letter by the Independent
Expert on Sexual Orientation and Gender Identity: https://www.ohchr.org/en/issues/sexualorientationgender/pages/
index.aspx
17.COVID-19: How to include marginalized and vulnerable people
in risk communication and community engagement, Sources
IFRC OCHA WHO Posted 15 Mar 2020 Originally published 15
Mar 2020
18.M J F s u p p o r t to Tra n s ge n d e r co m m u n i t y , h t t p : / /www.manusherjonno.org/latest_stories/caring-for-thecommunity-during-corona-crises/

COVID-19 pandemic and its impact
on the socio-economic context of
Bangladesh- Shamima Akter Rozy
Department of Humanities and Social Science, Bangladesh
University of Textiles (BUTEX), Dhaka, Bangladesh
Email: Shamimarozy737@gmail.com- Muhammad Ali, M.S.S.
Ex-student of Department of Sociology, Jagannath
University, Dhaka, Bangladesh
Email: aliemonjnu8@gmail.com
Abstract
The COVID-19 pandemic is causing a variety of socioeconomic changes around the world. There is a widespreadoutbreak of coronavirus in Bangladesh. Due to this terrible
situation, various changes are taking place in the context ofthe people of Bangladesh. In this paper, the social changes
caused by coronavirus economically and socially such as
food habits, communication system, communication
rituals, online education activities, online shopping,
unemployment, economical threat, and changes ofmarriage pattern have been highlighted. This commentaryalso reveals the challenging issues of Bangladesh due to
COVID-19. This commentary reveals the context of howpolitical and social organizations have stood by the
helpless people in dealing with coronavirus. Attempts havebeen made to ind out the social impact and challenges of
COVID-19 for the Rohingya refugees who came to
Bangladesh from Myanmar. Above all, the main goal of thiscommentary is to highlight the huge changes that havetaken place in the socioeconomic condition of Bangladesh
due to the COVID-19 pandemic.
Introduction
On December 31, 2019, the irst coronavirus outbreak took
place in Wuhan, China. Maintaining a safe distance toprotect against coronavirus infection, wearing mask, handwashing with soap and avoiding the touch of eyes, noseand mouth have been given more importance. It is also
important to stay at home to prevent COVID-19 (World
Health Organization, 2020). Coronavirus outbreaks usuallycause fever, cough, aches, and shortness of breath.
Coronavirus also causes headache, chills, vomiting,diarrhea and nasal congestion.
Schools, colleges, workplaces, public gathering havebeen temporarily shut down to protect from the outbreakof COID-19. Coronavirus infects people of all ages but puts
more at risk especially those with heart disease, chronic
disease, cancer and diabetes (WSJ, 2020). It is very dif icult
to maintain social distancing for a densely populated
country like Bangladesh where most people use public
transport. Also due to inancial dif iculties, many people
can’t afford services of auto rickshaw and taxi. In addition,
many people live in slums in extremely close proximity. So,
the coronavirus is a big threat to them (Aljazeera, 2020).

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
The outbreak of coronavirus has created a panic situation
among people and at this time people from many sectionsof the society are cooperating with foods, masks, handsanitizers, and soaps. It is possible to control the spread ofcoronavirus through social distancing and quarantine.
Nowadays people are using social media, electronic media
and other digital devices to spread various rumors in thesociety which later create various problems. For many
economically vulnerable people in society, regular soap use
and living in a separate room is actually much more
dif icult (Dhaka Tribune, 2020).
The irst COVID-19 in Bangladesh was found on March
7. But many people think that Bangladesh was affected bycoronavirus long before this. With the outbreak of corona
in April, 803 people tested positive and 39 people died.
Bangladesh cancelled all lights by March 15 with almost
all countries except United Kingdom. The government alsobanned all kinds of political, social, cultural, religious
rallies and gatherings. It was very dif icult to maintainsocial distancing in Bangladesh within the protocol,
especially in the capital city of Dhaka where about 1.1
million slum dwellers are living. Coronavirus has caused a
lot of stress and anxiety on people (Anwar et al, 2020). The
coronavirus is not con ined to any speci ic border and has
already become a pandemic. Healthcare systems in many
developed countries around the world are struggling tocontrol coronavirus, so it is a big challenge for Bangladesh.
Hospitals also do not have enough PPE. Doctors and nurses
also do not have enough training to deal with the virus.
The government of Bangladesh started a lockdown from
27 March 2020 to control the outbreak of coronavirus andhas done utmost effort to keep the people at home. In sucha dif icult situation for Bangladesh, there are many moreunprecedented problems (Siddika & Islam, 2020). The
most vulnerable people in Bangladesh have humanitarianneeds due to the coronavirus. Currently, business andeconomic activities are being managed through social
distancing and public health guidelines. At present, the
new normal and the standard of life is actually possible
through maintaining health guidelines and social
distancing. Depression, unemployment, joblessness, fallingof RMG export, remittances, socio-economic development
projects, insecurity, poverty and many more are occurringin society. (Shammi et al, 2020).
Impacts on the socio-economic context of Bangladesh
The impacts of the COVID-19 Coronavirus on various socioeconomic contexts in Bangladesh are highlighted below.

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The impact on the transportation system
The transport sectors in Bangladesh are losing around TK
5 billion (85 Bangladeshi taka is about 1 $US) everyday
due to the impact of coronavirus. There are about 4 million
vehicles in the country such as buses, trucks, covered vans,
pickup vans, three wheelers and easy bikes and they have
50 million associated workers (The Independent, 2020).
Comparing coronavirus time with before, only 25% ofbuses are working on long routes and 50% in Dhaka.

39

People used long route transports only for emergency
work. In addition, public transport buses may now carry
only 50% of the passengers in compliance with the healthguidelines but for this the passengers have to pay a 60%
higher fare (Dhaka Tribune, 2020). About 5 million people
in the transportation sector are facing a dif icult life due tothe coronavirus pandemic. Those low-income people,
especially drivers, helpers, workshop mechanics are going
through a miserable life because of the pandemic.
Nevertheless, trucks, covered vans, emergency service
vehicles in the lockdown have been kept running (TheBusiness Standard, 2020).
Impact on the middle-class social system
Every section of the society is facing various problems dueto the coronavirus pandemic. The middle class of
Bangladesh society is living a life of hardship which can becalled as a “no way-out situation”. Many people do not haveenough money to deal with this situation, but they are notable to talk about this dif icult reality. In addition, many
people are getting half-salary due to the coronavirus,
which is inadequate to manage their lives. On the other
hand, due to this dif icult reality, many of them have toreturn to their village from the capital city of Bangladesh(Bangladesh Post, 2020). Socially poor and migrant
workers bear the most brunt of coronavirus induced
lockdown; they include lower middle class such as unpaid
private school teachers, of ice assistants, salesman,receptionists, data entry operator, beauticians, mobile
phone service men, repair shops who having to go throughthe most dif icult times (The Asian Age, 2020).
Impact on the migration system
There are about 10 million migrants in Bangladesh whoplay a role in about 7% of Bangladesh’s GDP. Due to theimpact of coronavirus, remittances from previous year in
Bangladesh have decreased by 25% (World Economic
Forum, 2020). About 200,000 workers have not been able
to join the workforce due to lack of legal work permits andnecessary documents since the global lockdown began.
Due to such problems, the poverty rate in Bangladesh may
be 20.5% to 44% and 16-42 million people may become
poor. The Bangladesh government has decided to provide
two million TK returns and 200 million TK in cash
incentives for workers to get out of this situation. In
addition, various organizations have provided support
such as The United Nations access to information programservices in Saudi Arabia “Probash Bondhu” through which
medicine services were provided (UNDP, 2020). 60,000
workers go to different countries for different jobs every
month but due to the impact of coronavirus workers in
different countries are losing their jobs and the number
may increase further in the coming days (Rashid, 2020).
Impact on government and social organizations
Successful management depends heavily on political orderin any dif icult time in society. Also state capacity, social
trust, and leadership play a big role. The government of40

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
Bangladesh has also made efforts to keep people at home
to prevent coronavirus. Government also tried to keep
hospitals, kitchen, markets, drugstores and essential
services open. On the other hand, it has shut down
educational institutions and made essential businesses
online to reduce the spread of the coronavirus andcancelled the public programs of Pohela Boisakh andoutdoor activities of Eid-Ul-Fitr (The Independent, 2020).
Government and non-governmental organizations haveprovided various forms of assistance to help the poor andvulnerable people. But the roles of non-governmentalorganizations need to be further enhanced (E-International
Relations, 2020).
Impact on the communication system
Since the outbreak of the coronavirus, people have become
increasingly confused about some of the latest phrases
such as stay at home, social distancing, quarantine, andlock-down. But the government and non-governmentalorganizations provide different types of information to
help understand these phrases. Lack of communication has
often led to complication in hand washing and mask use.
There are different interpretations on different TV
channels.
Impact on the rural social system
The coronavirus has also had a major impact on the rural
education system in Bangladesh. The rural education
system has had to face various challenges such as the lackof electricity and inadequacy of computers and smart
phones (UCA news, 2020). In the case of the outbreak ofcoronavirus, there is often a negative reaction in the ruralsociety over maintaining the correct procedures of theWorld Health Organizations. Misinformation andunawareness have also created various problems in therural society for a long time (reliefweb, 2020). The
COVID-19 pandemic has a huge impact on the income
opportunities of rural society in Bangladesh. Unavailable
transportation system has caused huge losses in the
agricultural sector. The negative impact of coronavirus on
the agricultural sector has reduced GDP for 14.10%. Other
professions in rural society have also seen a reduction of
about 65%. To address this problem, workers and farmers
need free food, medicine, cash grants, and low interest
loans (Light Castle Partners, 2020).

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Increasing interest in becoming an online entrepreneur
Small businesses have faced multiple challenges and risks
because of the Coronavirus pandemic. They struggle to
make ends meet. However, online small businesses have
served as critical and recovery solutions (Youth Business
International, 2020). The coronavirus outbreak posed a
serious threat to small shops and factories (Ikea
Foundation, 2020). On the other hand, COVID-19
coronavirus can actually be called a blessing forentrepreneurs, because 85% of the commerce companies
that closed started working online again. Fashion related
products, medical equipment, masks, and hand sanitizers

have created a huge market (The Business Standard,2020).
Impact on the rising unemployment rate
Every group of people in the world has suffered physicallyand mentally from the effects of coronavirus but thevulnerability in the life of the unemployed is extremely
deplorable. According to the ILO, coronavirus can wipe out
7.20% of working hours or 125 million full time workers. If
such a situation continues for a long time, the economic
situation will be more deplorable (The Financial Express,2020). Along with the coronavirus, loods, landslides,
monsoon rain have created more unemployment problems
in vulnerable communities. About 72% of the people were
unemployed due to movement restrictions and the closureof their workplaces. Another reason behind the occurrenceof unemployment is lack of seeds, fertilizers, loods, home
isolation, lack of resources, lack of knowledge andguidance (Concern world-wide, 2020). 20 million people
working in the informal sector have already lost their jobs
due to coronavirus. There are about 60.8 million people in
the formal and informal sectors and 27 million people are
self-employed. Unemployment has also affected thereadymade garments sector. They have to depend on
foreign buyers. The Bangladesh Garment Manufacturers
and Exporters Association said on March 31 that 1048
factories reported that 907.14 million PCS worth $2.87
billion export was cancelled/ held up (E-Prothom Alo,2020).
Impact on mental health
To cope with the dreaded situation, people have to facevarious mental challenges. In fact, the viral outbreak in the
media and social media has in many cases created different
types of social panic among people. In quarantine there areoften victims of self-harm and emotional outburst due tohelplessness, depression, and sleeping disturbance. To get
rid of this situation, we need to have regular physicalexercise, healthy nutritional foods and mental strength. It
is better to avoid social media, limit browsing news andavoid unnecessary thinking (Hossain et al, 2020). Currently
our daily lives, relationships, workplace, and mental illness
have a huge impact on emotional exhaustion, exacerbation,of pre-existing condition, poor sleep, lack of concentration,etc. (reliefweb, 2020).
Expansion of online learning activities
Educational institutions in Bangladesh have been shut
down since March 26 due to the rapid spread of thecoronavirus. So, many students are staying in their native
town/ village and various surveys have been conducted foronline teaching of the student at college and university.
The survey has found that 34% of students were in rural
areas and 66% were in urban locations. On the other hand,these surveys found that 55.3% of students could accesslaptop, PC or tablet but 44.7% said they could not (TheBusiness Standard, 2020). Due to coronavirus, theeducation system in Bangladesh is going through a strange

