Eubios Journal of Asian andInternational Bioethics
EJAIB Vol. 30 (7) September 2020
www.eubios.info
ISSN 1173-2571 (Print) ISSN 2350-3106 (Online)
Official Journal of the Asian Bioethics Association (ABA)

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

Contents

page
COVID-19 community mask wearing: lessons fromfoot-binding and infibulation - Steven B Rothman
354
Balancing autonomy and justice in the U.S. with a coronavirus
outbreak - Ann Boyd and Brandi Davidson
358
Nursing students’ perception of mental health,mental illness and mental health nursing- Alia Nasir, Daizi Jafar, Ambreen Wasim
363
Mandatory COVID-19 vaccination in Africa: The philosophy ofobjectivism on individual rights vs public rights in a culturebound society, Nigeria- FN Chukwuneke AC Ezenwugo, OUJ Umeorah, IV Iyioke 368
Turning tragedy into creative work: experiences and insightsof plant lovers in Davao del Sur during COVID-19 pandemic-RP Bayod, EJ Forosuelo, JM Cavalida, BB Aves
371
Ethical issues of COVID-19 for persons with disabilities- Shahanaz Chowdhury
376
COVID-19 and mental health: government response
and appropriate measures-Genevieve Bandares-Paulino and-Randy A. Tudy
378
Challenges for organ recipients and elderly persons during the
COVID-19 Pandemic-Maria-Keiko Yasuoka
382
Gasping for breath: Is air pollution or moral blindness theunseen killer? A review - Alexander R. Waller
386
Ordering information
400

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

Editorial: COVID-19 and Vulnerability
The question of autonomy and mask wearing is
discussed in the first two papers in this issue. Ann Boyd
discusses how we can balance autonomy and justice.
These fundamental medical ethical principles really
epitomize the debates over the use of masks. The WeCope
Committee statement on why people should wear masks
was released in April 2020, and fortunately has been well
implemented in most countries. Stephen Rothman also
writes further on the use of masks with some interesting
comparisons to foot binding and infibulation. Ethicalprinciples have been applied over the millennia indifferent ways and we are still grappling with
fundamental issues on the appropriate balancing of
ethical principles in contemporary bioethics. For the sakeof the vulnerable there should not be any hesitation to
exercise solidarity with vulnerable people by wearing
masks, and exercising physical distancing.

There are many trials of potential COVID-19 vaccines
underway, and a very important question is whether or
not the vaccine will be available all around the world, andhow do we balance the interests of individuals opting out
versus the protection that we need from herd immunity,
This raises questions discussed by Chukwuneke et al. in
the Nigerian context with questions over mandatory
vaccination policies. Shahanaz Chowdhury presents
some of the important issues faced by persons living withdisability. This theme is one which has been addressed insome IPHA conferences and is being taken up in a WeCope
subcommittee. We invite readers to contribute to thisvery important question of how to balance thevulnerabilities of people living with disability, to combat
some of the harassment that people living with disability
have faced in the pandemic. For example, when going out
shopping some people with limited visibility need totouch items in the store, or some people are not able towear masks for medical reasons. Other’s may criticize
them. Bandares-Paulino and Tudy looked at some of thechallenges with mental health issues, and Nasir et al., lookat mental health nursing. We need to treat people
ethically despite the many vulnerabilities that we all have.
Maria Yasuoka looks at organ transplant recipients,
cancer survivors and elderly persons who are all at risk ofserious consequences if they are infected with COVID-19.
It is not all gloom and doom as shown in the paper by
Rogelio Bayod et al. who look at the way that plant lovers
have been able to spend more time cultivating plants andvegetables and flowers during the pandemic shut down.
Maybe this will also help us all as we gasp for fresh air ina very polluted world, as reviewed by Alex Waller.
This is the first of the extra issues of EJAIB for 2020,
and it includes five further papers from the Nine
International Public Health and Bioethics Ambassadors(IPHA) Conferences that have been regularly held overthe past few months, along with three other papers.
The Tenth International Public Health and Bioethics
Ambassadors (IPHA9) Conference will be held 1-3
October 2020. I invite many more readers to join. Pleasekeep on submitting your papers, and joining the virtual
conferences.
- Darryl Macer, Chair, World COVID19 Ethics Committee
https://www.eubios.info/world_emergency_covid19_pandemi
c_ethics_committee

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

COVID-19 community mask wearing:lessonsfromfoot-binding
andinfibulation- Steven B Rothman, PhD
Associate Professor, Ritsumeikan Asia Pacific
University (APU), Beppu, Japan
Email: srothman@apu.ac.jp
Abstract

Current scientific evidence promotes the use of masks asa primary measure, in addition to social distancing andself-quarantine, to prevent the further spread of COVID19 from person to person. Despite the importance ofmasks, compliance with requests to wear masks varies
across cultures around the world and low compliance
may increase transmission rates among communities.
After reviewing literature on mask-wearing, this article
first examines two models of social behavior based on
the Prisoner’s Dilemma and the Stag Hunt (tipping
point). Then, combining this work with research fromfoot-binding and infibulation mitigation, this article
demonstrates that social community behavioral
coordination along with game theoretic common
knowledge are important components to increasingmask usage. Finally, the article provides somesuggestions to increase mask usage among communities
by re-orienting the social culture and increasing
community common knowledge.

Introduction
Increasing evidence in epidemiological research
for COVID-19 suggests the importance of publicmask wearing as a means of preventing
exponential spread of the disease (Wang, Ferro,Zhou, Hashimoto, & Bhatt, 2020). Even cursory
examinations of the differences between the rate of
infection in Western (non-face mask wearing
locations) and Asia (common face-mask wearing
locations) suggests that mask wearing, at least
anecdotally, has a negative effect on spreading
infection. Despite this evidence, mask wearing in
the public remains controversial as a public healthmandated measure. President Trump has signaled
several times, for example, reluctance from issuinga national mandate for masks due to theimportance of individual choice and freedom (BBCNews, 2020). It is especially difficult forgovernments and authorities to encourage
individuals to wear masks in public, especially incultures where mask-wearing is not common placeor the sociopolitical costs may be higher (Utych,2020). Many political officials wear masks whennecessary to signal to their constituency or whennecessary outside of the public eye, yet do not wear
them in front of cameras due to public scrutiny andpossible criticism of their appearance. In contrast,
other officials, such as Prime Minister Abe in Japan,

consistently wears masks in public and during
public speeches and announcements.
This paper generates two possible models formask wearing suggesting a Prisoner’s Dilemma likegame or a Stag Hunt like game representing atipping point model. Using the tipping point model
as a point of particular examination, the paper
presents two other cases of tipping point social
behavior changes, foot binding and female genital
mutilation, to illustrate how social communitychanges can result in moving the tipping point andincreasing mask usage. The paper concludes withsome suggestions on increasing implementation ofmask usage in communities where it presents ahigher social cost. The paper proceeds byreviewing basic information on the efficacy of mask
wearing and the research on public mask wearing
practices. Following this brief review, the paper
establishes two common models for social
behavior related to mask wearing and discusses
the importance of common knowledge and group
signaling to increase social mask wearing amongcommunities. These practices draw on the research
related to two other social practices of foot-binding
and infibulation. The paper suggests two policies toencourage face mask wearing without therequirements of strict mandates.

Research on mask wearing during COVID-19
pandemic
The research on mask wearing consists of two
primary areas in regards to COVID-19. One area of
research discusses the importance and use ofmasks in relation to preventing the spread of thedisease,essentiallytheepidemiologicalexamination of masks in relation to disease and
COVID-19. The second area of research involves
the particular social behavior of individuals formask wearing. Most of the research on maskwearing concentrates on the issue of efficacy andeffectiveness of mask wearing while little research
discusses the social practices of mask wearing
among the public, where this paper begins to fillsuch a gap in our understanding.
There is little doubt that properly fitted masksworn in medical environments help prevent the
spread of infection to patients and to staff(Beckman et al., 2013; Klompas, Morris, Sinclair,
Pearson, & Shenoy, 2020). The WHO recommends
use of proper and rational PPE equipment for staff
depending on their risks of exposure (WHO, 2020).
Though this is commonly known and understoodwithin the medical community, the question ofmass mask wearing remains controversial andresearch has shown mixed results. For example,
the executive director of the WHO healthemergencies program stated that “There is noEubios Journal of Asian and International Bioethics 30(7) (September 2020)
specific evidence to suggest that wearing of masks
by the mass population has any potential benefit”(Howard, 2020). Since the emergence of Covid-19,
a number of studies emerged examining the effects
of mass public mask wearing on the spread of thedisease (Eikenberry et al., 2020; Gandhi, Beyrer, &Goosby, 2020; Pejo & Biczok, 2020; Wu & Zha,
2020). To determine whether and when masks are
effective in preventing the spread of the virus isfundamental to understanding whether and when
individuals might be asked to use and wear masks.
However, under uncertainty, many political
discussions advocate the precautionary principle
such that unless wearing masks are deemed
dangerous to individuals, it is better to wear themas a precaution. Today most officials ingovernments are recommending mask wearing
when in closed spaces and in close contact withothers to prevent spreading the disease, though
actual use of masks is still mixed in some areas of
the world.
In the second set of research, there is limited
discussion. Although there are some studies onsocial behavior and mask wearing, there are very
little conclusions drawn from this research and few
suggestions for policy makers and communities.
This research fills part of that gap by providing
both a social science understanding of mask
wearing behavior and suggestions for improvingsocial conformity to mask wearing. The researchfrom behavioral sciences is quite scant in the areaof COVID-19. It is clear, however, through somesurvey research in Japan, for instance, that social
factors pay a key role in community mask wearing(JapanLife, 2020). Though one research article inparticular points to a large number of factors that
contribute to behavior of individual during such acrisis pandemic, pointing to areas ofcommunication and risk/threat assessment,
political and social groupings, zero-sum thinking
and cooperation within groups, moral decision
making, leadership, and others (Bavel et al., 2020).
The discussion is comprehensive, examining many
areas of socio-behavioral variables that influence
individual behavior, though limited in depth andrecommendations on particulars to improve
behavior during the pandemic.

Modeling mask wearing for COVID-19
Game theory modeling is useful to examineinteraction between individuals when the actionsof each individual affect the behavior and benefit ofothers in the model. Game theoretic modeling is
widely used to examine behavior in social
situations, such as community mask wearing.
Modeling relies heavily on the importance ofassumptions of the models and the rationality of355

actors when comparing the results of the modelwith the general behavior of individuals, external
validity.
In the most basic model, we can simplify mask
wearing to two individuals with two choices (towear a mask or not to wear a mask). In thissituation, we can assume that there is some cost to
wearing a mask, whether that cost involves
breathing difficulties, the cost of buying or cleaningmasks or social difficulties. We also assume that
there is some benefit to the wearer of masks inrelation to the disease, but the benefit is greatest
when the entire community wears a mask. Whenone individual wears a mask and others do not, forexample, the benefits are very limited because
while the mask offers some protection, its greatest
benefit is in preventing exposure to others(wearing a mask). In other words, it would be best
for any individual if everyone else is wearing amask, thus he/she receives most of the benefits,
while that same individual does not wear a mask,
facing no cost (a free-rider). As a general guideline
we assume that if the benefits of wearing a mask
are greater than the costs, individuals will wear
masks. However, the difficulty in knowing whether
one benefits from wearing a mask comes from thefact that one’s benefit is at least partially contingent
on the behavior of other individuals. Wheneveryone else wears a mask and you wear a mask
the benefit is greatest.
There are two general game theoretic models
that might illustrate the situation with mask
wearing, the Stag Hunt model and the Prisoner’s
Dilemma model, depending on the assumptions
made. In general, we can assume that the costs ofgetting sick are very high and that therefore theinverse, the benefit of avoiding getting ill is veryhigh. Since these benefits are high, we can also
assume that the costs of wearing a mask aresomewhat small relative to the benefits. The issue,
then comes to whether wearing a mask actuallyresolves to provide the benefits of preventing
illness. The manifestation of this benefit depends
on the behavior of other individuals.
These two models are quite commonly usedwithin research on social behavior. In particular,
the Prisoner’s Dilemma is widely used to illustrate
situations where individuals would prefer toengage in individually beneficial behavior that
leads to sub-optimal social outcomes for thecommunity. The Stag Hunt model is widely used
more generally to illustrate the basic conditions ofa tipping point, where two outcomes are stable –everyone chooses one highly beneficial outcome tosociety or everyone chooses a lower benefit
outcome, individually beneficial but socially suboptimal.

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

For both models, we can illustrate theinteraction of individuals through a 2x2 gametheory model (Table 1). The model represents aninteraction between “society” and the “individual”
as two players in the model. Each player has two
choices, either to wear a mask or not to wear amask. This creates four potential outcomes, both
wear a mask, both do not wear masks, or one wears
a mask and one does not (for each player). Withineach outcome, we can illustrate the expected value
for that player of the outcome by designating theleft number for the left player (individual) and theright number for the top player (society). The
expected value represents a measure of benefit
relative to other outcomes possible in the model.
In the Stag Hunt model, we can assume that thebenefit only occurs when there is universal
compliance with social mask-wearing. If weassume that the benefit of avoiding illness occurs if
and only if all others wear the mask, we generate amodel that resembles the Stag Hunt or tipping
point model of behavior. Thus, for the Stag Huntmodel, the value of the outcome where bothplayers wear a mask is 10 because there is a large
benefit in this case when everyone wears a mask in
the group, compared to a case where the individual
wears a mask and no other person wears a mask.
In this case, there is no benefit because the benefit
only occurs when others wear the mask. By
comparing these expected values, two Nash
Equilibria emerge, where everyone wears a maskor no one wears a mask. Nash Equilibrium
represents a stable state of the model, where
neither player has an incentive to alter their choicewithout incurring a worse expected value. In thismodel, where there are two equilibria, the model
does not predict which outcome will emerge, but
illustrates the premise of a tipping point. If enoughpeople wear masks, the equilibrium will shift toeveryone wearing a mask, but if no one wears amask, it is not likely that any individual will
unilaterally decide to wear a mask.
In this model, illustrated in Table 1, we see that
there are two stable pure strategy Nash equilibria,
one where all individuals do not wear masks or one
were all individuals wear masks. This represents
closely to the Stag Hunt generalized model or thetipping point model. While both Nash Equilibria
are possible and stable solutions, the preferablesocial optimal Nash equilibrium is one in which
everyone wears the mask and prevents individuals
from getting sick (note that the model ignores
other social costs such as hospitalization andtreatment for the ill, but that should only increase
the benefits of wearing a mask and preventing the
spread, thus strengthening the results illustrated.)