situation. Home schooling and online learning lessons arebeing organized to help children control their risk in this
dif icult situation. Institutions are creating student
assessment through previous test scores, and assignments.
Institutions are also trying to provide proper guidelines tostudents using Google classrooms and Google meet (The
Daily Star, 2020).
Increased interest in online shopping
As a result of the coronavirus pandemic, people are more
inclined towards online shopping and all the maximum
products of small fashion in Bangladesh are going online(UNB, 2020). But issues of low-quality products, delayed,complicated refunds and selling fake products are
increasing. Facebook is often used for these tasks (Dhaka
Tribune, 2020). Facebook based shops are facing various
problems in their product collection because the industries
were closed for a long time. They also have to face practicalconstraints like shipment suspension (The BusinessStandard, 2020).
Impact on food habits
People are struggling a lot to adjust to the current situation
because. The restaurants, hotels, business were shattered.
Human food purchasing habits suffer the fear of being
infected by the virus. Food availability has also undergone
major changes during this time (CGIAR, 2020). In a surveyof the COVID-19 pandemic 18% of urban respondents and
10% of rural respondents said no food was stocked. In
addition, in the current dif icult situation, the condition ofnutrition in the lives of adolescents can be a big problem(gain, 2020).
Increasing domestic violence
Violence against women and children increased during thecoronavirus lockdown in Bangladesh. These violations are
due to social activities and inancial pressures. At least
4249 women and 456 children have been victims ofdomestic violence during this period. In addition, the levelof violence is increasing day by day due to their husband
becoming more frustrated in this situation. A survey by the
Manusher Jonno Foundation showed 848 cases of physical,
2008 mental, and 85 sexual violence cases and 1308
inancial restrictions. In addition, criminal activities likerape, kidnapping are happening at this time (DW, 2020).

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Impacts on early marriage and marriage system
The coronavirus pandemic has caused a number ofchanges to the wedding ceremony and cancellation oflargescale ceremonies to prevent the transmission of thevirus. The weddings are held in a family atmosphere (UNB,2020). Due to the report of coronavirus, catholic marriages
in Bangladesh have dropped. While in average there are1700 unions celebrating marriage on local churches every
year, 2020 has less than 200. Expenses have also been
reduced due to restriction on attending weddings(AsiaNews.it, 2020). On the other hand, many parents aretaking advantage of the spread of the virus to marry theirffEubios Journal of Asian and International Bioethics 31(1) (January 2021)

41

daughters at an early age. They can easily do this without
informing anyone in the community. Besides, many aretrying to reduce their poverty by marrying their daughters
during this dif icult situation (Dhaka Tribune, 2020). A
study of the BRAC interviewed 557 people in 11 districts,
72 of whom said 73 child marriages happened during thecoronavirus pandemic. Plan International said about 40
child marriages had already taken place in Kurigram(Financial Express, 2020).
Impact on Rohingya refugees
Rohingya refugees from Myanmar started living in
Bangladesh since August 25, 2017. Currently 1.1 million
people are in need of humanitarian assistance due to thecrisis of coronavirus in the Rohingya refugee camps. First
cases of COVID-19 were seen in 19 Rohingya refugees andcon irmed and 29 cases of 860,000 refugees in the periodof June became positive (World Vision, 2020). The
Rohingya refugee camps in Bangladesh, where 1.1 million
Rohingya people live in densely populated areas, are going
through a much more vulnerable situation due to thecoronavirus. The lack of potable water, running water for
toilets, lack of proper health treatment, lack of medical
facilities, shortage of testing capacity, low information
system, crowded houses are the cause of vulnerable
situation (reliefweb, 2020).
Among the Rohingya refugee camps in Bangladesh,various preparedness and responses issue have been taken
up for COVID-19. Among the sectors of preparedness andresponses are the health sector, water, sanitation hygiene
sector, nutrition sector, food security sector, protection
sector, education sector, and logistics sector. 44,972 wash
facilities and public buildings were disinfected in thecamps. The government has also arranged isolation forsurveillance testing and case management for COVID-19 inRohongya camps and has provided 21 Bangladesh Civil
Service doctors at Ramu and Chakaria upazilla healthcomplexes. Also working for the camps and hostcommunity are 289 staff and volunteers on mobile
nutrition (ISCG, 2020).
The trend of social rumors and lies is on the rise
Many people have already been arrested by the Digital
Security Act for spreading rumors about the coronavirus
on social media and television channels (Human Rights
Watch, 2020). In March, 79 people were arrested for
spreading rumors on social media in Bangladesh. Also 17
people including Upazilla Chairman, UP member, district
council member, municipal councilor have been suspended
for not distributing governmental aid among the helplesspoor people (UNB, 2020).

Conclusion
One of the biggest threats to the current social system isthe widely discussed human to human infection. It is
dif icult to describe all the socio-economic and politicalchanges that have taken place due to the coronavirus.
Developing countries like Bangladesh have to go through42

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
many challenges to overcome these social changes. Sincesociety is changing so fast, we can easily see these changes
due to coronavirus and the structure of our society. Due toglobalization, urbanization and re lexive modernization,
various types of risks and uncertainties are increasing inthe society. So, developing countries should pay more
attention to these issues. The country’s disastermanagement needs to be more robust as well as raiseawareness about coronavirus among the people. Since
most of the people in Bangladesh are still facing various
problems, the government should take various steps toprevent the crisis. Also, every person in the society should
help to prevent it on their own initiative activities. People
must take care of their mental health, deal with anarchic
situations, think positively, gather accurate information,and effectively counter various social rumors caused bycoronavirus. Since the coronavirus is already causing
various social changes in the society, it can be said that it
can bring about further changes in our socio-economic life.
Abbreviation
GDP- Gross Domestic Product
ILO- International Labor Organization
PC- Personal Computer
PCS- Personal Care Services
RMG- Ready-made Garments
TK-Taka
UNDP- United Nations Development Programme
UP- Union Parishad

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Banking against all odds: concernsof government bank workers in thePhilippines amid the COVID-19
crisis- Geroson C. Reginio (Corresponding author)
Land Bank of the Philippines, Philippines
geroreginio@gmail.com- Randy A. Tudy
Cor Jesu College, Philippines
randytudy@gmail.com- Rex B. Buac
Cor Jesu College, Philippines
rbbuac@gmail.com

Abstract
The COVID-19 crisis has been affecting workers from allwalks of life all over the world. While other government
agencies in the Philippines made drastic changes in theEubios Journal of Asian and International Bioethics 31(1) (January 2021)
delivery of services, the government-owned banks
continued to provide needed services, for these are very
important for the people and the economy. However, thebank employees faced many anxieties and inconveniences,knowing that they had to face clients during the pandemic.
The purpose of this phenomenological qualitative study isto understand the concerns of government bank
employees in their job as an essential workforce thatsafeguards the public's inancial needs amid the COVID-19
crisis. It employed a descriptive phenomenologicalqualitative research design. Ten government bank workers,
seven regular and three contractual employees,
participated in the semi-structured key informant
interview (KII). Results revealed two themes for theirstruggles: psychological pressures and physical exhaustion.
As regards their coping mechanisms, they relied on social
support, prayer, and resiliency. Although being public bankservants continued to be a challenge during this pandemic,
the informants found ways to serve the clients andremained committed to their banking profession.

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Introduction
Along with the adverse economic effects due to the
COVID-19 pandemic, government bank employees face
many dif iculties and challenges while still providing
uninterrupted inancial services. Despite having anassurance of security of tenure in their jobs, many
employees fear the chilling consequences of being infectedwith COVID-19 disease and can cause in their lives. As of
November 2020, the number of recorded positive cases
already breached the 50 million mark. With the absence ofa vaccine, this pandemic is causing misery to all humans(Yamin, 2020), not counting the effect on the economy
worldwide. How much more may be expected to the frontliners? For example, healthcare professionals experienced
both physical and psychological pressures. They had todeal with the fear of viral infection to oneself and family,
increased workload, new work arrangements, and caring
for patients and colleagues (Walton et al., 2020). In thePhilippines, some people were feeling fearful and anxious
in their dealings with people, which made them, especiallyhealth care professionals (HCP), hesitant to go to work
(Tudy, 2020). Non-clinical professionals performing
essential roles also experienced the same distress(Williamson & Greenberg, 2020). The increasing reports ofpositive cases forced the government to limit economic
activities to essential ones, affecting many Filipinos' lives(Nicomedes et al., 2020). Hence, the pandemic did notspare anyone or any sector with its devastating effect.
As the employees and workers worldwide struggledwith the physical and psychological pressures, they
somehow developed coping mechanisms that helped themsurvive during the COVID-19 crisis. For instance, frontline
staff are advised to seek social support, and areencouraged to access and seek COVID-19 information fromveri ied and reliable sources only (Williamson &Greenberg, 2020). Some people who were exposed to a
moral and traumatic event, aside from having a

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psychological injury, somehow develop a degree of "posttraumatic growth (Greenberg et al., 2020).
Several studies have already been published on the effects
of COVID-19 pandemic, although the indings are still
subject to in-depth analysis and validation as the pandemic
is still ongoing. However, very minimal literature looked
into the lived experiences of the bank front-liners. Actually,some people do not consider bank employees as essential
frontline workforce despite rendering services vital to thesustainability of the country's economy. Hence, this study's
indings can provide a glimpse of how bank employees deal
with the dif iculty brought about by the pandemic.
Moreover, the indings contribute to the literature as tohow bank employees deal with the challenges during apandemic. To understand the government bank employees’
experiences in their job amid COVID-19 pandemic, we
present a literature review focusing on the phenomenon.