Table 1: Social models of mask wearing
Stag Hunt

Individual

Wear
a
mask
Do not wear
a maskPrisoner’s DilemmaSociety
Wear amask
10*, 10*

Do not wear
a mask0, 22, 02*, 2*

Society
Wear amask
3, 3

Do not wear
a mask
1, 4*

Wear
a
mask
Individual
Do not wear 4*, 1
2*, 2*
a maskAn asterisk (*) indicates a preferred outcome, while twoasterisks in the same cell indicate pure strategy Nash
Equilibrium.

In the Prisoner’s Dilemma model, we alter theassumptions slightly such that the benefit does notdepend on universal compliance but depends onothers’ compliance. In other words, there is little
benefit to yourself when you wear a mask, butthere is benefit for others when you do so. Similar
to the Stag Hunt model, the Prisoner’s Dilemma
models interaction between an individual andsociety, though the expected values andpreferences over the outcomes differ. The model isdrawn the same way as for the stag hunt explained
above. Although in this case, the expected values
represent a relative value preference (ordinal)
primarily and should not be used to compare any
magnitude difference (cardinal) outcome. In thiscase, however, the most preferred outcome iswhere the individual does not wear a mask, suchthat it incurs no costs, and everyone else wears amask, achieving full benefit. This is essentially thefree-rider position where everyone else incurs thecost for one’s own benefit. The second most
preferred outcome consists of everyone wearing amask because there is a high benefit for each
person to do so, though there is some cost involvedin wearing the masks as assumed in the model. The
second to worst outcome is where no one wears amask. In such a case, there is no cost for wearing
the mask, but also there is no benefit for not
wearing a mask. Finally, in the worst case, one
becomes the “sucker” whereby they wear a mask,
but others do not. In this sense, the individual
wearing the mask is incurring the cost for others’
benefit, but not receiving any benefit of his/herown. In this case, we assume that if everyone else
wears a mask one can receive the benefit of notgetting ill though they do not have to wear the maskthemselves. The model is illustrated in Table 1,
which resembles closely to the Prisoner’s DilemmaEubios Journal of Asian and International Bioethics 30(7) (September 2020)
model. In this case, we have one pure strategy Nash
Equilibrium where no one wears a mask because
there is no additional benefit from wearing a mask
when everyone else is wearing the mask but there
is an additional cost to wearing the mask. In thismodel, the only stable pure strategy outcome is one
where no one wears a mask, but again we see abetter social optimal in which everyone wears themask.
In both cases we can consider policies that will
help motivate individuals to wear masks without
mandating such masks. One of the primary
requirements for moving from one equilibrium tothe other in the case of the Stag Hunt (tipping
point) involves public coordination of behavior andmaintaining common knowledge among theparticipants. For the Prisoner’s Dilemma, thesituation is only slightly more complicated as it ispossible to move from sub-optimal social
equilibrium to the optimal social equilibrium withincreasedtransparencyofactions
andcommunication between the actors. In both cases,
communication, transparency, and coordination
can shift the outcome from a sub-optimal one to asocially optimal outcome. In the case for this paper,
introducing specific policies oriented toward thesevariables would help move individuals from a nonwearing mask equilibrium, which is socially suboptimal, to a more socially optimal situation ofcommon public mask wearing. One of the policies
used previously in other cases to encourage such
behavior increases the social costs of noncompliance, such as is demonstrated in the cases offoot-binding and female genital mutilation. The
following sections discuss these two cases andillustrate the findings that might apply to the casesof COVID-19 and mask wearing for individuals
around the world and implementing government
policies.
Chinese foot binding and infibulation
Chinese practice of foot-binding began as a practicedesigned to reduce uncertainty around paternity
concerns during the polygamous period of theChinese elite and to restrict the movement ofconsorts. In order for lower class individuals,
fathers in particular, to help their daughters marry
upward in the social hierarchy, they also adopted
the practice and the practice became widespreadamong the population in China. In a sense, if afamily did not bind the feet of their daughters, thedaughter would suffer socially and would not be apreferred consort or marriage partner for higher
levels of society (Rosenburg, “How history getsthings wrong”).
Mackie (Mackie, 1996) identified two
background factors that encouraged the end of footbinding in China, in the introduction of westernized357

culture discouraging the practice and industrialchanges that selected against those who had theirfeet bound and restricted movement for work.
These factors altered individual preferences, but inthe larger societal system, foot binding was still
favored for marriage and consorts. In order tochange the system, the tipping point equilibrium or
Stag Hunt requires a large number of individuals
within the same community to change their
behavior to alter what is “normal” among that
population. As individual families slowly madechanges, the group of individuals and villages
became larger and larger, changing the equilibriumfrom foot binding to non-foot-binding practices.
Once the group became large enough it became
disadvantageous socially to have footboundchildren because they were selected against insociety (Mackie, 1996).
Similarly, these principles have been applied toother social practices encouraging the removal of
those practices, exemplified with infibulation.
Similar to foot binding, infibulation emerged in asimilar set of circumstances to control paternityand “enforce imperial male’s exclusive sexual
access to his female consorts” (Mackie, 1996). By
using the same methods of coordinating behavior
among a large group, it is possible to generate atipping point (Schelling, 1973) and shift behavior
from engaging in the practice to disengaging in thepractice. It is important to note that the tipping
point model usually has one outcome with a muchhigher benefit for society than the other, despite
the fact that both outcomes are stable Nash
Equilibria. This type of tipping point and moving
the equilibrium through common knowledge andsocial coordination of behavior is so strong thatdifferent organizations and advocates canimplement the policies in local communities(UNICEF, 2005). By applying similar social
common knowledge and coordination principles tothe mask issue, it may be possible to shift thecommunities on a local level and eventually on anational level to encourage mask-wearing andaway from the non-mask wearing equilibrium.
Recommendations
Policies oriented toward moving the equilibrium inthe above models are best suited to increase mass
mask-wearing
among
populations
andcommunities where mask-wearing is not generally
accepted. In particular, based on the experiences offoot-binding and infibulation practices, suchpolicies include reorienting culture toward maskwearing and building community common
knowledge. Although there is some difficulty inaccomplishing these goals, neither require
government forceful implementation of mask-

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

wearing and penalties. In both cases, the social
norms and tipping points can promote the use ofmasks among the community. When a small
community is able to meet together and promise towear masks, whereby all community members gain
common knowledge that all others within thecommunity also agree to wear masks, the policy
can be most successful. This common knowledge
requirement is vital to improving compliance with
the norm.
Of course, other social policies can also be
pursued to increase cooperation. This includes
repeated interaction among individuals, which
occurs within smaller communities and work
places. When people interact on a regular basis,cooperation becomes more likely based on themodels of repeating Prisoner’s Dilemmaindefinitely, which is usually the case in many workand social environments where the end of therelationship is unknown to the participants. In
addition, extending time horizons beyond
immediate gains can also improve cooperation
among the group. Orienting people toward longer
term relationships within the community makes
cooperation more likely, just as the institution of
marriage orients individuals toward long term
relationships and away from one-date or shortterm relationships.
By incorporating social policies such as those
discussed above, communities can increase thecompliance with mask wearing by building social
norms among communities and discouraging
individual non-compliance. Rather than focusing
on the disease themselves and the risks involved,
social norm compliance works better than
individual risk assessment. Similar to risk
assessment and error in processing long term risksof smoking (Slovic, 2001), individuals often
discount long-term risks associated with illness
and thus cost benefit analysis often fails to
encourage appropriate behavior. Social norms andsocial conformity, instead, allow for greater
compliance and conformity with mass mask
wearing for preventing the spread of COVID-19.
References

Bavel, JJV, Baicker, K, Boggio, PS, Capraro, V, Cichocka, A, Cikara,M, et al. (2020). Using social and behavioural science tosupport COVID-19 pandemic response. Nat Hum Behav, 4(5),460-471. doi:10.1038/s41562-020-0884-z
Beckman, S, Materna, B, Goldmacher, S, Zipprich, J,
D'Alessandro, M, Novak, D & Harrison, R (2013). Evaluationof respiratory protection programs and practices in
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Eikenberry, SE, Mancuso, M, Iboi, E, Phan, T, Eikenberry, K,
Kuang, Y, et al. (2020). To mask or not to mask: Modeling thepotential for face mask use by the general public to curtail the

COVID-19 pandemic. Infect Dis Model, 5, 293-308.
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doi:10.2139/ssrn.3563851

Balancing autonomy and justice in the
U.S. with a coronavirus outbreak- Ann Boyd and Brandi Davidson
Hood College, Frederick, MD 21701, USA
Email: boyda@hood.edu
Abstract

With the emergence of a new respiratory virus, SARSCoV2, in Wuhan, China near the end of 2019, it was soon
determined that person to person spread could lead to apandemic. Scientists quickly isolated and sequenced thevirus and identified the basic virus as a coronavirus withsevere respiratory pathology (COVID-19). WHO alerted
nations to the seriousness and rapid spread of the virus
in late January 2020. The Center for Disease Control(CDC) in the U.S. responded with public health alerts andlocal public health departments began preventative bestEubios Journal of Asian and International Bioethics 30(7) (September 2020)
practices: test, isolate, quarantine and treat. However,
the response was slow and inconsistent and by March,2020 states were imposing social distancing, closing
schools and other social gatherings to reduce spread.
Testing was limited in availability and individuals
responded to public health requests with variable
compliance. In less than a year, 5.5 million citizens in the
U.S. were infected and 172,000 died. Even as the
pandemic continues its natural course, and scientists
spare no time in creating a vaccine, it is clear that COVID19 reveals conceptual tension between autonomy andjustice.

Introduction
The coronavirus disease 2019 (COVID-19) caused
by infection with Severe Acute Respiratory
Syndrome – Coronavirus 2 (SARS-CoV2), a newly
emergent virus, is challenging public health andhealthcare systems globally. The national guidancefrom the Center of Disease Control (CDC) in the
United States, includes social distancing, selfquarantine, and closure of many businesses
including schools. The speed of virus spread
prompted more dramatic social restrictions thanare common in other pandemics such as seasonal
flu. Such actions are justified in order to protect thefunctional capacity of the healthcare system. It isdifficult to accurately predict the severity of any
one individual case of COVID-19. Individuals may
accept or reject messages about public healthconstraints. The pandemic reveals a shift in focus
from individual patient focused clinical care tocommunal strategies highlighting social justice.
Imbedded in the shift is the tension between
autonomy and social justice. The goal of this paper
is to analyze how harmony of autonomy and justicewould benefit response to this pandemic.

Coronaviruses
Four common coronaviruses circulate globally in aseasonal pattern causing common cold symptoms
and resolve without medical intervention unless
individuals have some underlying immunologicalor medical compromising condition. In 2002-2003,
a spillover occurred in Guangdong, China. On
November 16, 2002 a man in Foshan had fever andrespiratory distress, and three weeks later arestaurant chef in Shenzhen became ill with similar
symptoms. Both men had exposure to several wild
animals used in culinary dishes. Symptoms
included headache, high fever, chills, body aches,severe and persistent coughing, coughing up
bloody phlegm and progressive destruction of
pulmonary system, oxygen deprivation leading toorgan failure and death (Quammen, 2012). The
severe acute respiratory syndrome (SARS)
describes the medical symptoms, but the causative
agent was unknown. Scientists tested specimens

359

for antibody and searched for nucleic acid (RNAand DNA) matches by polymerase chain reaction(PCR) using probes to known infectious agents, e.g.
H5N1, Hanta virus, pneumococcus. Nothing was
found in the known agent collection that could
produce such symptoms. The interpretation wasthat a virus had crossed from some animal tohumans, an emerging zoonosis.
Efforts to cultivate virus from patient samples
succeeded and the publication cautiously
announced a new coronavirus as the “possible
cause” of SARS. It was the first coronavirus everfound to inflict serious illness in humans. Family
and health workers attending these cases were
infected and the virus spread to Hong Kong. Whena grandmother visiting family in Hong Kong,
returned to her home in Toronto infected, the virus
became an outbreak but good public healthintervention prevented it from causing a pandemic.
Eight thousand cases were documented with 774
deaths. The scope of the outbreak was limited bygood laboratory diagnostics, finding andidentifying the virus, coupled with efficient publichealth interventions: cases were isolated, contacts
were traced and quarantine measures were
instituted in southern China, Hong Kong, andToronto (Quammen, 2012).
In 2012 another coronavirus emerged in the
middle east causing a similar respiratory illness in2494 confirmed cases with 858 deaths. Thisoutbreak was called MERS for Middle East
Respiratory Syndrome. Scientists identified thevirus sequence and mapped both MERS and SARSCoV to a phylogenetic tree of coronaviruses. The
spike glycoprotein is the outer most structuralprotein on the virus and is responsible forattachment to cells through the angiotensin
converting enzyme (ACE2) in the case of SARS but
MERS uses a different receptor and antibody does
not cross react between SARS and MERS.
Furthermore, antibody that neutralizes SARS-CoV1
does not neutralize SARS-CoV2 (Ou, X. et al., 2020).
SARS-CoV2 was named an international publichealth emergency by World Health Organization(WHO) on 30 January 2020, following isolation andsequencing of the virus in January 2020 in Wuhan,
China. The announcement was preceded byscientific data indicating communal spread of therespiratory pathogen and reports of person toperson spread. By February 2020, cases wereconfirmed in Europe and the US. Incubation of 214 days with an unknown case fatality rate made itdifficult to limit exposure especially among
asymptomatic infected persons. In addition tointense study of the virus, its complex pathology,
scientists and medical personnel sought ways to360