The bank industry
The Philippines recognizes the vital role of banks in its
economy. Banks should be globally competitive, dynamic,
and responsive to the demands of a developing economy(R.A. 8791, "The General Banking Law of 2000").
Government bank employees have a commitment andpassion for serving even through tough times because they
have a sworn duty to their countrymen. Aside from having
a legal decree, government banks also have a social
mandate to spur countryside development and alleviate
poverty. According to a Philippines government bank, theirvision is “to promote inclusive growth, especially in theunbanked and underserved areas, through the delivery ofinnovative inancial products and services powered bydigital banking platforms” (Land Bank of the Philippinesof icial website, 2020).
Psychological and physical effects of the pandemic
Maintaining workers' psychological and physical health isan essential ingredient in winning the ight against any
pandemic. The quarantine, isolation, and other forms ofrestrictions imposed on individuals create a loss of
freedom, boredom, stress, anger, and anxiety (Sharma, &Verma, 2020). Consequently, these psychological effects
will have a long-term and negative impact on an individual
if not appropriately addressed. A study conducted during
the Ebola outbreak showed that mental disorders such as
stress, anxiety, and post-traumatic stress disorder (PTSD)
could occur even after the year of the outbreak (Sharma &Verma, 2020). In the same study, lack of information andmisinformation can also cause further mental injury.
Moreover, a pandemic's psychological effects include
depression, worry, anxiety, and poor quality of life
(Restubog et al., 2020). Indeed, exposure to the virus canalso lead to immense physical and psychologicalexhaustion (Nagesh & Chakraborty, 2020). This only showsthat this kind of pandemic really affects a person's physicaland mental health, whether during, or/and after a disease
outbreak.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
Challenges of non-healthcare workers performing
essential roles
Healthcare professionals are not the only ones
experiencing vulnerability to the COVID-19 pandemic.
Non-healthcare-related essential workers had also felt theeffects of this crisis when required to perform their jobs ina risky manner and dealt with it daily. For instance,
employees felt a higher risk of viral infection due to a lackof resources and support and no clear company policies or
guidelines, which made them feel that they were ignoredby their employers (Williamson & Greenberg, 2020).
Overcoming psychological pressures without social
support is not easy when social support structures such as
churches, schools, and workplaces have been closed (Jung& Jun, 2020). Another challenge for workers worldwide is asigni icant reduction in work hours, loss of jobs, and otherrelated effects (Restubog et al., 2020).
Aside from the struggles that government bank workers
are experiencing in their regular and normal job routine,the effects of COVID-19 have added up to their existing
luggage. Government bank workers are also suffering fromanxiety and stress due to the fast spread of the virus thatmakes their jobs even more dif icult. Banks ensured theiremployees and customers' safety by implementing social
distancing measures, thereby limiting over the counter
services and shortening banking operating hours (Khoo,
2020). This health safety protocol contributes to theburden of fears and anxieties that bank employees
experience. In another study, working from home had adownward effect on employee performance and teamperformance (van der Lippe et al., 2020). Undeniably, there
are several areas to understand the potential adverse
consequences of this phenomenon. Government bankworkers face so many pressures, whether internal orexternal, particularly from fear of the virus and work
productivity and ef iciency. Thus, the COVID-19 pandemic
hinders banking employees' satisfactory performance(Sembiring et al., 2020). Another study conducted in
Nigeria showed that some economic agents declined towork for fear of acquiring the COVID-19 disease (Ozili,2020). Hence, the situation of government bank employees
is understandably a dif icult one.
The concerns of non-healthcare-related essential
workers amid COVID-19 pandemic should be discussed
and addressed by the government. The focus should be to
mitigate the adverse impact of the COVID-19 pandemic on
the vital workforce, like the bank employees, because they
are continuously working hard and exposing themselves toa life-threatening risk to help stabilize the economy.

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Methods
Research design
In this study, we employed a qualitative phenomenologicaldesign. Phenomenology is about studying people's lived
experiences (Creswell, 2007), way of going deeper into
their world. Speci ically, we followed the descriptive
phenomenological approach to understand governmentbank employees' lived experiences in their job amid the45

COVID-19 pandemic. We dig into their struggles andstrategies. Our goal was to see who the government bank
employees are and how they live in the context of the
COVID-19 pandemic. Listening to their stories allowed us
to have a glimpse of how bank employees as essential
workers went through their routine work amid the
pandemic.
Study participants and sample
The participants of the study were employees of agovernment bank. We set up criteria for the participants sothat we can ensure that we could draw out the lived
experiences based on the objective of the study. The
criteria included the following: (a) The informants must be
Filipino government bank employees occupying of icer or
rank-and- ile position whether permanent or contractual
employment status; (b) They must be in the category of"in-active-duty,” meaning they are currently in service, and(c) They must have been with the bank for more than three
years. We limited the inclusion to a minimum of 3 years inservice because, below three years in service, governmentbank employees might not have adjusted well to theirsituation and might not have in-depth knowledge andcompetency in their job. In the end, ten government bank
employees, composed of seven men and three women,
were able to participate in the Key Informant Interviews(KII). The number was within the range suggested byMorse (1994).
Due to the nature of the study and the dif iculty ofgetting informants, we utilized purposive sampling. This
sampling technique enabled us to select the informants
who had the experience of the phenomenon and could give
credible information (Creswell & Plano Clark, 2011). We
selected the informants who were government bankworkers and work in the Davao Region and the National
Capital Region.
Data Collection
The main sources of the data were from the responses of
the Key Informant Interviews (KII). According to Kumar(1989), KII is usually chosen since a limited number ofparticipants are needed to provide information about thephenomenon. We decided to use this technique because
there were very few who satis ied the inclusion criteria. We
asked them face-to-face or through social media platforms.
We also made phone calls and asked if they were willing toparticipate. We received several denials from somegovernment bank workers, and others refused to reply to
our private social media request. After accepting ourinterview request for those willing, we wrote and sentletters to them asking for their participation. For those
who gave their positive responses, we then set theinterview immediately. Due to the COVID-19 pandemic, aface-to-face interview was done with social distancing andwearing a face mask. Social media interviews were also
carried out with delays in the question and response
between the main questions to follow-up questions. We

46

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
had to consider the informant's availability (online status)
in his/ her social media account.
We followed the data collection circle identi ied by
Creswell (2007). First, we located our intended informants
who satis ied our inclusion criteria by asking and seeking
their permission. Before asking them according to theinterview guide, we irst established good rapport withthem. They were allowed to use any language they wanted.
Second, we conducted the key informant interview (KII) as
the main technique in collecting the data. We depended on
the choice of the participants where the interview could
happen. However, due to the pandemic, most of theinterviews were through social media platforms. Third, forsocial media platforms, we copied in a word ile for thetranscription while for a face-to-face interview werecorded the information and transcribed it later.
Fortunately, we were able to deal with social distancing
issues except for some response time delays. Fourth, westored data safely. Fifth, we did the analysis andinterpretation after the interviews using the methodsuggested by Colaizzi (1978) and the technique applied by
Tudy and Gauran-Tudy (2020).
Analysis and interpretation of data
In the analysis of the data, we followed Colaizzi’s (1978)
method. The seven steps in Colaizzi’s method are: 1) Eachtranscript should be read and re-read to obtain a general
sense about the whole content; 2) For each transcript,
signi icant statements that pertain to the phenomenon
under study should be extracted; These statements must
be recorded on a separate sheet noting their pages andlines numbers; 3) Meanings should be formulated fromthese signi icant statements; 4) The formulated meanings
should be sorted into categories, clusters of themes, andthemes; 5) The study's indings should be integrated into
an exhaustive description of the phenomenon under study;6) The fundamental structure of the phenomenon should
be described; 7) Finally, validation of the indings should
be sought from the research participants to compare theresearcher's descriptive results with their experiences. For
steps one to 4, we used tables in the analysis as applied by
Tudy and Gauran-Tudy (2020).

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TrustworthinessTo ensure trustworthiness, we strictly observed credibility,transferability, dependability, and con irmability, asasserted by Guba (1981). We experienced pressures fromwork, co-employees, and family members. We could easily
relate to their experiences. Moreover, we subjected our
outputs to member checking and debrie ing. We showed
the informants the indings of the study and asked for theirapproval to ensure the correctness of the data. For
debrie ing, we asked experts to review our papers andconsidered their comments and suggestions.
Transferability refers to the application of the indings
into similar situations. For instance, we wrote the stories ofgovernment bank employees so that their experiences canbe relatable to other contexts. As Merriam (1998)

explained, transferability is about using the results in adifferent situation. In promoting transferability, we
provided a detailed description of government bank
employees' phenomenon in the Philippines by following
standards method in phenomenological research. We
discussed how we recruited the participants and how wecollected, analyzed, and interpreted the data. In thediscussion of the themes, we also provided actual
responses from the participants.
Dependability refers to consistency. We provided an
audit trail, including our social media conversations, audio
recording, research committee notes, experts' comments,
and peer reviewers' suggestions. We subscribed to the ideathat the shared experience of the informants would makethe study very dependable. We did this to analyze the data,
making sure we identi ied common themes from their
responses. In the discussion section, we provide
supporting literature.
Con irmability is the linking of the indings to thesources of the data. To achieve this, researchers must showthat the indings emanate from the source and not fromtheir predispositions (Shenton, 2004). We kept the original
texts of the interviews and provide audit trails of theprocess of data gathering. We ensured lexibility andsubjectivity through member checking.
Ethical considerations
We secured permission to conduct the study from the
manager and of icers of the chosen government bank,where our potential informants belonged. We assured theprospective informants that we would uphold
con identiality and respect their rights. We also secured
their informed consent by asking them to sign the form
before proceeding with the interviews. In the encoding ofnames, we used pseudonyms to protect their privacy andto ensure con identiality. We kept con idential any otherinformation, such as the place or the department where
the informants worked. We made adjustments subject totheir pleasure if they felt uncomfortable during theinterview. As a protocol, we were mindful of issues thatwere critical to disclose.

Struggles of government bank employees in theirjobs amid the COVID-19 crisis
Based on the study's purpose, we present the results into
two clusters: discussion on government bank employees'
struggles in their jobs amid COVID-19 crisis and theircoping mechanisms. Our irst line of questioning focusedon the struggles of the informants. After the interviews, weanalyzed the data, and two themes emerged. These werepsychological pressures and physical exhaustion.
Psychological pressures
One of the shared experiences among government bank
employees was the feeling of fear. The perceived chilling
effects of the COVID-19 pandemic created anxiety on theirpart. Most informants said that reporting to work wasscary because they might get infected with the virus. They

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
were uncomfortable being in constant contact with clientsand handling cash, checks, or bank documents. Lourdes, a40-year-old bank employee who had been working in thebank for more than 15 years, expressed her experience bysaying:“I fear being infected with the virus through our day to day
interaction with various clients and transmitting it to ourfamily at home. Handling of cash, checks, and otherdocuments from various clients whom we did not knowwhether they are infected, asymptomatic, or exposed to
COVID-19 makes us anxious every time we are at the of ice”.
Most of the informants considered themselves a threat
to their families. They knew they were in contact with a lotof people at work. One participant shared her experiencein this manner: “It is a struggle to wake up each day, notknowing if you will catch the virus or not, that you may takeit home to your family and compromise their health as well”.
Based on the informants' sharing, people, especiallyclients of the bank, are considered carriers of the virus,
thus creating an anxious situation for government bank
employees. They felt horri ied when dealing with clientsand handing or receiving money, checks, or other bankdocuments. Though these are part of their social mandateand commitment to serve, their effect was dreadful. In
short, they felt fearful.

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Physical Exhaustion
Government bank employees expressed having dif iculties
in traveling from residence to place of work and vice versa.
Added to that is the necessity of buying food, medicines,
and of ice supplies. Since the scenario where ourinformants live and work included a lockdown orquarantine having tight security checkpoints, they felt it
tough to survive in this crisis. For example, Vincent, a 26year-old bank employee who had been with the bank formore than three years, shared his struggle regardingtransportation: “I am having dif iculties in traveling to theassigned branch or of ice. During the enhanced community
quarantine, people traveling to different barangays,
municipalities, and provinces were required to undergo
strict checking through multiple checkpoints. Even though
we were essential government employees with IATF passes,
some checkpoints have different protocols. Some would noteven allow these IATF passes and would require providing
other documents before entering their barangay ormunicipality”.
Our informants also said they found it hard to look atand buy food, hygiene products, and of ice supplies. Someof them expressed their sentiments at work. They also
described scenarios wherein they found it dif icult toperform their role. For example, some of their co-workers
complained of lack of supply of alcohol and face masks.
They attributed this factor to the limited supply, the vast
demand, and only a handful of establishments that opened.
Alice, a 45- year- old Bank Of icer who had been in service
for more than 20 years, was more speci ic in narrating her
own experience: “There is a shortage of food supply,
availability, or accessibility of some of our basic needs. There47

is also a shortage of supply of masks and alcohol, and thecosts are super high. There are limits of going out like used
codes, and curfews were being implemented.”
These narratives provide a bird's-eye view ofgovernment bank employees who are having a tough time
during the COVID-19 pandemic, affecting them not justmentally but also physically. Undeniably, the struggles andconcerns were real experience for the informants. It
appeared that for them surviving in this crisis is not aneasy feat.

Coping mechanisms
We asked the informants how they managed all the
struggles they experienced. After analyzing all their
responses using Colaizzi’s method, three emerging themes
were identi ied. These were social support, prayer, andresiliency.
Social support
Government bank employees learned different strategies
and devised effective measures in dealing with theirstruggles. There were instances in the of ice where they
were confronted with the fear in dealing with clients. All
the informants supported and followed the government’s
guidelines which to them served as a light that guides themthrough the darkness. Lourdes, a 40-year-old senior bank
employee who had been in service for more than 15 years,
shared her way of surviving this crisis: “For as long as wefollow the government’s COVID-19 protocols and keep
ourselves healthy, we can go on with our customary routine.”
According to the informants, they protected themselves
by wearing face mask and shields, handwashing frequently,
and maintaining social distancing to avoid being infectedby the virus. Also, they tried to organize themselves anddevise measures to counter the spread of the virus. They
helped each other. Alice described it this way: “Strategies
being implemented include disinfecting the of ice as often as
possible. We put up plastic barriers and wear face masks andshields to protect ourselves and practiced social distancing
between ourselves and the customers. We buy tablets ofVitamin C for less exposure to the virus and boost ourimmune systems, and some of our branches do skeletal
workforce mechanism”.
Informants also noted that putting all their support,
con idence, and trust to government authorities and coemployees were not enough to counter those psychologicalpressures and physical exhaustion they experienced. First,
they tried to stay connected with their families and coworkers in the government. JeePat, a 26-year-old banker
who had just been in service for four years, shared her
mindset: “You cooperate with your co-employees and voiceout your concerns. Suggest strategies that may help the bankoperation, especially in crowd management. Take care ofyour mental and physical health. Maintain goodcommunication with your loved ones and pray”.
These statements show the kind of coping mechanisms
government bank employees apply to survive in this crisis.
Social support and clear communication from government

48

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
authorities and co-employees, and deep connection withfamilies and friends put the informants’ situation on thebrighter side. Government bank employees managed tosurvive this ordeal, and they found ways to keep on living.
They employed effective means not to be infected by thevirus. In other words, they would instead cooperate,
support, and help government authorities and coemployees rather than being fearful and querulous.
Prayer
For the informants, this catastrophic event allowed them toexperience the feeling of gratitude and amplify their
spiritual connectedness to God, knowing that manybusinesses were not able to sustain their operations, andmany employees lost their jobs. Being government
employees, they were lucky enough to keep their jobs.
They felt fortunate as compared to those in the private
business sectors. Jeepat said: “Be thankful (to God) because
you are part of a company that is well established and cantake a blow even during pandemic. Many people went joblessin a blink of an eye. Businesses closing down due tobankruptcy. But you are part of a government institutionthat can take care of its employees even on global crisis. So,
it is like a push and pull feeling in my everyday life.”
They get their strength by putting their trust in God.
Prayer had been their powerful weapon. For instance,
Mark, a 45-year-old security guard of the bank, narrated
his trust in God in this way: “We have to be careful not tocontract the virus. We have to pray every day because we donot see our enemy. We could be dead in an instant. Then, I
pray that God will help people understand to what we aredoing. They do not get angry. I hope we understand eachother.”
Informants also suggested that other government bank
employees live a simple and quiet life and surrendereverything to God. They needed to focus on things thatmatter, intangible things, and the things that nourished thesoul. Alice shared her thoughts in this way: “I learned tolive a quiet and simple life. No lipstick, no wearing of
makeup in going to the of ice, eat healthier food which aregood boosters to keep my immunity strong. I learned to focus
on things that are more important and useful. That
everything, from basic needs down to other life's essentials
and even life itself, is just being borrowed and that one-day
God, the giver of these all, will take them away from us.”
The participants felt blessed and spiritually nourishedthrough their contribution to their community, and theirself-worth was realized by providing inancial support totheir countrymen. Their suggestion to other governmentbank employees was to restore a healthy and balanced life.
There is a need to focus on activities that add value to one's
existence, thus inding God’s divine purpose and mission
set for us in our lives.

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Resilience
Undeniably, bankers should adapt and institute measures
to mitigate the impact of COVID-19 and sustain theireveryday jobs. This is about resilience. They need to enticeclients to use digital banking channels to do banking
transactions to sustain its operations. For example, while
limited banking hours reduced the level of services
provided, the informants introduced the use of digitaltechnology to counter the dif iculties induced by thispandemic. Restie, a 36-year-old government bank
employee who had been with the bank for more than 10
years, shared his game plan: “Government services andbanking transactions must be accessible throughtechnological and online means for the ef iciency of service
delivery and people must as well be introduced to the said
methods.”
Moreover, the informants practiced the art of positivity
in which they realized that dwelling in the past will justmake things worse. Instead, they practiced the attitude of
accepting adversities as opportunities and being prepared
to deal with it accordingly. Jemar, a 34-year-old utility/
messenger of the bank for more than 5 years, shared his
mechanism to survive in this pandemic: “I work doubletime and have a sideline job like aircon cleaning, computer,and electronic services to address and cope with my inancial
needs.”
Despite their situation, government bank employees
remained positive. They stayed hopeful by putting theirtrust on their colleagues, having con idence in government
authorities, constant communication with loved ones, andsurrendering their fate in God. With these mechanisms'
help, the informants did not lose hope and kept on ighting
to overcome the crisis that COVID-19 had brought them.
Similarly, despite the informants' struggles that prompted
psychological pressures and physical exhaustion, they
were immensely proud of being at the forefront in thebattle against the COVID-19 pandemic. They realized that
their commitment to serve during this pandemic af irmed
their obligation or their oath of of ice as public servants.
JeePat, when asked about her insights as a governmentbank employee, shared her views, saying: “We had to be
extra cautious for us to protect ourselves. At the same time,
we continue the same passion for work as stated in our
mandate to help people grow inancially. We are the channelof inancial assistance from the national government to the
LGUs. So, our operation is vital during this time.”
Also, some informants explicitly articulated their call of
duty despite risking their own lives in the name of public
service. As government bank employees, they weremandated to continue their operations as their services
become more vital and essential in this crisis. For example,
Vincent shared how he observed resilience in his job:
“Working amidst the COVID 19 crisis was more than just ajob. It was more of social welfare. It was giving good public
service. It is risking one’s life daily and facing the possibilityof getting the disease. Some are forced to live far from theirfamilies.”
Government bank employees showed how dedicatedthey were to their chosen profession. Their commitment
was beyond question. They felt ful illed and proud of theircontribution to their community, and their self-worth wasrealized by providing inancial support to theirEubios Journal of Asian and International Bioethics 31(1) (January 2021)
countrymen. Also, they were able to be resilient by
outweighing the cost of risking one’s life with the bene it of
having a sense of purpose and meaning in life by serving
and helping their countrymen during this dif icult time.

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Discussion
We learned good insights from the participants' sharing,such as their concerns and struggles during the present
pandemic. We also learned from their coping mechanisms,
particularly about the importance of social support, prayer,
and resilience in government bank workers' overall wellbeing. Their struggles and coping mechanisms were pieces
of information for us, other government bank workers, andsociety.
COVID-19 pandemic is a global phenomenon, and it ismuch felt in the Philippines considering the high increasein the daily positive cases as days and months go on. With
little or few attempts to study this phenomenon in the
country, particularly on bank employees' lived experience,
this study provided a glimpse of how the essential
workforce cope with the adverse impact of the pandemic.
Being a banker, and at the same time, a public servant is
not a comfortable journey for these workers. They
identi ied their struggles with psychological pressures andphysical exhaustion. The said struggles were expected,
considering the psychological and physical toll on theparticipants. COVID-19 is not just a health pandemic, but it
is rapidly becoming a global economic crisis (McKee &Stuckler, 2020). Fearing for one’s life created pressures forgovernment bank workers. Understandably, the informants
experienced different degrees of hardship. Although
limited studies were conducted on this topic, governmentbank workers and healthcare professionals in othercountries did have similar experiences and struggles.
Healthcare workers in Sardinia, Italy, for instance,experienced physical and mental exhaustion. The fear of
passing the disease to their families has added to thehardships they are now facing (Bellizzi et al., 2020). These
government bank workers, though not showing serious
mental fatigue, still shared the same sentiments brought
about by the pressures from the COVID-19 pandemic.
Government bank informants felt the fear of contracting
the disease. Several studies about the impact of the
COVID-19 pandemic on mental health showed that fear is aby-product of disease outbreaks. Moreover, fear of theunknown raises’ anxiety even in healthy individuals (Usher
et al., 2020). For example, people are rushing to go homeearly to avoid further exposure to the virus, which greatly
affects their job, such as low productivity or/and poor
quality of work output. Likewise, there are unveri ied
information that causes misinformation, which creates
psychological havoc among the people. Indeed, the
COVID-19 pandemic does bring health and life risks andpsychological pressures, which contributed to increased
anxiety (Cao et al., 2020), a reality felt by bank employees.
Working in a bank and serving the public amid
COVID-19 pandemic is not only scary but dif icult as well.
This was how psychological pressures and physical49