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

treat the infection and research escalated toward
creating a vaccine (Rabi, F. et al., 2020).
Every known vaccine creation strategy
previously used and several new approaches are indevelopment with over 140 trial vaccines being
developed and fourteen of them in human clinical
trials. The leading vaccines currently in Phase III
trials include AstraZeneca and University of Oxford
vaccine made from a weakened version of acommon cold virus (adenovirus) as vector andexpressing SARS-CoV2 spike protein. The Phase III
trials are taking place in Brazil and South Africa.
The developing company has promised to supply
more than 2 billion doses globally anticipating
delivery of 400 million doses before the end of
2020. Moderna in partnership with the NIH beganphase III trial July 27, 2020 with 30,000 adultvolunteers. The vaccine is mRNA-1273 that carries
instruction for cells to produce the viral spike
protein. BioNtech, Pfizer and Fosum Pharma
collaboratively are testing four vaccines each using
messenger RNA in different combinations totargeted antigens. The US government has placed
an initial order for 100 million doses paying $1.95
billion (Doheny, 2020). Lacking a thoroughknowledge of immunological requirements forprotection against infection if exposed, it is difficult
to assess each vaccine candidate’s worth (Amanat
and Krammer, 2020).
SARS-CoV-2 pandemic and US response:
Abiding by the public health guidelines to reducerisk of coronavirus infection, people were asked torestrict activity, many businesses closed, schools
and churches and other places of group gatheringsceased meeting. Self-quarantine and stay at homeorders were variously enforced by local officials
and by state authorities. Hourly wage workers
were more severely impacted than employees whoeither had paid leave or could work remotely fromhome. The economic toll was immediate andserious. While the rate of infection steeply rose insome areas, others were minimally affected. This
led to some skepticism about whether the
restrictions were necessary in relationship to theeconomic hardships. In some cities, groups
protested the shut-down, arguing the economic
impact was disproportionate to the public healthmeasures. Individuals expressed concerns that
autonomy and liberty was being infringed without
sufficient justification. It is difficult to measure thenumber of infections that did not happen due to theshut-down and mobility restrictions. If a person is
young, healthy, and dependent on income based onhours worked, it is harder to demonstrate that therisk to one’s health is more important than the
deprivations caused by lack of income. For thoseliving paycheck to paycheck, the hardships were

amplified, risking housing, food, and other life essentials. Here communication that is consistentand transparent and uniformly applied would help
but perhaps not satisfy everyone. Desperation anda highly valued individual autonomy made someindividuals defy precautionary restrictions.
Refusing to stay home, gather in groups, or wear
masks were expressions of individual freedom thatwould not meet the standard of a relational concept
of autonomy. Individual risk-benefit assessments
reflected many confounding variables in their lives,
from socio-economic, trust in public healthprotections, and perception of seriousness of
infection. Many choose survival of the family with
its accompanying risks in working jobs that
exposed them to infection.
Autonomy is the exercise and privilege of selfgovernance, advocated by people across a wide
spectrum of political philosophies. The Westernethical and philosophical notion of autonomy is the
cognitive ability and freedom, values and reason.
Eighteenth century philosophers such as
Immanuel Kant emphasized autonomy as an
ethical exercise of reason. Any person could apply
a reasoned analysis to a situation and create adefensible plan of action. Kant is clear that in thereasoning process the action decided upon will be
one that all others could act on simultaneously andwould never use others as a mere means. An
autonomous agent then recognizes his intrinsic
value as a rational being and sees no relevant
difference between persons, accepting all otherrational beings as equals.
Conditions in our social, physical and emotional
environment influence exercising the will set byautonomous reason. In the midst of a pandemic
with rapid spread of virus from person to person,
how many people can exercise the freedom toignore public health guidance without doing harm
to others? In the more traditional context of a
doctor-patient conversation regarding treatmentof a diagnosed illness, the freedom to apply reason
to decide how to medically proceed with treatment
is a very different scenario than having a virus andspreading it to others. Autonomy recognizes
individuals as moral agents but anticipates a levelof moral responsibility that is important.
Moral responsibility refers to the accountabilityof an agents’ voluntary choice and to a judgment
about the rational justification of the agents’choice. In both ways, a moral agent, while free tochoose according to reason, is neverthelessresponsible for the weight of considerations given
to the effect of an action on others. A person who
accepts responsibility for acting as a moral agent issubject to the critique of the community. The
willingness to take responsibility for our own

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
character as persons – to know who we are – andto care about how our choices affect others is moral
responsibility (Gauthier, 2000).
Justice: Individuals live within communities,
families, and societies. Recognizing the unfair
distribution of talents, abilities among individuals
within a society led Rawls to propose a system thatwould give special advantage to the disadvantagedby way of compensating adjustments. Developinga fair and just system could be obtained byimagining a hypothetical position in society where
our talents and position is unknown and can be
anyone within the collective. This so called “veil of
ignorance” awakens a sensitivity to economic andsocial inequality so that if we were at the “bottom”
of the social construct, we would advocate for adecent minimal assistance to be contributing
members of society. By elevating the worst-off
members of a social group, the entire society
becomes more attractive and socially stable(Rawls, 1971)
In the current context of a virus pandemic,
justice in health care would expect equivalent andequal medical treatment for persons infected by
the virus without limitations imposed by insurance
coverage and affordable treatment. For the benefitof the community in which a COVID-19 patient
resides, treatment and confinement of the sickindividual benefits the sick person and all who arepotentially exposed to the virus through him/her.
Equality would support a system in which every
worker could recover wages while socially isolated
for the benefit of others (MacKay, 2018). To
achieve fair distribution of risks and benefits, if we
ask hourly workers to keep the subways moving
and the nursing homes staffed, some protection
should be provided through regulations or policies(Rawls, 1993). It is clearly in the best interest ofsociety to make it possible for an infectedindividual to quarantine. Likewise, it is reasonable
for public health authorities to impose restrictions
on behaviors contributing to virus spread, being
particularly protective of the most vulnerable.
Public health is defined by the Institute ofMedicine (IOM) as “what we, as a society, docollectively to assure the conditions for people tobe healthy.” To address the problems spawned bypandemics, public officials are right to consider thecollective benefits of population health overindividual interests. It is tempting to stress thetension between individual and collective interestsand ignore the synergies. Without ignoring theimportance of individual liberty, freedom of choice,and the importance of autonomy, public health’s
charge is the health and well-being of the wholecommunity. Prevention of harm is prioritized inpublic health. The “harm principle” in bioethics

361

insists competent adults have freedom of action
unless they pose a risk to others. Just as statesrequire seat-belt use through legal means, publichealth authorities with the support of state
governors can and should act in paternalistic ways
to limit spread of a deadly virus.
Local public health agencies in high impact
areas struggled in the beginning of the pandemic
with allocation of personal protective equipment(PPE). Front line workers in health care, essential
workers whose exposure to the public increase
their risk of infection are due the protection of PPE
and should have first priority in distribution(Gostin, 2016). As vaccines clear clinical trials andare approved, it is likely that distribution of thefirst available batches will be another serious
distribution dilemma. Will the same priorities as
for PPE serve for vaccine?
Some states mandate vaccination for specificinfectious diseases for all school children,
providing exceptions on medical grounds. The
proponents of mandatory vaccination priorities
the collective welfare and health of community
over individual liberty claiming beneficence as theguiding principle. A public health mandate orpolicy should clearly articulate the justification andthe message needs to be delivered consistently andclearly. Careful analysis is required to ensure thatsuch policies don’t infringe upon some groups
more heavily than on others.
A sad example is the shortage of ventilators thatcaused rationing decisions in some hospitals. A
recommendation to limit elective surgeries wasintended to preserve high value resources for careof COVID 19 patients. Physicians were required tomake a rapid transition from patient centeredpractice to triage of limited resources (Dunham etal., 2020; DeBruin and Leider, 2020).
Vulnerable Groups: Age is one of several criteria
used to allocate beds in the intensive care units(ICU) in assessment of likelihood of survival. In
early weeks of the outbreak, younger people
appeared to not develop serious complications butthat turned out to be only partially true. It is
actually very hard to predict who will and will notbenefit from ICU intervention. Persons aged 50 orolder represent 35% of the US population, accountfor 40% of the gross domestic product andcontribute 43% of tax revenue according toAmerican Association of Retired Persons (AARP).
Respecting each person, regardless of age, andevaluating best treatment options is the most justapproach (Carrieri, et al., 2020). The rates ofsevere symptoms were observed to increase withage and among those hospitalized early in the
pandemic more than half were age 60 or older(Powell and Ehrlich, 2020). Preventing infections

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

among frail older adults with comorbidities may
have been better if the distribution of PPE tonursing home attendants and universal adherence
to public health best practices had been enforced
early and consistently.
African American and Hispanic communities
bear a disproportionate burden of disease thatreveal systemic injustice. CDC data reveal that one
in three people sick enough to require
hospitalization from COVID-19 were African
American who make up 13% of the U.S. population.
Underlying medical conditions and higher rates ofjob exposure to virus may account for increased
incidence. To protect older adults and those with
underlying medical conditions is the main
justification for preventive measures.
Applying these principles and the Rawlsian
society to the SARS-CoV2 pandemic, it is clear thatRawls would be concerned about vulnerable
groups and how they would be impacted by social
distancing, stay at home orders, or otherrestrictions aimed at curtailing virus spread. Somepeople have greater share of responsibility forkeeping society functioning, such as healthworkers, first responders, essential businesses.
Closing schools and day care centers created moredifficulty for families wherein the parents were
essential employees. Childcare became a sharedsocial, expanded family responsibility, in order toprotect children from exposure to the virus byparents who were professionally exposed to virus
daily. Children who receive free meals, staying
home could mean hunger, so efforts to provide
meals at a common location were efforts to address
the inequality of affect the imposed public healthmeasures had on different families.

Competing principles
Conflict and controversy arose after weeks ofimposed restrictions, with people expressing
concerns about loss of human freedom or liberty.
As free human beings, liberty cannot be taken away
but it can be restricted temporarily as the second
principle of Rawls suggested: unequal distributionis allowed as long as it is advantageous to all. Under
the conditions of restricted movement to limit
spread of a seriously pathogenic virus, social
distancing and self-isolation are the most effective
control measures available. Because SARS-CoV2 isa newly emergent virus, there is no known effective
treatment other than symptom control. Given the
rapid spread of infections globally, the mosteffective public health intervention was to limit
spread by quarantine (Lei and Qui, 2020).
Liberty infringing measures to control disease
are justified if the risk of harm to others can besignificantly reduced. Government authorities

have a responsibility to act and rule in favor of theircitizens. They are responsible for the well-being of
citizens and for provision of a framework in which
every person can pursue their self-directed goals(autonomy). Sadly, mistaking limited, temporary
restrictions to mobility as an assault on individual
freedom and liberty could contribute to the factthat confirmed cases of coronavirus infection grewfaster in the US than any other nation (Nace, 2020).
Healthcare coverage is a patchwork in whichsome benefit more than others. Whereas theAffordable Care Act (ACE) provided more Medicaid
coverage, and expanded access to health insurance,
opponents consistently chip away at the law,
seeking to either amend or repeal it. The US has
discussed universal health care since Theodore
Roosevelt was President and we still lackconsensus to make it a national policy. Pandemics
like SARS-CoV2 remind us again that the failure tocover all citizens with adequate health care access,leads to inequalities that call forth social justiceconcerns. It may be autonomous choice to have or
not have health insurance, but when your infection
goes untreated and you expose me to a potentiallylethal virus, the ethical issue quickly moves fromautonomy to justice. Larry S Tempkin remarks:“many believe that it is unfair when fundamentally
decent people don’t fare well…and since reasons ofjustice apply to everyone, there would be reason toprovide equal and high quality health care to all
fundamentally decent people whose illnesses leftthem worse-off than they deserved to be”(Tempkin, 2014).
Lacking universal health care in the U.S., wemight encourage empathy for fellow humanpersons. Empathy invites us to see andacknowledge human suffering and to integrate thatknowledge into the decisions we make. Common
humanity is a bridge to moral maturation and aleveler in mutual respect. The implication of
empathy moves us to see others as equivalent toourselves, deserving of healthcare if ill, andrespectful actions that limit exposure to infectious
virus. Leaving subpopulations without medical
insurance, vulnerable to higher rates of infection, isdifficult to reconcile with communal good. It is insuch limited choices where autonomy isconstrained by social inequalities. The autonomouschoice of individuals to not wear masks or selfisolate puts others at risk especially those invulnerable groups. Disproportionate sharing ofburden of disease by some suggests that social
justice needs more emphasis.
Understanding
autonomy as moral responsibility helps create
harmony with social justice requirements in publichealth. Where these two principles are out ofbalance, people suffer. Careful rebalancing isEubios Journal of Asian and International Bioethics 30(7) (September 2020)
needed to avoid more harm and to protect thehealth and wellbeing of everyone.
References

Amanat, Fatima and Florian Krammer, (2020) SARS-CoV-2
Vaccines: status report, Immunity 52: 583-589.
Carrieri, Daniele, Fedro Alessandro Peccatori, and Giovanni
Boniolo, (2020) COVID-19: a plea to protect the older
population, International Journal for Equity in Health 19:7276. At: @ https://doi.org/10.1186/s12939-020-01193-5
DeBruin, Debra and Jonathon Leider, (2020) COVID-19: the shift
from clinical to public health ethics, JPHMP 26 (4): 306-309.
Doheny, Kathleen, (2020) COVID-19 Vaccine: latest Updates,
accessed
August
25,
2020.
at:
www.WebMD.com/lung/news/20200610/covid-19-latestupdates.
Dunham, Aexandra M., Travis N. Rieder, and Casey J. Humbyrd,(2020) A Bioethical Perspective for Navigating Moral
Dilemmas Amidst the COVID-19 Pandemic, J. Am. Acad.
Orthop. Surg online 2020 Apr 10. Doi: 19.5435/JAAOS-D-2000371.
Gauthier, Candace Cummins. 2000. Moral responsibility andrespect for autonomy: Meeting the communitarian challenge.
Kennedy Institute of Ethics Journal 10: 337-352.
Gostin, Lawrence O. and Lindsay F. Wiley, (2016) Public Health
Law: Power, Duty, Restraint, 3rd edition, University ofCalifornia Press.
Kathryn MacKay, (2018) Utility and justice in public health, J.
Public Health 40(3):e413-e418.
Lei, Ruipeng and Qui, Renzong, (2020) Report from China:
Ethical Questions on the Response to the Coronavirus” for the
Hastings
Center.
At:
https://www.thehastingscenter.org/report-from-chinaethical-questions-on-the-response-to-the-coronavirus/
Nace, Trevor (2020), Confirmed coronavirus cases are growing
faster in the United States than any other country in theworld.
Forbesmagazine,at:https://www.forbes.com/sites/trevornace/2020/03/20/co
ronavirus-is-growing-faster-in-the-united-states-than-anyother-country-in-the-world/#6cfa3a87e72e.
Ou, Xiuyuan, et al., (2020) Characterization of spikeglycoprotein of SARS-CoV-2 on virus entry and its immune
cross-reactivity with SARS-CoV. Nature Communications. at:https://doi.org/10.1038/s41467-020-15562-9
www.nature.com/naturecommunications.
Powell, T, Bellin, E and Ehrlich A. (2020) Older Adults and Covid19: the most vulnerable, the hardest hit, Hastings Center
Report 50 (3): 62-63.
Quammen, David, (2012) Spillover, W.W. Norton & company,
NY.
Rabi, Firas, et al., (2020) SARS-CoV-2 and coronavirus disease
2019: What we know so far, Pathogens 9:231-245.
Rawls, John. (1971) A Theory of Justice. Cambridge MA: Harvard
University Press.
Rawls, John. (1993) Political Liberalism, NY, Columbia
University Press, p283.
Tempkin, Larry S. (2014), Universal Health Coverage: Solution
or Siren? Some Preliminary Thoughts. Journal of Applied
Psychology 31:1-22.