exhaustion came in as experienced by the informants.
Government workers struggled to cope with the mental
and physical hardships. Nevertheless, all informants
continue to weather the storms of living with the pandemic
because their trust and support in/from the government
seemed to produce positive results.
We found interesting responses from the informants
facing hardships how to avoid being caught up in thescourge of fear. They resorted to prayer, social support, andresilience tactics. They looked for ways to escape frompsychological pressures and physical exhaustion. They
seek guidance and protection from God. They also asked
for the attention, help, and support of society, families, andcolleagues. Social support diminishes the psychologicalpressures during a pandemic, and effective and robustsocial support is needed to survive in any health crisis (Caoet al., 2020). They managed to handle themselves insituations where they were very vulnerable despite mental
and physical fatigue. They tried lexible tactics to reduce
the likelihood of contact with the virus. Some informants
applied the “Eudaimonic Approach” to human resilience,“eudaimonia perspective emphasizes meaning-making, selfrealization and growth, quality connections to others, selfknowledge, managing life and marching to one's own
drummer. These qualities may be of importance in theconfrontation with signi icant life challenges” (Ryff, 2014).
In South Korea, the government highlights the importanceof getting reliable information, maintaining social
networks, expressing negative emotions, continuing daily
life activities, and pursuing pleasant experiences to copewith mental health problems (Jung & Jun, 2020).
Nonetheless, the informants developed coping
mechanisms that were important and necessary for themto avoid the adverse emotional, physical, and mental
effects.
The informants had their ways of resolving theirstruggles by clinging on to the intangible form of trust
acquired through social support. Trust is a key ingredientamong organizations and workers who are willing to work
during a public health crisis; trust among organizations
and professionals can be realized through the frequent
provision of information. It suggests that regularcommunication and encouragement to workers from thegovernment and employers make them feel protected(Imai, 2020). Certainly, trust will foster harmonious
relationships between organizations and individuals,
promoting cooperation and teamwork that will help defeat
this COVID-19 pandemic.
Social support and communication are critical in thesetrying times. Social connectedness and communication are
dif icult during this time because there is a need tomaintain physical distancing while lack of social
connectedness can cause physical, emotional, and mental
issues. Thus, setting up regular phone calls or videoconferences with family, friends, and colleagues can bridge
the gaps brought on by social distancing (Usher et al.,2020). As social beings, people need each other.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
Moreover, the informants consider resilience as one of
their coping mechanisms. Filipinos are known for theirresilience. They can adapt to life in any part of the world, as
manifested by the Overseas Filipino Workers (OFW)
scattered worldwide (Quito, 1994). Although theirstruggles may seem endless, they are determined to copewith the crisis. According to Smith et al. (2020), they
viewed the word resilience as an individual's ability toendure adversity; thus, the informants embody what it is tohave resilience in their work amid COVID-19 pandemic. We
found it inspiring because even our informant, a contract
worker with minimum salary, had been with the bank formore than ive years, was working double time and had asideline job addressing and coping with his inancial needs
due to reduced work per hour pay. His monthly householdincome had diminished, yet he still had to pay the bills andfeed his family. His situation is like those disadvantaged or
low-income workers who have essential jobs with nooptions for working from home, and alternative work
arrangements (Shaw et al., 2020). A government employee
may have to accept delivery services or similar contracts
after his half-day regular work shift. Still, government bankworkers remained optimistic, coupled with theiradaptability to the ever-changing situation that helped
them survive this pandemic. According to Mogaji (2020),
individuals must survive and adapt to change, especiallyinancial and emotional stress. Expectedly, none of theinformants feared of losing their jobs as the government
has this "security of tenure" principle, and they are
considered an essential workforce for inancial stability
and security in these trying times.
Implications of the study
The study indings provide essential pieces of information
for government banks. On the one hand, government banks
may maximize their employees' commitment and passion
for serving. They can channel the energies of these
employees to be more productive in work. On the other
hand, government workers continue to rely on social
support and strengthen their faith and resilience.
The indings of the study are also a good source of
information for bank clients. Everybody is having dif icultyat this time. Understanding and cooperation are mostwelcome, especially for bank employees who are there to
render service despite the pandemic's limitations anddangers. This study widens our understanding of the livesof the informants and opens other areas of interest to dig
deeper into the world of government bank employees. For
example, how does the pandemic affect the whole banking
industry? What about the experiences of those in privatebanks? Also, an in-depth study on people’s perceptions andreactions towards government bank workers could be
another interesting topic that would paint a bigger pictureof this phenomenon.

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Concluding remarks
This study highlights the struggles and coping mechanismsof government bank workers. The indings describe their

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struggles of psychological pressures and physicalexhaustion during the COVID-19 crisis. However, social
support, prayer and resilience are their coping
mechanisms. They continue performing their job despite
fear, inconvenience, and stress. They consider being apublic servant a plus factor in terms of having a sense of
ful illment. They even advise other government bank
employees to be proud and thankful of their situation.
Moreover, the results of the study may serve as aninspiration to other government bank workers because
working amid COVID-19 pandemic is not an apocalypse forthem but rather, it is a challenge and a way of life that they
are supposed to live. Finally, the indings would not only
bene it the informants, but also other government workers
and other professionals, inside or outside of the banking
industry. They might consider their coping mechanisms tocontinue living a happy and meaningful life while at thesame time being committed and having the passion toserve.
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COVID-19 and food security: The
Eastern Visayas State University
experience in the municipality of
Burauen- Sheldon Ives G. Agaton, Ph.D.
Eastern Visayas State University Burauen Campus
Burauen, Leyte, the Philippines
Email: shelds_just@yahoo.com

Abstract
The COVID-19 global health crisis has affected numerous
lives, jobs, and properties. The virus is infectious anddeadly, and the most vulnerable are the poor and theelderly. Due to its contagious nature, businesses wereforced to shut down causing tremendous damage to many
workers. The municipality of Burauen in Leyte as well as
its neighboring towns are not exempt from the virus wrath.
People perished and many lost their livelihood, disablingthem if not limiting their purchasing capacity for food andsustenance. The Eastern Visayas State University Burauen
Campus is primarily an agricultural school. With theexistence and persistence of COVID-19, such campus roseto the challenge by elevating its food production with thehope of providing food security not only in the town where
it is located but also to neighboring municipalities. This
paper will delve into the problems and challenges theschool faced, and likewise its methods and strategies tohurdle the dif iculties it handled to help provide cheap but
healthy agricultural products for the people.
Introduction
COVID-19 has brought considerable disturbance to thewhole of humanity. It began in China but rapidly spreadthroughout the globe as the virus was considered highly
contagious. This prompted the World Health Organization
to assess the situation as a pandemic (World HealthOrganization, 2020). Countless lives perished and thecount continues. Countries imposed shutdown, hoping to
mitigate its further spread. Health experts suggested

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
methods to lessen its transmission like frequent washing ofhands, wearing of face masks, and physical distancing(World Health Organization, 2020). Despite thesemeasures imposed, the COVID-19 continued its transfer
among hosts making it almost impossible to stop. This isbeside the fact that there those who elect to ignore thepractice of these health measures.
The spread was uncontrollable, and the Philippines was
not spared from the virus wrath. The moment it began
crawling out of China, the Philippine government issued alockdown beginning on March 15, 2020 (Staff, 2020).
Manila, the capital of the Philippines and the mostpopulous among the country’s cities, implemented
lockdown and immediately followed it with other local
government units. The strategy was meant to slow down
the transmission of the virus because the lesser the
movement of people, the lesser would be the transfer ofthe disease.
The disease may have slowed down, but for various
reasons, its transmission continued. A number of returning
residents from various parts of the country went back totheir homes encouraging local government units tointensify border control and the usual health protocols(Inter-Agency Task Force for the Management of Infectious
Diseases, 2020). It will be inhumane to bar these returning
residents from going back home because their lives awayfrom home was already dif icult and risky, and denying
them from returning home will be tragic. However, the risk
was always present that they might be carriers of the virus.
The possibility that the virus would reach the provinces
was real and imminent and if this happens, lives, jobs, andthe local economies will be in danger.
The Eastern Visayas State University Burauen Campus isan academic institution, and its lagship is agriculture. It
has a land area of approximately 33 hectares, big enoughso that when utilized up to maximum capacity, it can
produce agricultural products to supply food in the local
market and hopefully stabilize the food demands ofconsumers. Food is essential for human survival, andshortage of it has negative implications to his socioeconomic life.
The campus has envisioned that if this unfortunate event
reaches the place, it would be wise to prepare beforehand.
The dreadful virus started in December of 2019, andhaving learned of its high transmissibility, EVSU Burauen
campus tried to anticipate its effects beginning February of
2020.

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COVID-19 and food security
The COVID-19 has interrupted various facets of human life
ranging from jobs, businesses, trades, commerce,
production of goods and many others. These distractions
have resulted in closure of businesses, job losses, hunger,
and despair plunging revenues of billions of dollars fromvarious businesses (Maboloc, 2020). Governments from allover the world addressed these concerns by imposing
lockdowns and stricter health protocols, while addressing
repercussions that may affect economic activities. This isan extraordinary phenomenon as it is a fact that man needs
to work in order to survive. The pandemic is affecting all
four pillars of food security which are availability, access,utilization, and stability (FAO, 2008).
Among the effects of community quarantine being
imposed by the Philippine government is for people to stayhome. This strategy lessens movement of social life thus
minimizing contacts among people. Physical distancing canbe properly imposed since few people will be going out(Devereux, Bene, & Hoddinott, 2020). Agriculture in thePhilippines is not highly mechanized even in the
production of the country’s basic staple food, rice. Humanlabor is still the primary force in rice production, and thisis further evident in rural areas. Limiting the movement of
persons as well as imposing physical distancing diminishes
the availability of food, and gravely affects poor farmers
from earning their usual income (Laborde, Martin,
Swinnen, & Vos, 2020). However, the same government
initiated a method in order to safeguard the food necessityof Filipinos. They presented the P17.5-billion refocused2020 DA budget and the proposed P24-billion stimulus
package for agriculture under the “Bayanihan to Recover as
One Act” or “Bayanihan 2” (DA Communications, 2020)
Closure of business establishments has both affectedowners and workers. Bigger establishments like foodchains resorted to take out of food only. Shopping malls
limit the entrance of shoppers in order to avoid crowding
and to maintain health standards. These scenarios
illustrate laying off of employees, causing them great
discomfort where majority of them are minimum wage
earners (Maboloc, 2020). The usual number of waiters in a
restaurant is no longer pragmatic for a very few customers.
The rampant job losses experienced by a number ofFilipinos resulted in shortage of purchasing power. Food
may be available but, if the purchasing power of anindividual is impaired, food insecurity is possible. The
extent of the increase of poverty due to the pandemic may
still be incalculable considering that the phenomenon isstill ongoing, but the reality of it is certain (Laborde,Martin, Swinnen, & Vos, 2020).
Utilization is another pillar of food security that also
needs to be addressed. Are the consumers taking the rightnutrients in their food intake? Food does not have to bedelicious to be nutritious. The basic food nutrition of Go,
Grow, and Glow is a decent guide for a person to live
healthily. Laborde (2020) mentions a recent survey in
Ethiopia that shows the pandemic has caused poor
households to reduce nutritious food intake and redirect
the loss of less nutrient food, making consumers
susceptible to adverse health problems (Laborde, Martin,
Swinnen, & Vos, 2020). The Philippines is a developing
country, and there are many poor families. If the pandemic
perpetuates, then food utilization will be a factor in the
country’s food insecurity.
This health crisis poses greater risk on food stability orsustainability. There is no guarantee that if this situation
sustains, agricultural activities continue. There is always
the possibility of interruption whenever there is infection

among workers. For instance, in the harvesting of crops
like sweet potato, social distancing can be applied implying
lower risk of virus transmission. But this is not the case inrice production. In the Philippines, planting rice is mainly
done by human hands and plenty of hands at that, and timeis always essential. Here, social distancing is a remotepossibility, and the danger of virus transmission is high. In
such case, production will be hampered causing workers to
be isolated under quarantine resulting in low or nonproduction (Laborde, Martin, Swinnen, & Vos, 2020).

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The agricultural production of Eastern Visayas State
University Burauen campus: striving towards cheaperand healthy food sustenance
The Eastern Visayas State University Burauen Campus isunder the auspices of the Eastern Visayas State University
Main Campus of Tacloban City, Leyte, Philippines. The
Burauen Campus is located 46 kilometers from Tacloban
City. It is mainly an agricultural school where its lagship is
Bachelor of Science in Agriculture. It covers a vast landarea consisting of approximately 33 hectares.
COVID-19 irst struck in Wuhan City, China in December
2019 (World Health Organization, 2020). From there, it
spread rapidly to other countries due to its highly
contagious nature causing alarm among nations. Besides
its high infectious rate, it was likewise initially perceived as
deadly, but later data showed that it was particularly soamong the elderly. When quarantine measures were
imposed, the irst reaction was how to gather food while
citizens were limited from going out of their houses. The
most vulnerable in this situation are the poor. Citizens in
the upper class have savings, so food hoarding is not aconcern. But for the poor, to ind money is one thing, and tobudget the food they bought is another thing (Abellanosa,
2020). The risk of losing one’s job was critical since aside
from the limitations imposed, business owners were also
forced to close down for fear of contracting the virus. Food
security became the major concern for the administrationof EVSU Burauen. In February of 2020, it immediately
directed its focus on cultivating as many land areas as
possible.
With the virus’ communicability, the school perceived
that it was only a matter of time that this dreaded disease
would infect some inhabitants of the town. Unfortunately,
the municipality of Burauen was the irst among the towns
in Leyte to register its irst COVID-19 patient and until
today the number is growing but recovery rate is also high.
The campus since then has planted various agricultural
products like rice, corn, eggplant, bottle gourd, sweet
potato, cassava, squash, upland spinach, watermelon, andmany others. Rice is the basic staple food among Filipinos,
so it was the irst priority. Vegetables have always been
generally considered as nutritious and good source ofvitamins and minerals. These farm goods have a goodchance of helping stabilize food supply in the area and eventhrough neighboring towns.
Budget to initialize the endeavor was initially a deterrent
for the campus because it only caters to a thousandff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

53

students during that semester, and the money it generates
from such number is minimal. There are also otherinancial matters that needed to be addressed likepurchasing of antiviral measures, like alcohol,
disinfectants, wash areas and thermal scanners, salaries of
employees and farm workers, and other miscellaneous andoperating expenses. But the meagre budget coupled withhardworking individuals made the propagation of these
agriculture products a reality. Another hindrance thecampus faced was manpower. Strict health protocols werestrictly monitored by government of icials. For instance,
the compliance with social distancing and wearing of facemasks at all times in workplaces was a concern in riceproduction. On the one hand, a bigger number of farmworkers is necessary but if one is infected, it will hamper
the entire procedure. On the other hand, a smaller numberof workers will faithfully comply with these protocols, but
this will impair the time element in the production of rice.
Working under the warmth of the sun with face masks on
is hard. This condition weakened the farm workers body
prompting them to ask for break from time to time. The
advantage was that since workers worked alternately, theproduction was complying indirectly with protocols. The
production of farm products other than rice was not an
issue and health standards were carefully exercised. For
instance, planting of corn seeds needs proper spacing fromone seed to another. During harvest time, farm workers do
not crowd since grown corn plants are already distant fromeach other, so health standards are followed. Healthprotocols were the major concern, but they wereaddressed well through initiative and creativity.
Data based on the report submitted by the school showsthat the area for rice production increased from 0.7
hectares in 2019 to 1.6 hectares in 2020. As a result, there
was a signi icant increase of rice produce from 9,240 kilos
to 25,760 kilos in 2020 (Eastern Visayas State University
Burauen Campus, 2020). As a basic staple food among
Filipinos, there should be a substantial increase for thisparticular product in order for it to be catered to themarket (Eastern Visayas State University Burauen Campus,2020).
In order to coincide with the concepts of food security
and catering nutritious food primarily to the people ofBurauen, vegetables and fruits plantation was enhanced.
Vegetable and fruit production was second among the listof priorities. From 0.4 hectare of tilled land in 2019, it wasincreased to 1. 3 hectares in 2020 resulting in 7,212.85
kilos of various vegetables harvested and sold for humanconsumption at a low price (Eastern Visayas State
University Burauen Campus, 2020).
These were the initial fruits and vegetables planted andharvested for the irst half of 2020. There are othervariations that have been planted that await harvesting likejackfruit and guyabano. Meanwhile the administration isstill planning on other variants to plant.
Root crops are also good sources of nutrition. In rural
areas, several types of root crops are grown in the
backyard among households. These types of food may be54

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
eaten during breakfast, lunch or dinner and even snack
time. They are so rich in nutrition that sometimes locals
replace rice with these products. The school increased its
root crops production from 0.2 hectare in 2019 to 0.4
hectare in 2020. The increase in land area cultivatedgenerated 1,435 kilos and the produce was made available

to consumers inside and outside of the school. In addition,corn production was likewise ventured but only on aminimal extent harvesting only a total of 400 kilos for theentirety of 2020 (Eastern Visayas State University Burauen
Campus, 2020).

Rice

Bottle Gourd
Dragon Fruit

CitrusUpland Spinach

Watermelon

SquashThere is no certainty yet as to when this pandemic willend. Vaccines are already on their advanced stage ofhuman trial, while some pharmaceutical companies havealready applied for emergency use authorization of theirproducts in some countries. Vaccines are primarily
developed by wealthy countries, and it is likely that third
world countries like the Philippines will be at a
disadvantage. Hence, multilateral agreements among
countries must be at stake for humanitarian purposes(Maboloc, 2020). However, a new variant of the virus has
been discovered in some countries like the United

Eggplant

Ampalaya

Kingdom which is again another challenge for scientists.
This new unfortunate development will be another puzzle
on the human mind as to until when this unfortunate
occurrence will last and then return back to normal. The
continuous rise of COVID-19 cases all over the world is still
evident despite promising results of several vaccines.
Everyone probably hopes to go back to where our world
used to be without the need for masks and physicaldistancing; the Citrus
freedom to go shopping in malls without
going through strict measures; and the liberty to holdconferences, social gatherings, meetings and even religious

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
assemblies. The challenge continues for the Eastern
Visayas State University Burauen Campus, but theopportunity to rise above the hardship remains steadfast.
From agricultural products, EVSU Burauen will expand
helping the municipality and even the province to achieve
food security. It has started to venture into farm animal
products. At present, it owns 4 water buffalos and 2 cows,
but already intends to purchase 1 male water buffalo and 1
bull. This will allow the female animals to propagate theirown kind. Additionally, the campus recently purchased 1
set of chicken layers, several native chicken, and a pair ofgoats. A piggery is next in line, but since it needs more
preparation like a concrete pig pen and a comfortable andclean place, it will take a few months before it can berealized. Further, since pork is a food generally favored by
Filipinos, the EVSU Burauen administration will pursue for
its realization.
The challenge was enormous, but hard work pays off.
This objective is founded on the campus’ altruistic concern(Bautista, 2020) for the people. The sight of remarkableharvest of all these agricultural crops coupled with theservice the school offers to the general public is humbling.
The school does not intend to compete with the same
goods in the market. Its proximate goal is to increase thesupply of food at an affordable price at this time of tragedy.
The general mood and disposition at this time is down andtaking advantage of the situation like increasing the pricesof commodities will not help with the burden, but to do theexact opposite will. Its ultimate goal is to stabilize foodsecurity in the immediate municipalities.
Conclusion
COVID-19 is here to stay even with the availability ofvaccine. In fact, even before it reached the market forhuman consumption, a new variant of the virus was
already discovered. Experts scramble to test whether their
newly created vaccines will combat the new variant.
Promising signs of these vaccines’ ef icacy and safety are
documented, and signs of a better tomorrow might becomea reality. people need to be pragmatic to life’s approach.
Food is a necessary element in human survival, and its
production must be sustained. COVID-19 will not be thelast virus that humankind will face. Realistically, there will
be more and they might be deadlier and extremely
contagious. Health protocols will be upgraded to protect
humanity and cheaper but healthier food must be madeavailable for human consumption.
References

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Abellanosa, R. J. (2020). Poverty in a Time of Pandemic: A Critiqueof Philippine Democracy and Some Imperatives Moving
Forward. Social Ethics Society Journal of Applied Philosophy(special Issue), 306-332.
Bautista, D. M. (2020, July). The COVID-19 Pandemic in the Lensof Comtean Altruism. Social Ethics Society Journal of Applied
Philosophy (special Issue), 359-376.
Coronavirus disease 2019 (COVID-19). (2020). Retrieved fromWorld Health Organization: https://www.who.int/ docs/

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default-source/coronaviruse/situation-reports/ 20200423sitrep-94-covid-19.pdf
DA Communications, G. (2020, September 4). The Way Forward,
Level Up Philippine Agriculture! Retrieved from Departmentof Agriculture: https://www.da.gov.ph/da-refocusesremaining-2020-budget-to-ensure-food-security/
Devereux, S., Bene, C., & Hoddinott, J. (2020). Conceptualising
COVID-19’s impacts on household food security. International
Society for Plant Pathology and Springer Nature, 769-722.
doi:10.1007/s12571-020-01085-0
Eastern Visayas State University Burauen Campus. (2020).
Accomplishment Report. Municipality of Burauen, Leyte,
Philippines.
FAO. (2008). An Introduction to the Basic Concepts of Food
Security. Retrieved from Food and Agriculture Organization:
http://www.fao.org/3/a-al936e.pdf
Inter-Agency Task Force for the Management of Infectious
Diseases. (2020, July 21). Retrieved from Of icial Gazette:
https://www.of icialgazette.gov.ph/downloads/2020/07jul/
20200721-IATF-RESOLUTION-NO-57.pdf
Laborde, D., Martin, W., Swinnen, J., & Vos, R. (2020, July 31).
COVID-19 risks to global food security. Science, 369(6503),
500-503. doi:10.1126/science.abc4765
Maboloc, C. R. (2020). Globalization and Consumer Culture: Social
Costs and Political Implications of the COVID-19 Pandemic.
Eubios Journal of Asian and International Bioethics, 30(3),77-79.
Staff, C. P. (2020, March 12). News. Retrieved from CNN
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3/12/COVID-19-Metro-Manila-restrictions-Philippines.html
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Changes of health care practice inthe field of ophthalmology during
the COVID-19 pandemic- Sibel Inan, MD
Associate Professor of Ophthalmology, Afyonkarahisar
Health Sciences University, Faculty of Medicine, Turkey
Email: drinan33@gmail.com
Abstract
The new coronavirus SARS-Cov-2 (COVID-19) has
disrupted all aspects of medical care around the world.
Ophthalmology practices have also been affected by thispandemic all over the world. Due to this pandemic, newregulations were introduced in ophthalmology for patient
examinations and surgical practice. Ophthalmologic
procedures requiring close examination and physicalcontact have been reported to pose a high risk for SARSCoV-2 transmission for ophthalmologists. Guidelines on
measures to prevent the risk of contamination related to
COVID-19 have been published in this regard, and it wasstated that all treatments should be stopped, except for
emergency situations. The number of patients has been

56

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)
reduced. It was recommended to pay attention to
examination rooms and sterilization of instruments anddevices. It was recommended to provide personal
protective equipment during examinations, to make these
examinations as short as possible focusing on diagnosis.
Non-urgent procedures were postponed. In addition,breathing shields were placed on biomicroscopes toprotect against contamination.
In an assessment of the American Society of Retina
Specialists (ASRS), it was reported that a signi icant
percentage of retinal patients were at risk of vision loss
and required regular intravitreal injection therapy. At thesame time, the age range of this patient group has become
one of the special groups because it is included the age
range above 65 years of age, which is de ined as the age
range at higher risk of the COVID-19 epidemic worldwide.
Also these patients were found to be the group at risk forhigher mortality and morbidity in this epidemic due to theprevalence of other pre-existing systemic diseases. Amongthese patients in the risky group, there were those who did
not want to come to the hospital with their own requests,
those whose treatment was disrupted, and therefore also
experienced vision loss. The patients were recommended
to continue their treatment and their treatments werecarried out in order to prevent vision loss, by arranging
examination and operating rooms in a way that thepatients were least likely to be exposed to contamination.
It is important to plan the treatment and follow-up of thepatients in a way that minimizes the risk of contamination
as much as possible and at the same time considering thesituations that require emergency treatment. These aresome of the ethical issues I will discuss.
Key words: COVID-19, examination, ophthalmology, practiceIntroduction
The new type of Severe Acute Respiratory Syndrome
coronavirus 2 (SARS-CoV-2), which was irst seen in China
in December 2019 and spread rapidly to the world, is thecause of the coronavirus (COVID-19) disease [1].
The World Health Organization (WHO) declared the
COVID-19 virus outbreak a pandemic on March 11, 2020,and designed guidelines and strategic responses to containinfection worldwide. Proactive efforts and lockdowns
designed to contain the spread of the virus have been
implemented in many countries [2,3].
Governments have established wide-ranging control
measures to reduce COVID-19 transmission and thus
reduce the pressure on health systems. Most countries
initially imposed travel bans from certain locations (e.g.
China), followed by the establishment of quarantine
measures. Movement of people was restricted except fornecessity, working and health conditions [4].