363

Nursing students’ perception of mental
health, mental illness and mental
health nursing- Alia Nasir
Associate Professor, Mohiuddin Islamic
University, College of Nursing, Azad Kashmir,
Mirpur, Pakistan- Daizi Jafar
Sr. Nursing Instructor, Mohiuddin Islamic
University, College of Nursing, Azad Kashmir,
Mirpur, Pakistan
Email: daizipices@gmail.com- Ambreen Wasim
Assistant Professor, Ziauddin University, Karachi,
Pakistan
Abstract
The shortage of healthcare providers in psychiatry bothin mental health nursing and psychiatrist is evident
globally. Multiple factors lead to making the decision towork in a psychiatric setup. The perception of nursing
students and other health care providers play anessential role. This study was aimed to identify theperception of nursing students regarding mental health,mental illness and mental health nursing. A crosssectional study was conducted with 73 nursing students
enrolled in BSN 3rd year. Participants completed aquestionnaireofdemographicandclinicalcharacteristics on mental health, illness and mental
health nursing. Purposive sampling was used and data
analysis was done through SPSS version 23. A total of
13.7% (n=10) male students and 86.3% (n=63) female
students with a mean age of 19 years (SD±5) participatedin this study. 76.5% participants belonged to rural and
23.2% to urban population. 90.4% of nursing students
reported a positive contribution in providing services toindividuals suffering from mental problems. However,
only 43.9% responded that they are neutral to apply inmental health nursing. On the other hand, 52% of
students showed high anxiety dealing with mentally illpatients in contrast to 50.6% participants who reported
they are self-confident at work with mentally ill
individuals. On stigmatization, 71% of participants
responded that mentally ill patients are unpredictable.
This study highlights the knowledge and skills of nursing
students in mental health, mental illness and mental
health nursing and may serve to encourage nursing
students to pursue a career in mental health nursing.

Background
Mental health is satisfactory functioning in dailyliving activities towards individual’s full potential.
Mental illnesses are health circumstances thatinvolve alteration in emotion, thought process andbehavior, and mental health nursing is about
promoting and supporting an individual sufferingfrom mental illness to recovery and to enable themto have more participation and control over their

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

disorder1. Globally, the leading cause of disability ismental illness and approximately 450 million
suffer from mental illness. Unfortunately, there is
scarcity of healthcare providers including well
prepared nurses and physicians to look after
mentally ill persons. A WHO report shows that lessthan 1 psychiatrist and 7.7 nurses are available per
100,000 population2,3,4. In Pakistan, 10% of the
population (20 million) suffer from mental healthissues 5. In a state summary of Pakistan, 10-16% of
individuals suffer from mild to moderate, and 1%
suffer from severe mental health conditions.
Mental health illness institutes 11.9% of the entire
worldwide illness burden and adds to the 1,607
Disability Adjusted Life Years (DALYs/100,000) of
the people in Pakistan6. The alarming statistics inprovinces, Sindh 16%, Punjab 8%, Baluchistan
40% and Khyber-Pakhtunkhwa 5% indicate that
immediate measures are needed to prevent further
rise in mental illnesses7.
In order to deal with the alarming burden inhealthcare system of Pakistan, manpower
development is required and nurses and other
healthcare workers should be trained. In order toprepare nurses related to mental health illnesses,
nursing education faces many challenges. Nurses
belong to the same racial, religious and social
background where the concept of mental illnesses
is stigmatized. In order to prepare nurses
effectively, we need to identify their perception
related to mental health, mental illness and role ofmental health nurses. That is why this crosssectional study was designed. The purpose of thispaper is to highlight the burden of disease, its
causes and share the perception of nursing
students related to mental health, mental illness
and mental health nursing. Authors shall propose
recommendations based on the results, limitationand conclusion of the study.
Teaching nursing students to deal withindividuals with mental disorders is very
challenging where students need to collaborate inteaching. After entering the psychiatric setup,
nursing students feel nervous and incapable to
make therapeutic interactions8,9. The learning
process for nursing students in a psychiatricsetting is very complicated. Anxiety is a common
response of many students as they become
prejudiced by media publicity and community
about individuals with mental disorders. Anotherconcern in nursing students is poor attitudes
toward mental illness and consumers of mental
health facilities may be accountable for a lack ofattention in mental health nursing. This leads
nursing students away from seeing a career in thefield of mental health10.

Mental illness is considered negatively inPakistani community; individuals suffering mental
illnesses become stigmatized and this causes abarrier in recovery of mental health11,12. Evidenceshows that 70-80% population do not seek mental
healthcare services due to stigma and that is one of
the major barriers13,14. These stigmas include
views that individuals with a mental illness arehazardous, impulsive, more likely to commit
violence, and are somewhat responsible for theirillness. Previous research has recommended that
attitudes toward mental illness by healthcare
professionals are very alike to those of the overallpublic. Nursing students ‘attitudes reflect the
predominant observation of the overall population,
toward individuals with mental illness15,16.
Research proposes that students’ stereotypes
and negative perceptions of the mentally illpatients and mental healthcare affect theirprofessional selections and unfavorably affectlooking for a career in mental health nursing17.
Nursing students learn about mental health andmental illness and their management in their thirdyear of training, so that they can develop goodunderstanding about health situation and relevantbaseline knowledge. However, preparing nursing
students for mental health and illness is somewhat
challenging
due
to
their
pre-conceived
perceptions, beliefs and attitudes. When they enter
the clinical phase, this causes anxiety andhindrancestodeveloping
therapeuticcommunication with the clients, patients and theirfamily members. The consequences of firstinteractions with mentally ill patients can beparticularly distressing18. Furthermore, thesemisunderstandings can lead to a lack of acceptanceof individuals in the psychiatric setting with
undesirable opinions and attitudes held towards
them1. Therefore, this research study attempts to
identify the nursing students’ perceptions towards
mental health, mental illness and mental healthnursing.
Methodology
A cross-sectional research study was planned toachieve the research objective. This study was
conducted at a private university college of nursing
in Karachi, Pakistan. Purposive sampling of a totalof 76 students enrolled in BSN-3rd year nursing
program was done who were going to take Mental
Health Nursing course. Data was collected using
MHN-I questionnaire which is pre-tested by Furr
(2014) in his study about perceptions ofundergraduate students. The questionnaire wasdistributed to all nursing students after consenting
to the study. Students were briefed about the study
and were assured of anonymity and confidentiality.

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
Data collection and instrument
The study participants were examined with MHN-I
pretest questionnaire which is an educational tooland is self-descriptive originated by Wynaden, Orb,
Mcgowan and Downie to measure the specificperceptions towards mental health, illness andmental health nursing. The instrument wasadministered to nursing students. The instrument
consists of 24 responses. The subscale contains thelevel of preparedness for the mental health setting,understanding of mental illness, beliefs on
stigmatization; pursue it as a career, course
efficacy, anxiety about the mental conditions andimportant contributions.
The responses 1, 4, 7 and 10 refer to level of
preparedness while responses 9, 18, 19, and 23 areabout knowledge of mental illness. Anothersubscale about stigmatization consists of
responses 8, 21 and 24. The subscale of pursuing
Table 1: Descriptive analysis of demographic
indicators
Age Mean ± SD

Belongs
Gender

Province

19 ± 5
No.

%

Rural

56

76.5

Urban

17

23.3

Male

10

13.7

Female

63

86.3

Sindh
PunjabBaluchistan
KPK
Gilgit Baltistan

20
1
1
41
10

27.7
1.4
1.4
56.2
13.7

career in mental health is 6 and 12. Course
effectiveness included responses from 14 to 17.
The subscale on anxiety was responses 3, 5 and 22.
The subscale about valuable contribution forproviding services to mentally ill was in responses
2, 11 and 20.

Data analysis
Data was analyzed using SPSS version 23.
Descriptive statistics were formulated such as
frequencies and percentages to compute relevantsociodemographic characteristics. For descriptive
analysis all responses of mental health nursing
education survey were grouped. The response
items were grouped into three categories as“strongly agree”, “agree” and “somewhat agree”
combined to form agree category while neutral
remained on its own and another category was
made as disagree with combination of “strongly
disagree”, “somewhat disagree” and “disagree”.
Interpretations were agreed upon by the authors.

365

Ethical approval
Approval was granted from college of nursing toconduct the study as part of faculty development.
Nursing students were briefly informed of theirvoluntary participation and consent form wasfilled.
Results
A total of 76 questionnaires were distributed and
73 questionnaires were returned completely (96%
response rate). Respondents were mainly females(86.3% n=63) with a mean age of 19 years (SD =5).
The province wise percentage of the participants
was Sindh (27.7%), Punjab (1.4%), Baluchistan(1.4%), KPK (56.2%) and Gilgit Baltistan (13.7%).
Participants were taken from BSN year three
because they were taking mental health nursing
course and need to attend the clinic of mentally illpatients as course requirement. 43.9% ofparticipants responded neutral whether to apply
for graduate program in mental health while 28.8%
disagreed. On the issue of mental health nursing
makes a positive contribution, 90.4% of nursing
students agreed, 52% reported that they feelanxious working with individuals suffering mental
health problems and 50.6% reported they are
confident working with mentally ill patients.
Discussion
In expressions of general perception about mental
health nursing, students showed mainly a positive
perception, which is consistent with previous
research studies conducted across the world.
The level of preparedness reported throughattending mental health clinic and also knowledgeof mental illness is reported with positive regard asshown in table-I. This is consistent with otherresearch study findings of encouraging nursing
students exhibiting their competence in terms ofskills, knowledge and their abilities in mental
health nursing19,20. Stigmatization is an issue
where individuals cannot work up to the potential
for prejudice which is a negative behavior and isreported with high percentage which is consistent
with other research studies because stigma is belief
about mentally ill that they are dangerous, more
prone to violence and are responsible for theirillness. These beliefs are due to lack of knowledgeof community21,22,23.
Pursuing a career in mental health nursing is
not a favorable choice as shown in table-1 which isseen in other research studies where lack ofinterest in mental health services is highlighted
due to poor attitudes to individuals suffering frommental conditions. These negative attitudes direct
nursing students not to choose mental healthnursing as career.

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Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

Table 2: Descriptive analysis of demographic indicators
Strongly
disagreeDisagreeSomewhat disagree

NeutralSomewhat agree

Agree

Strongly agree

3
(4.1)
5
(6.8)
7
(9.6)
2
(2.7)

8
(11.0)
7(9.6)
8(11.0)
7(9.6)

8(11.0)
22(30.1)
12(16.4)
14(19.2)

35(47.5)
18(24.7)
12(16.4)
23(31.5)

5(6.8)
18(24.7)
7(9.6)
8(11.0)

16(21.9)
14(19.2)
11(15.4)
20(27.4)

12(16.4)
14(19.2)
16(21.9)
17(23.3)

11(15.1)
14(19.2)
28(38.4)
24(32.9)

18(24.7)
14(19.2)
14(19.2)

26(35.6)
26(35.6)
28(38.4)n (%)

level of preparedness about MHN
1 I feel well prepared for mental health clinicalplacement
4 I have a good understanding of the role ofpsychiatric nurse
7 I feel confident in my ability to care for people
experiencing mental health problems
1 Theoretical components of mental health have
0 prepared me well for me clinical placement.
knowledge of mental illness
9 Mental illness is not a sign of weakness in a person
1
8
1
9
2
3

Someone I know has experienced a mental healthproblem
When a person develops a mental illness it is nottheir fault
The way people with mental illness feel can beaffected by other people’s attitudes towards them
Stigmatization in mentally ill patients
8 People with mental illness are unpredictable
2
1
2
4
6
1
2
1
4
1
7
3
5
2
2
2
1
1
2
0

-

-

19
(6.0)
20
(27.4)
13(17.8)

1
(1.4)
10
(3.7)
-

11
(15.0)
1
(1.4)
2
(2.7)
1
(1.4)

10
(13.0)
3
(4.1)
5
(6.8)
-

8
(11.0)
9(12.3)
4
(5.5)
3
(4.1)

-

2
(2.7)
2
(2.7)
2
(2.7)

6
(8.2)
4
(4.5)
2
(2.7)

3
(4.1)
6
(8.2)

8
(11.0)
4(5.5)
8(11.0)

12(16.4)
12(16.4)

20(27.4)
20(27.4)

17(23.3)
17(23.3)

11(15.1)
11(15.1)

4
(5.5)
4
(5.5)

6
(8.2)
13
(17.8)

8(11.0)
2(2.7)

18(24.7)
20(27.4)

26(35.6)
23(31.5)

13(17.8)
10(13.7)

7(9.6)
12(16.4)
7(9.6)

18(24.7)
22(30.1)
18(24.7)

7(9.6)
21(28.8)
7(9.6)

22(30.1)
7(7.6)
22(30.1)

9(12.3)
2(2.7)
9(12.3)

7
(9.6)
-

-

-

3
(4.1)
2
(2.7)

13
(17.8)
12(16.4)

30(41.1)
25(34.2)
29(39.7)

36(49.3)
32(4.8)
26(35.6)

People with mental illness can’t handle too much
13
responsibility(17.8)
People with mental illness are more likely to20
commit offences or crimes(27.4)
pursuing career in MHN
I will apply for graduate programs in
1
8
psychiatric/mental health(1.4)(11.0)
I intend to pursue a career in psychiatric/mental
18
health nursing(1.4)(11.0)
Course effectiveness
My course has prepared me to work as a graduate
2
nurse in a medical graduate program(2.7)
My course has prepared me to work as a graduate
2
3nurse in an age care graduate program.
(2.7)
(4.1)
Anxiety attending mentally ill patients
I feel anxious about working with people
37experiencing a mental health problem
(4.1)
(9.6)
I am uncertain how to act towards someone with a5
4
mental illness.
(6.8)
(5.5)
I feel safe about this psychiatric/mental health3
7placement
(4.1)
(9.6)
valuable contribution for providing services to mentally ill
Mental health nursing positively contributes topeople experiencing a mental health problem
Placement in mental health nursing will provide
valuable experience for my nursing practice.
Mental health services provide valuable assistance1
1
to people experiencing a mental health problem.
(1.1)
(1.1)

11
(15.1)-

2(2.7)

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
These negative perceptions of nursing students about
the field of mental health nursing unfavorably affects
them as not to pursue mental health nursing as career.
24,25,26. On the responses about anxiety related to dealing
with mentally ill clients, students reported fear which issimilar to the other research findings because nursing
students encounter issues of mental disorders during thebachelor program in nursing. Research showed nursing
students to have fear and anxiety about mentally illpatients thus it is very important for nursing students tohave communication before encountering real patients to
reduce their level of anxiety. Fear is a common reaction
after entering the psychiatric area because of negative
media about mental disorders. This becomes a challenge
for nursing students to provide teaching and dotherapeutic communication with patients.27, 28, 29.
Valuable contribution in terms of recovery from mental
illness is a major factor which is enhanced through group
volunteer services; also good physical health is a major
contributor in recovery through providing services30, 31.
Conclusion
This study found that nursing students showed positive
perceptions regarding working in mental health setup.
Although working with mentally ill clients is muchstressful but it is really valuable to provide services toindividuals suffering from mental conditions. Throughteaching the course of mental health nursing and byattending the clinic nursing students can make a positivechange towards selecting mental health nursing as acareer choice.
Limitations

This study was conducted at one private college so sample size
was only from one class which is not enough representation.
Through these findings it is recommended, to conduct a quasiexperimental study on the same group and make a comparison
after they complete the course of mental health nursing.