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Transmission Risk In Ophthalmology
One of the irst to announce the COVID-19 outbreak in
China was doctor Lin Wenliang. Lin Weliang was an
ophthalmologist who was infected with COVID-19 from aglaucoma patient he examined. Dr. Lin Weliang died weeks

later due to COVID-19. He was one of our irst colleagues todie due to COVID-19. Ophthalmology specialty is one of therisky areas for COVID-19 transmission so concerns in theophthalmology community have grown. Ophthalmologists
are also included in the group of high-risk healthcare
professionals, such as dentists, otolaryngologists, andanesthesiologists who are routinely exposed to aerosolized
respiratory secretions, especially because they are very
close to patients during the examination. It has beenreported that ophthalmologists are particularly at risk ofinfection in terms of interaction with a large number ofpatients, close contact with patients, and spread throughcontact with infected secretions [4].
In the study of Loon et al., it was stated that
ophthalmologists and other healthcare professionals work
close to patients' eyes and this can be a source of infection.
Seitzman and Doan stated that occupational exposure to
the virus in the healthcare industry is mostly due toairborne transmission through infected droplets. They
reported that for biomicroscopic eye examination andophthalmologic procedures involving face-to-face contact,
the risk of exposure to this infection is high because theviral load is particularly high in the nasal cavity [5,6].
On the other hand, since the ophthalmological practiceincludes more than one examination, it can be said that therisk of cross infection to other patients and healthcare
professionals increases as a result of the longer hospital
stays [7].
In our country, in the guidelines of the Ministry of
Health, ophthalmological examination and operations havebeen classi ied among high-risk procedures for COVID-19
transmission [8].
COVID-19 disease caused by the new coronavirus SARSCov-2 has disrupted all aspects of medical care all over theworld. Ophthalmology practices have also been affected bythis pandemic all over the world.
To avoid possible viral autoinoculation by touching the
mucous membranes of the face, the United States Centers
for Disease Control and Prevention recommended the useof protective glasses over contact lenses or a face shield[9]/
Transmission Protection Recommendations andPrecautions in Ophthalmology
Although the possibility of viral transmission through tears
is low, it has been emphasized by the American Academy ofOphthalmology that personal protective equipment should
be used to cover the mouth, nose and eyes forophthalmologists. In most ophthalmological examinations,high risk of SARS-CoV-2 transmission to ophthalmologists
has been reported due to close distance and physicalcontact between patients and doctors. [10]Therefore, it has been reported that ophthalmologic
examination procedures should not be performed without
the use of personal protective equipment. Sterilization ofdevices and instruments should be part of the routine
examination. In addition, it has been stated that patient
education is also important in disinfection of the surfaces

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that patients come into contact with during their visits andto prevent infection through the ocular surface. It wasstated that patients should wash their hands properly andavoid any contact to face and eyes. In addition, it has been
recommended to pay attention to hygiene rules whenusing contact lenses and to use glasses if necessary [11].
During the pandemic period, with the recommendationof the Ministry of Health, all examinations and procedures
have been postponed except for eye examinations that
require urgency and eye diseases that may result in vision
loss if not done urgently. The Turkish Ophthalmology
Association has published information on diseases that
require urgent intervention, with the opinion of its subspecialties and in parallel with the practices in the world.
Thus, it is aimed not to neglect the treatment of patients
who may be harmed if they are not treated due to thepandemic, that these patients bene it from health services
primarily and that there is no additional health handicap.
In health services, these guidelines, which were createdwith these criteria, were tried to be followed [12].
Despite this, in our ophthalmology practice, when theirst peak of the pandemic passed and ophthalmology
examinations increased in the relaxation phase, we noticed
some patients who did not come to the hospitalenvironment voluntarily despite having symptoms in the
restriction phase and some of these patient haveexperienced irreversible vision loss with different degrees.
Infection precautions are divided into three categories.
1-Use of personal protective equipment
The American Academy of Ophthalmology published areport for ophthalmologists advising them to wear masks
and eye protection when caring for patients with thepotential to become infected with COVID-19. Reports
highlighted that COVID-19 can be transmitted by aerosol
contact with the conjunctiva if eye protection is not used.
In addition, patients should be asked to avoid speaking as
much as possible during the slit lamp examination[10,13,14].
2- Environmental Control
In biomicroscopic examination, protective breathing
shields should be added to biomicroscopes to prevent
contamination through droplets due to the close distance
between the patient and the ophthalmologist. The patient
and the physician must wear a mask, and talk should be
avoided during the examination. After each examination,
the protection shield of the biomicroscope unit and thesurfaces in contact with the ophthalmologist and thepatients should be disinfected frequently. Lai et al.,reported the importance of ventilation in waiting areas andsuggested taking measures to achieve a higher proportionof fresh air with improved air dilution [15].
3-Administrative Control
For every patient, the balance between the need to provide
patient care and vision protection and the risk oftransmission of COVID-19 must be considered. In theguidelines of the American Academy of Ophthalmology andin a review of Lai et al. about ophthalmology practiceduring the COVID-19 outbreak, it was recommended thatff

Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

57

the patient be examined in emergency situations and thatappointments be postponed for individuals suspected of
COVID-19 [15]. In general, elective visits and elective
surgery should be delayed. Medical care should only beprovided in emergencies. In recent studies, it has beenreported that most patients with COVID-19 wereaccompanied by fever indings. For this reason,
temperature measurement should be done at theophthalmology clinic admissions. If eye conditions are noturgent, patients with fever should be directed to necessary
places and their eye appointments should be rearranged. A
triage procedure should be performed to identify patients
who may bene it from telemedicine or internet-based
visits, and whose appointments can be rescheduled safely,
except for patients who need to be seen urgently by anophthalmologist [16,17].
It has been stated that teleophthalmology will emerge
as an important part of clinical practice as technology thatprovides opportunities in the digital environment,
especially for examination techniques, advances [18],In administrative control, efforts should also be made toprevent crowding of waiting areas. For this purpose,measures should be taken by paying attention to social
distance in waiting areas [17], Throughout the pandemic,
each hospital has created its own algorithms and ensured
control in terms of infection control measures, adhering to
the circulars issued by the Ministry of Health and relevant
authorities.
Health Service Delivery In Ophthalmology During The
Pandemic Period(Determination of the groups to be treated)
The American Society of Retina Specialist (ASRS) reported
in its March 2020 assessment of COVID-19 that asigni icant percentage of retina patients are at risk ofvision loss and should receive regular intravitreal injection
therapy. For this reason, it has been reported that there is a
special group in this pandemic period. The risky age range
de ined by this worldwide pandemic is over 65 years ofage. The patient group who received intravitreal injection
in ophthalmology practice is generally in this age group[19]. These patients were also in the risky group in termsof mortality and morbidity in this pandemic due to thefrequency of accompanying other systemic diseases.
For patients with retinal disease during the COVID-19
pandemic, the plan should be aimed at minimizing risks.
During the pandemic, it has been reported that the risk of
exposure to COVID-19 disease should be reduced for boththe healthcare workers and the patient, and action should
be taken in consideration of the risks of irreversible vision
loss for the patient. It has been reported that it isappropriate to avoid regimens requiring frequent followup for those who receive treatment. The necessity ofdetermining strict safety practices and the treatment that
requires urgent care and setting priorities are also
reported [20].
In the study of Yang et al., consistent with previous
studies, they showed that disruptions in treatment can

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021)

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cause a remarkable deterioration in visual acuity. It has
been stated that visual acuity results may change
depending on the length of treatment interruption. The
effects of thetreatment interruption should be
investigated in long-term studies. In addition, moredetailed guidance of global medical retina specialists isneeded in the dif icult conditions during the COVID-19
pandemic [21-23].
The patients were advised to continue their treatment
in order to avoid vision loss. With the arrangement of
examination and operation rooms in a way to reduce therisk of contamination, the treatment of the patients was
carried out. Some of the patients did not want to come tothe hospital of their own accord and disrupted theirtreatment and therefore suffered vision loss. It is
important to plan the treatment and follow-up of thepatients in a way that minimizes the risk of contamination
as much as possible and at the same time considering thesituations that require emergency treatment.
In Turkey, the number of patients in eye clinics has been
reduced, disinfection of the equipment in the examination
room, widening of the waiting rooms, determination of thenumber of patients according to the capacity of the waiting
room, keeping patients' relatives in the garden rather thanin the clinic, triage at the hospital entrance, screening thepatients to be operated, to arrange the operating rooms, touse full laminar low theaters for the operating room, touse mobile ventilation devices that clean the room fromextra viral load, to take a 30-45 minute break between
operations and to perform extra disinfection measures in
the room to reduce the aerosol load during eye surgery.
Measures such as the use of sterile medical drapes
covering the patient's head with an operating microscope
have been implemented. Each patient to be taken into theoperating room was screened, although it varied according
to the practice of the health institution. In someinstitutions, all patients were asked for lung X-ray scanning
and, if necessary lung CT scanning, blood tests andevaluation of these tests by the internal medicine doctor, if
necessary, COVID-19 tests in suspected cases. Some
medical centers stipulated more strict criteria such as
direct COVID-19 antigen test for all patients to be operated.
During these screenings, some patients who have noknown typical symptomatic disease, were diagnosed as
COVID-19, and were quarantined. The treatment of thesepatients were arranged accordingly, based on the degree ofthe urgency.
The procedures applied in ophthalmology practice inthe pandemic have also been the cause of a separate
discussion. Before the pandemic, in especially high volume
ophthalmology clinics in our country, due to the highnumber of patients and the demand for eye care, there
were too many people in the appointment list and it wasvery crowded in the waiting rooms of the ophthalmology
departments and the ability to allocate very little time topatients. Ironically, because the patients were allocated atregular intervals with longer times in the pandemic period,
new arrangements with less number of patients waitingfor eye examination in the ophthalmology departments
during the pandemic is actually thought to be must be innormal eye care practice. An eye care service where thephysician can spend better time for the patient in a
reduced number of patients may be more ethical and evenmore effective or cost-effective in the management of someeye pathologies. This model could be experienced in ourcountry or possibly in similar countries due to thepandemic. Solution must be found for more patient low toserve more patients in the new normal after the pandemic.
Expectations after the Pandemic Period
It is highly likely that changes in pandemic ophthalmology
practice will have an impact on future ophthalmic healthdelivery practices. After the pandemic period , there will bean hard work low due to patient density and delayed
surgeries. In addition to the importance of innovations thatwill help in the remote diagnosis and decision-making
process with arti icial intelligence, the importance of eachcountry having guidelines based on ethical rules andregulations is understood. It is expected to develop policies
compatible with the solidarity in the ield of healthbetween countries. Patient management with remotetelemedicine is expected to become a model in some
applications in the future. Research that has been
postponed due to the pandemic will continue to increase
after the pandemic. In ophthalmology education, theshortcomings in practical application will be tried to becompleted.
Possible Ethical Situations in Ophthalmology PracticeDuring the Pandemic Period
The COVID-19 pandemic has raised the issue of ethics
in ophthalmology healthcare, as in all medical practices. In
the COVID-19 pandemic, it is important how to implement
the health service that will be offered as restricted as wellas protection from transmission. At this point, the issue of
ethical principles should be discussed. As a matter of fact,
it should be determined how, and to whom, health services
will be provided in addition to non-urgent, postponed,
elective surgical interventions. Performing elective
surgeries that may be delayed, not intervening in patientsrequiring urgent surgery, and not taking necessary
precautions in patients to be examined may cause ethicalconcerns. Therefore, guidelines regarding ethical situations
in medical practice during the pandemic period can be
guiding.
Guidelines prepared by the Ministry of Health andprofessional organizations in different countries can help
in this regard. There are four basic principles of medical
ethics. The autonomy of the patient, the principle of nonharm, the principle of bene icience and justice are thesefour basic principles. In one article, ethical issues are
discussed in case studies related to patients inophthalmology practice during the COVID-19 pandemic.
Medical ethics experts have recommended that decisions
be made regarding these situations, following four basic
principles. Of course, each patient will be evaluatedEubios Journal of Asian and International Bioethics 31(1) (January 2021)