Acknowledgements

The authors would like to acknowledge all nursing students
enrolled in BSN-III year for providing their contribution andcommitment. The study data was collected after having
permission by the research committee of College of Nursing.
Written consent was taken from the study participants after
assessing the confidentiality of participants. Autonomy right
was given to the study participants of withdrawal anytime fromthe study.

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Mandatory COVID-19 vaccination in Africa:
The philosophy of objectivism on individual
rights vs public rights in a culture boundsociety, Nigeria- Chukwuneke F N, MPH- Ezenwugo A C, MPH- Umeorah OUJ, MPH- Iyioke, I V, PhD
College of Medicine, University of Nigeria Ituku-Ozalla
Campus, Enugu State, Nigeria
Email: felix.chukwuneke@unn.edu.ng
Abstract
The mandate to ensure and protect the health of the public is an
inherent moral pursuit of any responsible government whose
obligation is to care for the well-being of its citizens. Throughwell planned prevention of ill health, individuals can spend
more of their years in good health and contribute meaningfully
to the development of the society. Because of the concern inbalancing respect for individual autonomy and liberty, ethicaljustification for government intervention to promote publichealth through vaccination deserves renewed scrutiny. A case inpoint is the suggestion for a mandatory vaccination necessitatedby the latest COVID-19 pandemic. Vaccination campaigns
aiming to eradicate disease have been deployed in the past to
create herd immunity within a given population. Depending on
the epidemiological situation, vaccinations may be voluntary insome countries but mandatory in others, with mandatory
policies sometimes leading to resistance against the
government. Acceptance of vaccination for preventable diseases
is often high at various places. However, in Africa, as its often thecase with many developing countries, a significant number often
refuse vaccination due to various concerns, including culturaland religious perceptions, ideological differences, or stark
ignorance or misinformation about vaccines. Proponents ofmandatory vaccination argue with justification that under such
epidemiological condition the state is right to act in the interestof public health. But the complexity of African society withvarying cultural and religious practices also reflects on thepeople’s perception and understanding of their health matters.
Many African cultures have different notions and understandingof the causes of diseases and may thus reject vaccination for adisease they believe is spiritual or even non-existent. We are of
the opinion that mandatory vaccination for COVID-19 for
Africans given its heterogeneous and complex nature andsignificant uncertainties in both the pathophysiology andmanagement of the virus calls for intentional and robust
community engagement and dialogue. This paper will explore
any ethical dilemma and present a platform to address concerns
around safety, access and dissenting opinions as well assustainability before any form of implementation.

Introduction
The historical journey to prophylactic vaccination as oneof the least costly and most effective forms of medical
intervention started from Edward Jenner’s work in 1796
(Dohertya et al., 2016). Jenner is considered the founderof vaccinology after he inoculated a 13 year-old-boy withvaccinia (cowpox) virus and demonstrated immunity tosmallpox that led to the development of the first smallpox
vaccine in 1798. Today several vaccines are produced
based on new knowledge and better understanding ofmolecular biology and have led to a reduction in themortality rate of many infectious diseases. In the 18th
century they used the vaccinia virus while in the 19th
century, Louis Pasteur and Émile Roux demonstrated thatinactivated or attenuated organisms could provide
protection (Dohertya et al., 2016). The 20th century
witnessed an accelerated development of new vaccines
involving many new technologies which became available
for immunization against many diseases with highmortality. Despite being one of the most widespread andsuccessful of all health interventions after the provision ofsafe drinking water, immunization has been controversial
since its introduction, with opponents claiming it was
unnatural or contaminating (Schwartz,2012) and could
be harmful. Because vaccines are different from mostmedicines and are administered to large and mostly
healthy populations including infants and children, there
may be low tolerance for potential risks or side-effects. In
addition, the long-term benefits of immunization in
reducing or eliminating infectious diseases may induce
complacency due to the absence of cases (Di- Pasqualea etal., 2016). In some cases, there may be associated vaccine
scares.
The largely unproven relationship of measles-mumpsrubella (MMR) vaccine with autism, and whole-cell
pertussis vaccines with encephalopathy, can result in
reduced vaccine uptake and consequent disease
resurgence (Di- Pasqualea et al., 2016). Vaccinations have
had an enormous impact on population health and theprevention of disease and have been one of the greatest
public health achievements of the last century. However,
over the past decade, acceptance of vaccines has beenchallenged by individuals and groups who question thebenefit and safety (Kristin and Sarah,2017). Ethical issues
pertaining to mandatory vaccination activities and the
public health versus individual rights debates areimportant in the implementation and the public's
response to vaccination programs. The debates willcontinue, and as healthcare professionals, our duty is toempower and educate consumers so that decisions can bemade with the best interests of all in mind (Luke etal.,2014). Notwithstanding, a comprehensive vaccination
program is a cornerstone of good public health and will
reduce health inequities and the universal disease
burden.
From a human rights perspective, vaccination
equitably promotes and protects public health when thefocus is on its public good. On the other hand, individual
rights issues come up where there is hesitancy and refusal
to be vaccinated based on some reasons such as religion,
personal belief and culture. The ethical principles ofbeneficence, non-maleficence, justice and autonomy tend
to provide a morally justified basis for mandatory
vaccination, even though the autonomy of the individualEubios Journal of Asian and International Bioethics 30(7) (September 2020)
becomes restricted. The final goal of a mandatory
vaccination program, to prevent disease, disability anddeath, is noble and moral both from the deontological andutilitarian perspectives (Umeora et al., 2012). The
philosophy of objectivism and distributive justice isbetter served by mandatory rather than voluntary
vaccination programs when dealing with a known disease
that has demonstrated success in control with known
vaccines.
This may not be the case with COVID-19 vaccine until
the safety and efficacy are determined through clinical
trials. COVID-19 is an official recognized name for a novel
coronavirus first isolated from persons with pneumonia
in Wuhan city, China (World Health Organization, 2020).
The virus can cause a range of symptoms, from mild
illness to pneumonia. Symptoms of the disease are fever,cough, sore throat and headaches. In severe cases
difficulty in breathing and death can occur. At the moment
there is neither a definitive cure for COVID-9, nor aneffective vaccine.
Methodology
We carried out Internet search of articles, conference
proceedings, media reports, and textbooks on vaccination
with focus on mandatory vaccination and human rights,
public health ethics and cultural norms published locallyand globally without limitation of time span and language
using Google search, Google Scholar, PubMed, African
Journal Online, Medknow, Hinari and NIH.gov,
ResearchGate, and Elsevier. We also searched for
published papers and technical reports on the novel
disease COVID-19 and biomedical care in Africa from theInternet and university libraries. The search engines
yielded 25 relevant publications which, in addition to theauthors’ knowledge and experience in public health andbioethics, supported the information as presented in thisarticle.
Mandatory vaccination: individual rights vs publicrightsIn discussing this issue, some pertinent questions must be
addressed and they include;
vAre the rights of individual more important than therights of the society?
vWhen should an individual right be sacrificed for thecollective good?
vWhen should a collective concern be eliminated toprotect an individual's rights?
vDo governments have the right to determine what isbest for everyone within their domains?
vShould people surrender their autonomy to get
vaccinated at the cost of probably having adverse
reactions to the vaccine for a novel disease such as
COVID-19 that has not yet been properly understood?
There is no doubt that ethical challenges abound in
making vaccination mandatory especially in a pluralistic
society with different cultural dispositions. Because mostof the diseases being vaccinated for prevention aretransmitted from person to person, there is a need toprovide both individual and public protection against thedisease. A mandatory vaccination in Africa for a novel369

disease such as COVID-19 will inevitably present strong
ethical concerns when weighed against a risk –to- benefit
ratio. This is because the immunogenicity is not yet
properly understood and despite clinico-pathologicalsimilarities with the seasonal influenza viruses (flu), it ismuch more contagious and fatal. In sub-Saharan Africa(with the exception of South Africa and parts of the
Maghreb) flu vaccination is rare. Nigeria does not have avaccination program against flu because it is rare andwhen it occurs, it runs a mild course with or withoutmalaria or other common infectious disease like typhoidfever.
Respecting individual concerns and the right to accept
or refuse COVID-9 vaccination as well as acknowledging
exemptions seems a good ethical decision in the light ofthe present outbreak. When an adequately large
proportion of individuals in a community is immunized,
those persons serve as a protective barrier against thelikelihood of transmission of the disease, thus indirectly
protecting those who are not immunized (Kevin and Alan,2007). This means not everyone will be vaccinated forseveral exemption reasons such as medical conditions
which governments may accept as a waiver irrespectiveof the individual autonomy to opt out due to personal,
cultural or religious beliefs. Exemption should not only bebased on medical grounds; people have a right to decide
whether they should be vaccinated or not based on
vaccine safety concerns and risks they may feel outweighthe benefits.
In children, proposals for vaccination requirements
often precipitate vigorous discussions of ethical issues,
especially among parents. Some parents do not accept
existing safety evidence. Others oppose the concept of
mandatory vaccination for speciﬁc reasons such as
religious or philosophical beliefs that conflict withvaccinations (CDC, 2015). Because several scientificstudies have found that individuals who exercise religiousor philosophical exemptions from mandated vaccinations
are at a greater risk of contracting diseases, which puts
themselves and their communities at risk, public healthadvocates often struggle to balance the ethics ofprotecting individual beliefs and the public's health(David and Saad, 2006). A society is made up of numerous
individuals without which, the society does not form.
Individual right is a person's justifiable claim, protectedby law, to act or be treated in a dignified manner that
protects the liberty and right to decision making.
However, in reality, the individuals’ rights are grounded
in relativism when the issues of collateral damage andpublic harm are envisaged by the state especially on
issues of epidemic and pandemic disease outbreak. In
such a situation an individual right may be sacrificed forthe collective good so as to avoid group harm andcollateral damage.
Autonomy and right to personal liberty mean that anindividual deserves the right to take decisions affecting
him/her in all issues including right to receive or reject
any form of healthcare, preventive or therapeutic (Lavery
et al., 2007). A mandatory vaccination policy implies noconsent is to be sought before the vaccine is administered
to an individual. This obviously negates the individual’s
rights to liberty and autonomy and could therefore be

370

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

argued on this basis as illegitimate irrespective of theintended outcome (David and Saad, 2006). The
government has the mandate to ensure and protect thehealth of the public in its moral pursuits and obligation to
duty in caring for the well-being of its communities
through vaccination but governments cannot always
determine what's best for everyone within the society.
Forced vaccination against a person’s right to decisionmaking may in certain cases lead to serious harm or
possible death following vaccine reactions which on its
own violates the fundamental right to life of an individual.
Vaccination in Nigeria: an overview
The complexity of African society with different culturaland religious practices often reflects on the people’s
attitude and understanding of their health matters. The
influence of culture on the health-seeking behavior of
Africans cannot be underestimated as many African
cultures have different notions and understanding of thecauses of diseases (Chukwuneke et al., 2012). Anecdotal
evidence suggests that a significant percentage ofNigerians and indeed many Africans, believe that COVID19 does not exist or is a Western disease. This default
position has placed Africans on the quagmire of dealing
with the impending catastrophe as predicted (Zhao et al.,2020). In Nigeria, vaccination (immunization) began in1956 when smallpox was severe nationwide. The national
expanded program of immunization (EPI) started in 1979
to combat deadly childhood diseases, which wereregarded as the cause of high infant morbidity andmortality in Nigeria (Endurance et al., 2014). Nigeria is
divided into six geo-political zones: North Central, North
West, North East, South East, South West and South South,that make up 36 states and the Federal Republic of
Nigeria. The most populous country in Africa, Nigeria isestimated to have a population of 167 million (National
Population Commission, 2008).
The Expanded Program of Immunization (EPI),
introduced in 1979 with the aim of providing routine
immunization to children less than the age of two years,
recorded initial but intermittent successes (Odusanya,2008). Immunization has always been a very difficult
health project in Nigeria because many families do notalways allow their family members including children to
be immunized mostly due to cultural and religious beliefs.
Some studies have shown Nigeria as the worst
immunization defaulter in the West African sub-region,
only better than Sierra Leone (Green, 2004). The vision of
EPI in Nigeria was to improve the health of Nigerianchildren by eradicating all the six killer diseases: polio,
measles, diphtheria, whooping cough, tuberculosis, andyellow fever (Endurance et al., 2014). As outlined in thenational health plan between 1985 and 1990, theobjectives of EPI were to strengthen immunization,
accelerate disease control and introduce new vaccines,
relevant technologies and tools (Endurance et al., 2014).
However, these objectives were hampered by somechallenges such as rejection of selected vaccination byparents or on religious ground. Many decision-makers
and caregivers reject routine immunization due torumors, incorrect information, and fear of complications
that may follow the vaccination (Endurance et al., 2014).
In the past, some Nigerians objected do so due to fears andworries regarding routine vaccination because of little

knowledge or limited information and mistrust. Some areof the opinion that the Western world is indirectly using
vaccination to reduce the population of the Africans as
they are determined to regulate and impose population
control especially in Northern Nigeria (Feilden, 2005;
Yola, 2003). This lack of trust and confidence in routine
immunization is also found in many parts of Nigeria(Babalola and Adewuyi, 2005).
Ethical considerations and right to personal liberty: A
mandatory vaccination program implies that no consent
from the individual is to be sought before the vaccine isadministered. This obviously negates the principle ofpersonal liberty and ownership of one’s body because anindividual deserves the absolute right to determine what
happens to his or her health including vaccinations. For
the minors, this autonomy resides with the parent or legal
guardian. Mandatory vaccination is therefore an affront
on autonomy as it negates the protestations of parents
and the voluntariness that should follow informed
consent (Colgrove, 2006). The principle of autonomy
demands that each individual has a competent right toself-determination (Belmont report) and be treated as an
end in itself, never to be used as a means whileconsidering a mandatory COVID-9 vaccination program.
Mandatory COVID-9 vaccination bears the human rights
and ethical burden of relegating informed consent,
restricting autonomy and liberty against the population.
The proponents of mandatory vaccination of a novel
disease such as COVID-9 may argue that such vaccination
program may provide the requisite herd immunity but
this could also be interpreted in terms of using theindividual as a means and not as an end for a disease notyet clearly understood. A further concern would be theachievable goals of the mandatory program since theeffectiveness of the immunization in poor developing
countries such as Nigeria will be hampered by chains ofreaction of events: lack of good infrastructure for effective
movement of health personnel to most rural areas, erratic
power supply which can compromise the integrity of thevaccine cold chain, lack of adequate manpower, poverty
and ignorance especially amongst the rural populace. At
the end, not everyone willing can be vaccinated,
mandatory program notwithstanding.
Some proponents (Chukwuneke, 2020; Alberto andJulian,2017) of mandatory vaccination have argued that it
is ethically justified because people have a moral duty not
to harm or risk harming other people especially when
avoiding harm, or risk of harm comes at a small cost to
individuals. Apart from moral obligation, mandatory
vaccination is justified based on the fundamental
principle of fairness. On the basis of this principle,
everybody should make their fair contribution toimportant public good from which everybody benefits(Alberto and Julian,2017). Though the COVID-19
pandemic may pose a health threat to many people acrossthe globe, we suggest that there may even be a greater
threat to personal liberty by mandatory vaccination. With
respect to more preventable diseases, especially thosethat affect children, the emphasis on COVID-19 manyargue, may be exaggerated (Alberto, 2017). With thesuccesses gained in childhood vaccinations forpreventable disease such as polio, diphtheria, measles

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
without mandatory vaccination, would that of COVID-9 benecessary since it is yet unclear that the vaccine (whenone is developed) may provide lasting immunity such as
seen in the common flu.
Conclusion
Mandatory vaccination policies apart from moral
obligation would guarantee that everybody makes theirfair contribution to an important public good such as herd
immunity. However, in the case of a mandatory
vaccination for a novel disease whose vaccine has notbeen fully developed and clinically tested on risks andbenefit ratio, it is fraught with many ethical concerns.
People are also concerned about proposals from certain
quarters for a mandatory vaccination without any
evidence of clinical trial outcome of the vaccine. We are of
the opinion that mandatory vaccination for COVID-19 for
Africans is particularly worrisome. Efforts must be madeto account for the numerous cultural beliefs of the people,
and proper community engagement and ethical dialogue
to address different concerns and dissenting opinions
before any form of implementation.
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Belt Analogy" https://blog.oup.com/2020/04/why-vaccines-shouldbe-compulsory/ . Accessed June 28, 2020.
Babalola S, Adewuyi A (2005). Factors Influencing Immunization Uptake
in Nigeria: A Theory-based Research in Six States. Abuja: PATHS; 2005
Belmont Report (Accessed, 2020: http://www.hhs.gov/ohrp/
humansubjects/guidance/belmont.htm. Accessed, May 27, 2020.
CDC (2020). "State School Immunization Requirements and Vaccine
Exemption Laws’ Public Health Law.
https://www.cdc.gov/phlp/docs/school-vaccinations.pdf . Accessed
July 10, 2020
Chukwuneke F (2020). COVID-19 vs. Childhood Immunization: A
Bioethics Perspective from Nigeria. Bioethics in the News: Center for
Bioethics in Humanities and Life Science, Michigan State University.
https://msubioethics.com/ 2020/06/25/childhood-immunizationcovid19-nigeria-chukwuneke . June 25, 2020.
Chukwuneke F et al. (2012). Culture and Biomedical Care in Africa: thein-fluence of culture on biomedical care in a traditional African
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Colgrove J (2006). The ethics and politics of compulsory HPV
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Total Environ (2020), 10.1016/j.scitotenv.2020.138959.

Turning tragedy into creative work:
experiences and insights of plant lovers in
Davao del Sur during COVID-19 pandemic- Rogelio P. Bayod- Erikka June Forosuelo- Jean M. Cavalida- Bernadette B. Aves
Cor Jesu College, the Philippines
Email: roger.bayod@gmail.com
Abstract
The Covid-19 pandemic has resulted in disruption ofwork and other social activities of so many people. Somewere forced to stay at home and many decided to stay athome for fear of being infected with the virus. Thisphenomenon brought different reactions and even mental
stress to many people. However, there were people whoturned this kind of tragedy into creative work. This paper
discusses the experiences and insights of known plant
lovers in Digos City, Davao del Sur Philippines. Digos City
is one of the heavily affected places during the series ofearthquakes that jolted Davao del Sur last year. Whilepeople are still recovering, COVID-19 added an additionalburden to the residents. In this paper, we argue that theirdecision to focus on gardening was not only to fightboredom and to divert their attention during lockdown
but this was their way of maintaining their well-being byparticipating in the on-going work of creation and recreation and to rise from the tragedy. We further argue372

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

that it might be good that this creative work will go
beyond home gardening and beyond pots and slowly
extend to creative work for environmental protection andpreservation through more active engagements into
reforestation activities.
Introduction
The COVID-19 pandemic created several unforeseenchallenges and has taken a significant toll on people all
across the world. Our daily routines have beeninterrupted, work has been displaced, school time forchildren and adult stopped and the once busy streets atnight turned into peaceful paths. All these we are
currently embracing as we gradually face the reality of the
new normal. But this circumstance also ignites character
formation. According to (Rashid, n.d), character is thevirtue of hard times. Individuals, despite many set-backs
in life, try to utilize their strength to deal with challenges
adaptively. It is said that applying our strength helps us toreframe and reappraise challenges, and provides us witha steady dose of well-being to build positive coping
mechanisms. Research, informed by positive psychology
concepts (Southwick, Satodiya & Pietrzak, 2016) showsthat tapping onto our strengths helps us to tackle toughchallenges (Niemiec, 2018; Niemiec & Mcgrath, 2019). To
some, strength means resorting to plant collecting andplant growing. A person who loves plants and flowers iscalled an anthophile. Plant and flower growing andcollecting have been proven to stimulate the mind,
improving focus and concentration. Bringing naturalelements indoors and outdoors helps memory retention
and productivity in the office and the environment we arein.
As we gathered stories and experience of people whoare into home gardening, plant growing and plantcollecting, we argue that the reason that they are into
gardening is not only to do away with boredom during
lockdown and quarantine, but because it is theirmechanism to maintain their well-being through actively
participating in the on-going work of creation and recreation and to also rise above the series of tragic events
they have experienced. We also further argue that thiscreative pastime needs to go beyond pots and garden soil,
and shall extend to creative work for the purpose ofprotecting and preserving our environment and more so,
active engagements with reforestation activities.
We asked our participants the following questions:
What is your main reason you resorted to gardening
during this time of pandemic? How does gardening help
you during this time of pandemic? What lessons can you
get from engaging into gardening?
Reasons why they resorted to gardening: Homegardening can be very exhausting and time consuming if
it is not considered as a passion or a pastime. In this timeof pandemic, when there are government mandates tostay at home for safety, we can actually sustain for a week
or a month but adding more days and weeks would result
to boredom, depression and worse, laziness andprocrastination. According to the Center for Disease andControl Prevention (2018), well-being is a positive
outcome that is meaningful for people and for many
sectors of society, because it shows that people perceive

their lives as going well. This is true to the individuals who
resorted into home gardening, plant growing and plantcollecting. They perceive these activities as meaningful inthe midst of the strains brought about by COVID-19
pandemic; to them there is still hope that their lives gowell by taking care and growing plants and flowers intheir gardens. There is no consensus around a single
definition of well-being, but there is general agreementthat at minimum, well-being includes the presence of
positive emotions and moods (e.g., contentment,
happiness), the absence of negative emotions (e.g.,
depression, anxiety), satisfaction with life, fulfillment andpositive functioning (Andrews & Withey, 1976; Diener,
2000; Ryff and Keyes, 1995 cited by Center for Disease
and Control Prevention, 2018). These ideas also arelikened to George Kelly’s Personal Construct (1963) whichstated that any event happening in our lives is open to avariety of interpretations and it is the individuals’
perception on how they make sense of it (Engler, 2010).
If individuals perceived gardening as a way of coping withstress and fear of being infected with the virus, thenindividuals create their own way of understanding theevents in a positive manner. Instead of becoming
paranoid to the situation and hysterical to the negative
information, they do something to make their lives
productive. Thus, when asked about the reasons why they
are into home gardening, these people say they engaged
into this activity because of the following: To relieve stress,
strengthen family bonding, and to focus on positive things
while staying at home.
To relieve stress. It cannot be denied that COVID-19
pandemic has caused so much stress to people in many
countries in the world. Stress according to the US National
Library of Medicine (2020) is a feeling of emotional or
physical tension. It can come from any event or thoughtthat makes you feel frustrated, angry, or nervous. In orderto release the stress brought about by COVID-19, ourparticipants resorted into home gardening because it
eases out and relieves the stress they are feeling. One
participant said: “gardening is fun and removes stress”.
Another participant said: “for a short time I do not worry
about the healthcare; instead, doing gardening work
relaxes me and eases my worries”. In other words, they
engaged into gardening because they experienced a senseof happiness and fulfillment and that gardening takes
away their worries about what is happening in thesociety. It is therefore important to learn to manage stresswhich includes avoiding stress and taking actions todecrease stress as it occurs. Human beings are gifted withpowerful dispositions and it is up to us to maximize thispotential to be able to adjust to various adversities that
we go through in our lives.
This is very true to people who engaged into homegardening during this pandemic. They experienced andthey believe that by engaging into gardening, they wereable to manage the stress brought about by the current
pandemic. Aside from taking away their stress, gardening
gives them a feeling of enjoyment and relaxation when
they see their plants and flowers growing. In short,
gardening enhances their well-being. Gardening relieves
their stress and since plants are living beings, it serves ascompany in the house and plant owners do not feel alone
while staying at home during the pandemic. They takeEubios Journal of Asian and International Bioethics 30(7) (September 2020)
control of the situation by managing their mental wellbeing and hold on to the hope that growing plants andcollecting its varieties divert their attention from thetoxicity brought about by the pandemic.
To focus on positive things while staying at home.
Another reason that motivates our participants to engage
into home gardening is that they want to focus on positive
things while staying at home. During the interview, one
participant said: “stay at home, work from home, lockdown,
quarantine caused me to think about what other things to
do during this period”. Another participant said: “I finddiversion from the negativities that our environment isexperiencing at the moment”. The tragic events that theyexperienced allowed them to focus on positive things andto enhance their capabilities to rise above the tragedy.
The capability approach purports that the freedom toachieve well-being is a matter of what people are able to
do and to be, and thus, the kind of life they are effectively
able to lead (Sen 1992: 48; Robeyns, 2005: 94–96;
Qizilbash, 2008: 53–54; Sen 2009a; Robeyns, 2016). It issaid that optimists find opportunity in every difficulty.
This implies that despite the negative situation, people
chose to find ways and means to live with positivity bytaking care of plants and flowers and engaging into homegardening. And thus, quarantine and lockdown allow ourparticipants to think of other beneficial things to do andbecause they already have plants at home, they decided topropagate them and cultivate their soil.
Cultivating the soil is cultivating life. For Kumar,(2013) as cited by Bayod (2020), “soil is the source of alllife, literally and metaphorically and that, all life comesfrom the mother soil and returns to her”. Thus, Kumar
loves soil as his mother and takes care of her (Bayod,2020). Kumar even made a beautiful analogy of theinterconnectedness of life when he said:“If my outer body is soil, then my inner being is thesoul. As I cultivate the soil to grow food for the body,
I take care of the soul and cultivate love, compassion,
beauty and unity to realize the harmony within andwithout. When I am at ease within, I am at easewithout. I am at ease with the whole of humanity.
Through caring for soil (land) I am a member of the
Earth community and through caring for society I ama member of the human community.” (Kumar, 2013,p. 10).
According to Bayod, (2020), Kumar’s new trinity of“Soil, Soul, Society” is a way of saying in three words theinter-relatedness, inter-connectedness and interdependence of living organisms on earth. Indeed, it is atrinity of wholeness and unity of life in its myriad forms(Kumar, 2013).
How gardening helped them during this time ofpandemic: In this new normal, people got so much crazein buying pots, plants, flowers, and some even propagatedmore plants by growing seedlings at home. Friendly
neighbors, office friends and even social media vlogs
shared tips on how to grow healthy plants thriving in an
everchanging environment. People were happy andexcited because of these activities despite the presence ofthe pandemic. In her capabilities’ theory (Nussbaum,373

2002, cited by Kleist, n.d) she emphasized: “if a person
lives a life where she is unable to exercise her humanpowers (for example, self-expressive creativity) then she
is living her life in more of an animalistic manner than asa human being”. Nussbaum seeks a capabilities’ approachthat can fully express human powers and not just provide
opportunities for people to perform certain functions. As
human persons we are gifted with capabilities andchoices which transcend us from the rest of the living
creatures. We can do something to turn trying times intoa worthwhile undertaking and these activities help us
sustain during the pandemic that stripped us of things weare accustomed with. The answers of our participants fall
into the following themes: Provides relaxation andcalmness; Enhances self-esteem and well-being; Provides
source of income.
Provides relaxation and calmness. To relax means tocalm the mind, the body, or both. Relaxing can quiet our
mind and make us feel peaceful and calm. In fact, our bodyreacts when we relax. According to the American Instituteof Stress (2019), one is lucky to live in a home thatprovides its own garden or green space because one canfeel a sense of tranquility. For our study participants,
gardening helps them to slow down, be calm andreflective about life. It also provides them enjoyment andcomfort while seeing the plants grow. As mentioned by
one of our participants: “Home gardening makes me slow
down the pace of my busy life because plants and flowers
bring calmness and serenity. I found comfort with theplants every time I see them. They are immediate medicine
to my worries in this time of pandemic”. Mental focus andmindfulness are popular ways of combatting the stressand anxiety caused by the COVID-19 pandemic. Indeed,gardening helps them to slow down, relax and be calm. It
also provides them with enjoyment, relaxation andcomfort while they nurture their plants. Certainly,
spending time in the garden is a great way to relax andcalm. Plants and flowers have magical power to relax our
mind and body. That is why in many retreat houses where
people are expected to pray and be still, they are
surrounded with plants and flowers. Aside from theoxygen that they provide to help people breath normallyand comfortably, gardens are also pleasing to the eyes andhelp you stay calm and relax.
Enhances self-esteem and well-being. Due to theincreasing demand of plant and flower varieties, several
social media groups are created to answer these needs ofplant growers. A very good example is a Facebook pagethat allows people to sell, barter and introduce plantvarieties and discuss matters related with plant growing
and home gardening. Our participants were very proud toexpress their thoughts on the fact that home gardening
enhances their self-esteem. One participant said:“Gardening enabled me to appreciate my talents andcapabilities. That I have the capability to give life andnurture life. This enhances my self-esteem. Instead of
focusing on the problem, gardening helps me re-align myenergies to be more productive in the society. Every time
people come and see my plants, they are happy and I’m alsoproud of myself”. Another participant mentioned: “It gives374