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individually. Detailed information about the patient's
illness, the principle of autonomy, the principle of notharming the patient, the principle of bene icence based on
the bene it of the patient, as well as the principle of justice,which expresses justice among individuals for patient care,summarizes these principles. It is autonomous in patientdecisions. It should also respect the principle of justice.
The physician should respect the patient's autonomy, take
into account the bene it-harm situation for the patient andwatch over the principle of justice. In an article discussing
ethical dilemmas regarding ophthalmological care, the casescenarios asked to the ethics experts and the ethicalsituations related to COVID-19 were asked. Ethics experts
seek answers to four questions that need to be addressedin any situation. What is the proximity and severity of the
expected harm without intervention? What is theeffectiveness of the intervention under consideration?
What are the treatment risks for the patient? What are therisks of treating the patient for the healthcare team? It wasstated that each case needs an individual risk bene it
analysis. As in the teachings in medicine, there is nodisease, just like the saying there is a patient, each patientis evaluated in their own way. A detailed informed consent
interview with the patient is required. Different responses
may be obtained for similar situations among patients.
Although there is no objective scoring tool for the processof treating patients in ophthalmology, the approach shouldbe the same [24].
Among the restricted appointment schedules, it wasevaluated how a physician could make risk strati ication ina limited information environment (such as the patient's
retinal status, estimated risk of infection). In this case, it
was stated that as a moral responsibility, triage should be
performed for each patient whose appointment will bedelayed, according to the proximity and severity of theharm. Although it is dif icult and time consuming in termsof logistics, it is stated that this is the ethically appropriate
situation.
During this pandemic, risk strati ication is required
based on what is known about the patient's ophthalmic
status. Every physician should do his best. As stated in thearticle, the law enacted in New York state (USA) on thetreatment of critically ill patients in inadequate conditions
due to human and resource scarcity, during the emergency,
hospital physicians and nurses, unless gross negligence,
decision and action has been granted exemption from legal
and criminal liability [24]. This pandemic period reminded
everyone that we have responsibilities for both ourselves
and others. As a public disclosure, the security measures tobe followed regarding COVID-19 were presented in bothpublic spaces and private sector. Warning messages were
published in the form of public service announcementsfrom the media. An effort was made to raise publicawareness. The number of patients was reduced in order
to avoid density in hospitals. During this period, it
happened in patients who did not want to take the risk ofvision loss and come to treatment.

59

Conclusion
With the COVID-19 epidemic that affects the whole world,
patients with diseases other than COVID 19 are greatly
affected by this situation. Throughout the pandemic, wemust act by minimizing the risks so that patients,
healthcare professionals and our environment can escapefrom this situation with as less harm as possible. As
ophthalmologists, while managing the acute pandemic inthis dif icult period, we must take the necessary protective
measures to protect ourselves, while treating our patients'
ophthalmological conditions that threaten their vision,
independence and even their quality of life. While doingthese practices, we must deliver health services byadhering to the principles of professional ethics.
References
1. Zhang L, Shen FM,Chen F, Lin Z. Origin and Evolution of the2019 Novel Coronavirus. Clin Inf Dis. 2020:ciaa112.
2-World Health Organization (WHO). WHO timeline – COVID-19;
2020. Available from: https://www.who.int/news-room/
detail/27-04- 2020-who-timeline—covid-19.
3. Situation Report −51 WHOC disease 2019 (COVID19). WHO
report to declare pandemic. Available from: https://www.who.int/docs/default source/coronaviruse/situationreports/20200311-sitrep-51-covid19.
4-Saleh OA, Jammal H, Alqudah N, Alqudah A, Abu-Yaghi N.
Clinical Experience in the Administration of Intravitreal
Injection Therapy at a Tertiary University Hospital in Jordan
During the COVID-19 Lockdown.Clin Ophthalmol. 2020 Aug
24;14:2473-2480. doi: 10.2147/OPTH.S269179. eCollection
2020.
5- Loon S-C, Teoh SCB, Oon LLE, Se-Thoe SY, Ling AE, Leo YS,
Leong HN.The severe acute respiratory syndrome coronavirus
in tears. Br J Ophthalmol. 2004 Jul;88(7):861-3. doi: 10.1136/
bjo.2003.035931.
6- Seitzman GD, Doan T. No time for tears. Ophthalmology 2020,
doi: https://doi.org/10.1016/j.ophtha.2020.03.030
7- Penbe A, Kanar HS, Simşek S. COVID-19 Pandemic and the Eye.
SCIE. 2020; 31(1): 56-61
8-https://covid19bilgi.saglik.gov.tr/depo/rehberler/covid-19
rehberi/
COVID19_REHBERI_TEMASLI_TAKIBI_EVDE_HASTA_IZLEMI_
VE_FILYASYON.pdf
9- https://www.cdc.gov/coronavirus/2019-ncov/infectioncontrol/control-. Centers for Disease Control and Prevention,
Interim Infection Prevention and Control Recommendations
for Patients withSuspected or Con irmed Coronavirus Disease2019 (COVID-19) inHealthcare Settings, COVID-19.
(recommendations.html (2020)
10- American Academy of Ophthalmology. Alert: Important
coronavirusupdates for ophthalmologists. https://www.aao.org/headline/alert-importantcoronavirus-context]
11- Bozkurt B, Eğrilmez S, Şengör T, Yıldırım Ö, İrkeç M. The
COVID-19 Pandemic: Clinical Information for
Ophthalmologists. Turk J Ophthalmol. 2020;50:59-63
12-https://koronavirus.todnet.org/pandemi-nedeni-ile-acilkabul-edilengz-ameliyatlar
13- Zhou Y, Zeng Y, Tong Y, et al. Ophthalmologic evidence against
the interpersonal transmission of 2019 novel coronavirus
through conjunctiva. medRxiv 2020:2020
14- Wei LC, Fen LX, Fang JZ. 2019-nCoV transmission through theocular surface must not be ignored. The Lancet 2020;395:e39

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15- Lai THT, Tang EWH, Chau SKY, et al. Stepping up infection
controlmeasures in ophthalmology during the novel
coronavirus outbreak:an experience from Hong Kong. Graefes
Arch Clin Exp Ophthalmol.2020;258(5):1049-1055.
16- Huang C, Wang Y, Li X, Ren L, Zhao J et al. Clinical Features Of
Patients Infected With 2019 Novel Coronavirus İn Wuhan,
China. Lancet Feb 2020.
17- Safadi K, Kruger JM, Chowers I, et al. Ophthalmology practiceduring the COVID-19 pandemic. BMJ Open Ophthalmology
2020;5:e000487. doi:10.1136/ bmjophth-2020-000487
18- Danesh-Meyer HV, McGhee CNJ. Implications of Coronavirus
Disease 2019 for Ophthalmologists, Am J Ophthalmol. 2021
Mar; 223: 108–118. Published online 2020 Sep 22. doi:
10.1016/j.ajo.2020.09.027
19- COVID-19 : Updates and Resources. ASRS
20- Korobelnik JF, Loewenstein A, Eldem B, Joussen AM, Koh A,
Lambrou GN, Lanzetta P, Li X, Lövestam-Adrian M, Navarro R,
Okada AA, Pearce I, Rodríguez FJ, Wong DT, Wu L. Guidance
for anti-VEGF intravitreal injections during the COVID-19
pandemic. Graefes Arch Clin Exp Ophthalmol. 2020
Jun;258(6):1149-1156. doi: 10.1007/s00417-020-04703-x.
Epub 2020 Apr 23. PMID: 32328757; PMCID: PMC7179379.
21- Kim JH, Chang YS, Kim JW. Natural course of patients
discontinuing treatment for age-related macular degenerationand factors associated with visual prognosis. Retina. (2017)37:2254–61. doi: 10.1097/IAE.0000000000001494..
22- Gao X, Obeid A, Adam MK, Hyman L, Ho AC, Hsu J. Loss tofollow-up in patients with retinal vein occlusion undergoing
intravitreal anti-VEGF injections. Ophthalmic Surg Lasers
Imaging Retina. (2019) 50:159–66. doi:
10.3928/23258160-20190301-05.
23- Boyer DS, Hopkins JJ, Sorof J, Ehrlich JS. Anti-vascularendothelial growth factor therapy for diabetic retinopathy:
consequences of inadvertent treatment interruptions. Am J
Ophthalmol. (2019) 204:13–8. doi: 10.1016/j.ajo.2019.03.005
24- Prager KM, Dagi Glass LR, Wang M, Chen RWS, Liebmann JM,
Ciof i GA,Ophthalmology and Ethics in the COVID-19 Era,
American Journal of Ophthalmology (2020), doi: https://doi.org/10.1016/j.ajo.2020.11.008

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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EJAIB adopts and complies with the Committee
on Publication Ethics (COPE) Publication ethics
and malpractice policy. Our policy is on the
EJAIB website. All potential authors should haveread these guidelines and by submission of anarticle for publication you acknowledge that you
have complied with this policy. Violations will behandled in proportion to the intention andseriousness of the violation. Registered addresso f E JA I B : P. O. B o x 1 6 3 2 9 , H o r n by,
Christchurch 8441, New Zealand

For forthcoming conferences see:www.eubios.info or www.ausn.info Email toDarryl@eubios.info
NEW: Postgraduate Certi icate in Epidemics
and Ethical Global Health

American University of Sovereign Nations (AUSN) has
just launched a new Postgraduate Certi icate Program- classes from March 2020. Do not delay to join us toprepare yourself and your community to respond to
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https://www.ausovereignnations.org

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EJAIB Editor:
Darryl Macer (Chair, Accredited Universities ofSovereign Nations)
Associate Editor:
Nader Ghotbi (Ritsumeikan Asia Paci ic 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 of Korea), Takao Takahashi (Japan),N o r i t o s h i Ta n i d a ( J a p a n ) , A n a nya
Tritipthumrongchok (Thailand), Yanguang Wang
(China), Daniel Wikler (USA), Jeong Ro Yoon
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