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

me positive outlook. I love seeing little ones growing. And it
gives me a very wonderful experience, especially on
knowing plant names and propagation process that makes
me more excited waking up each day”. The same concept
was shared by another participant when she said:“Gardening makes me happy and develops my self-pride. It
builds my patience, clears my mind and challenges me toenjoy simple things in life without spending too much”.
Seeing their plants grow enhances their self-esteem andthey are affirmed of their capabilities to nurture life.
Sharing these experiences with their fellow gardeners
also allows them to establish and develop friendships
with them. According to Scott, Masser and Pachana,(2020), gardening groups offer a way for people toconnect with nature and each other, allowing social
benefits to accrue. Connecting with other members of agardening group allows people to receive social support
and to contribute positively to the lives of others, an
important protective factor against isolation andloneliness (Haslam et al, 2019). As expressed by majorityof the study participants, they think and feel thatgardening really enhances their self-esteem and wellbeing as they enjoy simple things in life. Gardening makes
them feel excited to wake up each day as it provides themwith a positive outlook in life.
Provides source of income. A lot of people have been
displaced due to the pandemic. Some lost their jobs andothers are forced to stop going to work because they are
directed to have home quarantine. With meager amountof income, these people looked for ways and means to live
by and to sustain especially that they have mouths to feed.
This is one of the major reasons why home gardening
became a source of income to plant and flowers growers.
According to one participant: “I started my investment incollecting different varieties of plants for future plans likehaving a nursery/farm as additional income”. Anotherparticipant said, “For economic survival, gardening reallyhelps me.” It reveals that home gardening provided theman opportunity to earn money especially in this time ofpandemic. According to Wallin (2019), flowers are among
the most profitable plants, producing one of the highest
returns of any specialty crop. One can get started withvery little, just enough for seeds and supplies, and most
new flower growers make money in the first year. There
are plant and flower growers especially during the time ofpandemic, who only collect for home beautification at firstand later turn their love of plants and flowers into
profitable ventures. They make money out of their hobby
which becomes an addition to their income.
Lessons they get from engaging into gardening.
Planting flowers and vegetables can reap good harvest. As
stated by Frost (n.d): “Beyond the reward of homegrownproduce, gardens provide health, environmental andenjoyment advantages for the gardener”. It is a fulfilling
job and it also bring us back to commune with thewonders of nature. As mentioned by our participants,
the lessons they get from engaging into gardening are:
To be patient and to treat and enjoy life properly;
Promotes physical, mental and emotional health; To focus
on gratitude instead of competition and to let the flowers
bloom in its perfect time; To go beyond backyard
gardening to take care of our environment.

To be patient and to treat and enjoy life properly.
Patience is a virtue especially when it comes togardening. According to Kinzler (2017), gardening is arefreshing throwback to a quieter, more patient time,
which is part of its charm. And since plant and flower
growers are very excited to see their flowers bloom andtheir plants produce, there will always be strides inquickening the pace because plants take all the time theyneed in order to grow. As cited by Ellison Chair inInternational Floriculture (n.d), flowers generatehappiness. Having flowers around the home and officegreatly improves people’s moods and reduces thelikelihood of stress-related depression. According to oneof the participants: “I learned that you have to be patientin life because you cannot rush your plants’ growth. They
have to be treated properly, tended regularly so that they
can grow right”. Another participant said that “It taught
me patience, tolerance and endurance. It made me realize
the simple things in life. That joy can be attained by simply
looking at your plants blooming and giving back the love”.
Indeed, gardening really develops your virtue of patiencein waiting. But while waiting, you are full of excitement
and joyful anticipation of the development of your plants.
Gardening helps us to reflect about life in general – that
we need to be patient as we journey and in every step of
the way, let us just enjoy the journey and embrace whatlife has to offer.
Promotes Physical, Mental and Emotional Health. Asemphasized by (Eliades, 2013), gardening promotes
physical and mental health through relaxation,satisfaction and better nutrition. There is no greater joy
than seeing the plants thrive well, healthy and green.
According to Ellison Chair in International Floriculture(n.d), flowers can help achieve a more optimistic outlook
in life, which pleases visual stimulation and helps increase
the perceived happiness of the planters. Researchers
often find in their studies that subjects who participate ingardening have a positive mental outlook (Lombard,
Forster-Cox, Smeal, O’Neill, 2006; Armstrong, 2000). As
one of our participants said: “home gardening helps me tobe mentally and emotionally healthy”. Another participant
expressed: “Plants are our outlet and one that boosts ourenergy to continue living with grace and enthusiasm in thischallenging time”. Studies reported in the Journal of
Health Psychology in 2012 show that people who feel aconnection to nature are indeed happier (Cervinka,
Roderer & Hefler, 2011).
To focus on gratitude instead of competition and to let
the flowers bloom in its perfect time. It is said thatpeople who spend extended lengths of time around plants
tend to have better relationships with others. As theyshare stories of their plant varieties and their experiencesin home gardening; these people also have expressedgratitude to friends and neighbors who share seedlings
and other plant materials that can be added to the homegarden. As one participant happily said: “Despite all thenegative things happening around us, there is always
something to be thankful for and to look forward to. Just
like plants, we all bloom in our own ways and in God’s
perfect time”. Throughout generations, plants have been aEubios Journal of Asian and International Bioethics 30(7) (September 2020)
beautiful medium through which we can learn some oflife’s valuable lessons (Click and Grow, 2019).
To go beyond backyard gardening and to take care of
our environment. Gardens are not just aestheticallypleasing, they are a building block of a healthy space anda reduction in carbon footprints (Throne, 2018). Gardens
help keep the environment healthy and strong. The
absence of plants and flowers in our gardens can increase
pollution, global warming, carbon dioxide, and unhealthy
lifestyles. As mentioned by a participant: “It would be goodto plant trees. I wish I had a big area here. I am still notenergetic enough to climb up mountains to plant trees. But
I can just plant few trees or fruit trees here in our
backyard”. And another participant said: “I realized that
God has a reason for letting us experience home quarantine,
not only to value the presence of our loved ones and pets but
also to help mother earth revive its beauty throughplanting/gardening.” The more people decide to engage inhome gardening, they will not only be helping themselvesto improve their well-being but also help protect andnurture the environment we live in. Many of our study
participants have the desire to go beyond backyard
gardening and to get involved in large-scale tree planting
activities to really protect the environment if given the
chance.
Conclusion
Our environment is an important part of our existence.
As we journey together in facing the tremendous effects
brought about by the COVID-19 pandemic, people areable to turn tragedy into creative work by doing homegardening and by growing plants and flowers. These
plant lovers resorted into gardening during this time ofpandemic to relieve stress and to focus on positive
things while staying at home. Furthermore, gardening
provides relaxation and calmness, enhances self-esteem
and well-being and provides a source of income. Thus,
people who engage in gardening have not only earned
additional income but also gain lessons in life that are
priceless. They learn to be patient and to treat and enjoy
life properly. Gardening also helps them to promote
physical, mental and emotional health and to focus on
gratitude instead of competition and to let the flowers
bloom in its perfect time. While momentarily they are
just doing gardening in their own backyard, many ofthem also share that they are willing to go beyond
backyard gardening to take care of the environment if
given the chance to do so. It might be more noble if thiscreative work that is discovered and transpired in thetime of pandemic like home gardening and love of plants
and flowers shall go beyond the garden soils and pots in
the gardens (including projects for greening of
backyards at home) and lead to active participation andinvolvement in activities on environmental protection
and preservation. It is already established that loss of
biodiversity and deforestation will result in virus
outbreaks (Climate Council, 2020; Walsh et al, 2017;
Kessler et al, 2108; Plowright et al, 2015; Martin et al,2018). Thus, to prevent a future pandemic, there is aneed to restore our ailing environment. Restoring ourailing environment through reforestation and greening

375

projects may not only prevent a future pandemic but will
also give, nurture and protect life not only for thepresent generation but for the next generations yet tocome.
The present pandemic also allows us to channel ourenergy in enhancing our capabilities. As discussed by theStandford Encyclopedia of Philosophy (2016): “thecapability approach is a theoretical framework thatentails two core normative claims: first, the claim that the
freedom to achieve well-being is of primary moral
importance, and second, that freedom to achieve wellbeing is to be understood in terms of people's capabilities,
that is, their real opportunities to do and be what they
have reason to value”. According to many philosophers,
the best description of the capability approach is aconceptual framework for a range of normative exercises,
including most prominently the following: (1) assessmentof individual well-being; (2) evaluation and assessment ofsocial arrangements; and (3) design of policies andproposals about social change in society. In other words,
the capability approach prioritizes the capacity, freedom
and opportunity of people to do important actions thatwill also enhance the core of their personhood. Martha
Nussbaum (2011) has described the general capability
approach as consisting of two clusters: one focusing on
the comparative quality of life and the other on theorizing
about justice. While most experiences of our participants
are still centered on their own well-being, we can glean
from their insights that some of them are willing to extend
their activities to a much broader context and issues suchas environmental protection and climate justice.
It has been said that great things start from small
beginnings. This gardening venture of many people,
while primarily intended only to help themselves
physically, emotionally and spiritually, must extend into
greater involvement into the different collective actions
towards taking care of the environment, protecting ourremaining forests and even restoring denuded forests.
While we need to take care and maintain the beauty andbounty of our home, let us be reminded that we are
citizens of this one big home – our planet. Thus, we needto take care of our common home by establishing a deep
reciprocal relationship with our planet and all that it
contains. While we take good care of our planet and allthat it contains, it shall take good care of us. Indeed,
there is no tragedy, no matter how big and terrible it is,if people continue to sing our SONG – our relationshipwith Self, Others, Nature and God.
References
American Encyclopedia of Philosophy (October 3, 2016). The Capability
Approach.
Retrieved
July
30,
2020
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Ethical issues of COVID-19 for persons withdisabilities- Shahanaz Chowdhury, PhD
Associate Professor, Dept. of Community Medicine,
Faculty of Public Health, Bangladesh University of Health
Sciences (BUHS), Bangladesh; Visiting Professor, AUSN
Email: dr.shahanazch@gmail.com
Introduction
Globally, more than 1 billion people, roughly 15 percentof the world population, live with some form of disability.
People who are older, people with chronic healthconditions, or people with disabilities that, for example,
affect their respiratory capacity, may be at particular riskof serious illness or death from COVID-19 infection.1
In the current situation of a global health crisis due
to COVID-19, there is the higher risk faced by persons
with disabilities or chronic illnesses, especially in low andmiddle-income countries. In order to successfully meetthis challenge and comply with the 2030 goals, persons
with disabilities must be included in all plans to manage
the current COVID-19 corona virus outbreak. This implies
that the information provided by governments andinstitutions to prevent infection and to know how to act
in case of illness must be available in accessible formats,including sign language, video captioning, the use ofalternative text in images and graphics displayed digitally,and easy-to-read versions.2
Even in normal times, people with disabilities andchronic illnesses confront biases in medical care, facewaiting lists to get support in their own homes instead ofat nursing homes, and struggle to access government
benefits. But amid a global pandemic, those challenges areheightened. 3
While the COVID-19 pandemic threatens all membersofsociety,personswith
disabilities
aredisproportionately impacted due to attitudinal,
environmental and institutional barriers reproduced in
the COVID-19 response. Many persons with disabilities
have pre-existing health conditions that make them more
susceptible to contracting the virus, experiencing more
severe symptoms upon infection, leading to higher levels

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)of death. During the COVID-19 crisis, persons withdisabilities who are dependent on support for their dailyliving may find themselves isolated and unable to survive
during lockdown measures, while those living ininstitutions are particularly vulnerable, as evidenced by
the overwhelming numbers of deaths in residential carehomes and psychiatric facilities.4
Impact of COVID19 in different institutions: COVID-19
has shown a disproportionate impact in psychiatricinstitutions, social care institutions (orphanages, daycare centers, and rehabilitation centers) and institutions
for older persons, resulting in high rates of infection anddeath. In some preliminary studies, the number of deaths
in care homes represented from 42% to 57% of all COVID19 deaths in those countries. Institutionalized persons
with disabilities face a heightened risk of contracting
COVID-19 due to underlying health conditions, difficultyin enforcing social distancing amongst residents and staff,
and abandonment by staff. Persons with disabilities living
in institutions also face greater risks of human rights
violations, such as neglect, restraint, isolation andviolence.4 COVID-19 could be catastrophic in settings suchas refugee camps or other temporary camps, where
people live in close proximity and often lack access tobasic services. People with disabilities in such places face
severe obstacles to basic services such as shelter, water,
sanitation, and medical care, including in countries
like Bangladesh, Cameroon, the Central African Republic,
Greece, Syria, and Yemen.1
Facing discrimination and barriers during COVID19
crisis: Persons with disabilities also continue to facediscrimination and other barriers in accessing livelihoodand income support, participating in online forms ofeducation, and seeking protection from violence.
Particular groups of persons with disabilities, such as
prisoners and those who are homeless or without
adequate housing, face even greater risks.4 It is also
important to remove the barriers in accessing healthservices and hygiene products, as well as to consider
reasonable accommodation measures to allow them towork from home and, if that is not possible, to ensure theyreceive a paid leave to guarantee their income.2 Olderpersons are at an increased risk of multiple rights
violations in the COVID-19 pandemic,5 such as
discrimination based on age, and must be supported toaccess services on an equal basis with others. While
having a disability probably doesn’t by itself put someone
at higher risk from coronavirus, many persons withdisabilities do have specific underlying conditions thatmake the disease more dangerous for them.6
For people with disabilities, all the general challenges
that come with the pandemic certainly apply, but there
are additional barriers. Equitable access to healthcare is along standing barrier worsened by COVID-19. This ranges
from getting a coronavirus test to being seen in an
emergency room. The use of personal protective
equipment, including masks, can make communication
more difficult for patients with hearing loss. Medical
resource allocations, including ventilators, may bediscriminatory against patients with disabilities. Thisissue echoes an underlying misconception that people

377

with disabilities cannot have a high quality of life andtherefore the lives of disabled people may not beprioritized. There has been a shift toward telehealth for
non-urgent medical visits. That has provided challenges
but also future opportunities for the disability
community. 7
People with disability may be at greater risk ofcontracting COVID-19 because of:a) Barriers to implementing basic hygiene measures,such as hand-washing (e.g. hand basins or sinks may
be physically inaccessible, or a person may havephysical difficulty rubbing their hands together
thoroughly);b)Difficulty in enacting social distancing because ofadditional support needs or because they are
institutionalized;c)The need to touch things to obtain information fromthe environment or for physical support;d)Barriers to accessing public health information.
Depending on underlying health conditions, people
with disability may be at greater risk of developing
more severe COVID-19 if they become infected. Thismay be because of exacerbating existing healthconditions, particularly those related to respiratory
function, immune system function, heart disease ordiabetes;e) Barriers to accessing healthcare. People withdisability may also be disproportionately impacted by
the outbreak because of serious disruptions to theservices they rely on. The barriers experienced bypeople with disability can be reduced if key
stakeholders take appropriate action. 8
Responses during the COVID19 crisis: Personal
assistants and interpreters should be, when possible,
proactively tested for COVID-19 to minimize the risk of
spreading the virus to persons with disabilities.9
Similarly, confinement measures should be adapted to
the needs of specific groups to ensure their well-being.
For example, people who need home assistance should
keep receiving it and, in the case of persons withpsychosocial disabilities, they cannot be required to live
in total isolation. 2
The government and healthcare responses to the
COVID-19 crisis are having a significant impact on the
lives of people all over the world. It is vital thatgovernments and health officials ensure that humanrights are part of this response. In particular, they mustensure that the rights of people from marginalized
communities—those who are most likely to see theirlivelihoods evaporate, their healthcare needs gooverlooked, and their lives upended during a crisis—are
top priority.10 All preparedness and response plans must
be inclusive of and accessible to all persons withdisabilities, including women and girls with disabilities. 9
Children and adults with disabilities should be enabled toparticipate in decision making and their treatment andwhen required they should be supported to communicate
their needs while under treatment.11
Governments should take urgent steps to move people
with disabilities (who can be moved safely) out of closed
institutions and similar settings and stop new admissions.

378

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

Children with disabilities in residential institutions
should be reunited with families, wherever possible.
Governments should provide adults with disabilities withsocial support and services to live in the community.
Inside institutions, authorities should follow strict
hygiene and physical distancing and should develop
visitor policies that balance the protection of residents
and staff with needs for family and connection. With
policies requiring social isolating to stem the spread ofcoronavirus, people with psychosocial disabilities, such as
anxiety or depression, may be in particular distress andmay benefit from additional mental health support
services. Indeed, self-isolation and quarantine could be
distressing for most people in general.
Government policies should ensure community-based
services continue and crisis counseling programs areaccessible to all. Disruption of community-based services
should not result in the institutionalization of people withdisabilities and older people.1 All service providers mustensure that people with disabilities are not left behindduring the COVID-19 outbreak and that they are treatedwith respect, dignity and without discrimination. Specificactions must be taken by various groups to ensure thatpeople with disability have equal access to information,
healthcare services and the support they need to stayhealthy and safe.12 We must ensure that telehealth visits
are accessible to patients with vision or hearing loss orother disabilities in order to maintain equity in healthcaredelivery. If accessibility is prioritized as we make thischange, a transition to telehealth could open the door to amore accessible healthcare system.7 Ensure persons withdisabilities receive information about infection mitigatingtips, public restriction plans, and the services are offeredin a diversity of accessible formats, including easy to read
format, high contrast print and, where possible, braille,
along with the use of available technologies such as
subtitles in verbal messaging.9
Conclusion
With the spread of COVID-19, it is vital that everyone,
including people with disability follow basic measures toprotect themselves and others from becoming ill with thevirus. Equally as important is social distancing and selfisolation that can be difficult for some people withdisability.12 Ensure access for persons with disabilities toessential services and protection on an equal basis withothers.9 Persons with disabilities, through theirrepresentative organizations, are the ones who can better
advise the political authorities to include the disability
dimension in the prevention, mitigation and monitoringplans related to this disease.2 The issues of pre-pandemiccare delivery only become more urgent in a time of crisis
because people with disabilities have often been
considered in a disaster or pandemic planning. We needto learn from this crisis and ensure disability in part of
future pandemic planning.
Many people with disabilities are at high risk of
COVID-19, but their perspective is not being included inefforts to address inequities in the response. This includes
understanding the unique challenges of this community
during this crisis. COVID-19 has elevated thatconversation, and the legacy should be a continued focus
on disability disparities and constant efforts to address
disability inequities. As we all make substantial changes

in our daily lives, such as working from home andadjusting how we connect to others, look to people withdisabilities for guidance, as we have always usedalternative strategies. We must look forward that COVID19 will lead us to better understanding of inclusion andbringing an opportunity to the disability community.13

References
1. https://www.hrw.org/news/2020/03/26/protect-rights-peopledisabilities-during-covid-19
2. https://bridgingthegap-project.eu/the-impact-of-covid-19-onpeople-with-disabilities/
3. https://time.com/5826098/coronavirus-people-with-disabilities/
4. https://www.ohchr.org/Documents/Issues/Disability/COVID19_an
d_The_Rights_of_Persons_with_Disabilities.pdf
5. Help Age Protecting older people in the coronavirus (COVID19)(2020)
6. https://www.un.org/development/desa/disabilities/covid-19.html
7. https://hub.jhu.edu/2020/04/23/how-covid-19-affects-peoplewith-disabilities/
8. http://www.emro.who.int/violence-injuries-disabilities/violenceinfocus/considerations-for-people-with-disability-during-covid19.html
9. TowardaDisability-Inclusive
COVID19
Response:
10
recommendations from the International Disability Alliance,
International Disability Alliance (IDA). (2020)
10. https://docs.google.com/forms/d/e/1FAIpQLSdgrf14DRGtDam8
hkL6spXTxBkAXl5IijAcF58mMWcbAuImzg/formResponse
11.nws_disability-inclusive_covid-19_response__twg_on_inclusion_guidance_note_-april_2020
12.http://www.emro.who.int/violence-injuries-disabilities/violenceinfocus/considerations-for-people-with-disability-during-covid19.html
13. https://hub.jhu.edu/2020/04/23/how-covid-19-affects-peoplewith-disabilities/

COVID-19 and mental health: government
response and appropriate measures-Genevieve Bandares-Paulino
Dean, Law School, Cor Jesu College, Philippines
atty.paulino@gmail.com-Randy A. Tudy
Director, Research and Publication Office, Cor Jesu
College, Philippines
randytudy@cjc.edu.phAbstract

As governments around the world imposed lockdowns or stayat-home measures, people began to feel the stress as time
dragged on. There were already reports on some individuals
committing suicide. How do governments respond to such aphenomenon? Our main focus is the Philippine government andhow it responded to the COVID-19 pandemic. In this paper, we
argue that the problem with COVID-19 went forth just dealing
with physical health. First, people suffer not just from being
infected but the psychological stress of possibly getting the virus
and the toll of the government lockdown or quarantine. Second,
the Philippine Bayanihan ‘We Heal As One Act’ lacks focus on
mental health issues while the government's response seemed
to focus on security issues. Third, there are countries around theworld that have acted effectively in protecting people’s mental
health. Lastly, we propose appropriate measures to help address
the people's mental health while still in the pandemic and for a
future one.

Introduction
COVID-19 has brought so many problems both forindividuals and governments. These problems could leadEubios Journal of Asian and International Bioethics 30(7) (September 2020)
into enduring health problems, isolation, and stigma(Torales, O’Higgins, Castaldelli-Maia & Ventriglio, 2020).
However, it seems that most of the news nowadays centeron one thing: national security. In the Philippines, themilitary is actively involved in the fight against the COVID19 pandemic. With the nationwide imposition ofcommunity quarantine in different levels such as General
Community Quarantine (GCQ), Enhanced Community
Quarantine (ECQ), and Modified General Community
Quarantine (MGCQ), the military and the police are in theforefront of implementing it. There were also criticismson the composition of the Inter-Agency Task Force (IATF),
a body responsible for the country's response to thepandemic. Some people were critical of the absence ofexperts in the medical field, except the chairman who is
the Secretary of the Department of Health (DOH), a doctor
by profession; others were retired military personnel.
While the military and the police must be involved, somepeople questioned if other aspects of this pandemic crisis
are taken care of. One of these is the mental health of thepeople.
In this paper, we present the scenario of mental healthsituation as reported. We argue how important thisproblem has to be addressed just like other health-related
concerns. We also point out the lack of government
response about the people's psychological and mental
needs, particularly during the prolonged lockdown orquarantine, the term used by the Philippines. Moreover,
we also identify measures that cater to mental health intimes of a pandemic. This paper addresses the gap of
having a comprehensive plan in fighting against the
COVID-19 pandemic. It also contributes to the body ofknowledge on the importance of mental health and how
governments must include it in the whole spectrum of
healthcare.
COVID-19 and mental health
The devastating effect of COVID-19 was not just death due
to complications. People suffered mental problems.
Staying at home and the fear of death took a toll for some.
For example, preventing people’s mobility caused
distress and loneliness among Indians and led to suicides(Dsouza, Quadros, Hyderabadwala & Mamun, 2020). In areview of literature of articled published related to
COVID-19 pandemic, Rajkumar (2020) found anxiety,depression, and stress as the most common psychologicalreactions. In Pakistan, reports suggested that the cause ofsuicides in the country was mainly due to lockdown
related economic recession (Mamun & Ullahm, 2020). In
Bangladesh, a man committed suicide because of pressure
from villagers who suspected him of having the virus
despite no diagnosis (Mamun & Griffiths, 2020).
Despite being known for their resilience in times ofdisaster or crisis, Filipinos did not escape from thepsychological battle. There were reports of Filipinos who
committed suicide like the case of a Filipina mariner who
took her own life inside her cabin while waiting forrepatriation back to the Philippines (Ramos, 2020). In
Lebanon, a Filipina domestic helper took her life while atthe shelter run by the Philippine embassy (Agence
France-Presse Reuters, 2020). A 34 year-old in Occidental
Mindoro, Philippines, diagnosed with Dengue Fever,379

thought himself of having the COVID-19 virus, andcommitted suicide. He also wrote a note to his wife toquarantine herself, although the wife did not show any
symptoms (Delos Reyes, 2020). There were otherunconfirmed reports both in the Philippines and abroad
who succumbed to the same fate. These reports were very
alarming. People and the government should realize thatmental health is as important as other health-related
problems.
COVID-19 and national security
We pointed earlier that national security seemed to takea priority stance in the Philippines in dealing with the
pandemic. When one speaks of the Philippine National
Security Laws, they actually refer to the following: (a)Philippine Constitution; (b) Laws enacted by Congresssuch as the Revised Penal Code and the relatively newlaws, the RA 10173 otherwise known as the Data Privacy
Act of 2012, RA 10175 or the Cybercrime Prevention Act
of 2012, the RA 11036 or the Philippine Mental HealthAct. Also included are the anti-terrorism laws, namely: RA
9372 or the Human Security Act and RA 10168 or the
Terrorism Financing Prevention and Suspension Act of
2012; (c) Executive issuances; (d) Jurisprudence; and (e)International treaties.
National security is defined as a “state or condition
wherein the people’s welfare, well-being, ways of life,
government and its institutions, territorial integrity andsovereignty and core values are enhanced and protected”(2011-2016 National Security Policy, Securing the Gainsof Democracy). Based on the definition of national
security, it is correct to say that almost all laws of thePhilippines are national security laws. Laws that enhanceand protect the people's welfare, well-being, ways of life,
government and institutions, territorial integrity andsovereignty, and core values are national security laws.
But there is a need to amend the present national security
laws to be truly responsive to the needs of the people andof the times, especially during a pandemic.
Experiences may show that the present national
security laws are insufficient to address the situations andproblems that threaten national security. The current
national security laws may be inadequate to address theconditions and issues that threaten national security. The
Marawi Siege, the Yolanda and Pablo typhoons, and the
Mindanao major earthquakes, and now the COVID-19
pandemic only reveal the inadequacies of the Philippine
laws in response to both man-made and naturalcalamities. For example, RA 10121 or the Philippine
Disaster Risk Reduction and Management Act or law
which was enacted to (a) strengthen the Philippine
Disaster Risk Reduction and Management System; (b) to
support national disaster risk reduction and management
framework and; and (c) to institutionalize the National
Disaster Risk Reduction and Management Plan do noteven contain a specific provision on the mental health ofsurvivors of these natural or man-made calamities. The
mental health of the internally displaced persons brought
about by these disasters is not prioritized.
Philippine Government and the Bayanihan ‘to Heal as
One Act’. On March 20, 2020 Republic Act No. 11469,

380

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

otherwise known as the Bayanihan to Heal as One Act,
also known as the Bayanihan Act, was enacted to grant the
President of the Philippines additional authority tocombat the COVID-19 pandemic in the Philippines. A
cursory reading of the law shows that the law provides
the President with the power to implement temporary
emergency measures to respond to the crisis brought
about by COVID-19, such as but not limited to thefollowing:• adopting and implementing measures, which are basedon World Health Organization guidelines and bestpractices, to prevent or suppress further transmission
and spread of COVID-19 through education, detection,
protection and treatment;• hastening the accreditation of testing kits;• providing an emergency subsidy amounting to five toeight thousand pesos to low income households basedon prevailing regional minimum wage rates;• providing all public health workers with "COVID-19
special risk allowance";• directing the Philippine Health Insurance Corporation
to shoulder all medical expenses of public and private
health workers related to exposure to COVID-19 or any
work-related injury or disease during the pandemic
emergency;• enforcing measures against hoarding, profiteering,
injurious speculations, manipulation of prices, productdeceptions, cartels, monopolies or other combinations
to restraint trade or affect the supply, distribution, andmovement of food, clothing, hygiene and sanitation
products, medicine and medical supplies, fuel,fertilizers, chemicals, building materials, implements,
machinery equipment and spare parts for agriculture,industry and other essential services;• ensuring that donation, acceptance, and distribution ofhealth products for COVID-19 public health emergency
are not unnecessarily delayed;• ensuring the availability of credit especially in the
countryside by lowering the effective lending rates ofinterest and reserve requirements of lending
institutions;• liberalizing the grant of incentives for the manufacture
or importation of critical or needed equipment or
supplies for carrying out the policy of this law provided
that importation shall be exempt from import duties,
taxes and other fees;• ensuring the availability of essential goods by adopting
necessary measures to facilitate and minimize
disruption to the supply chain;• moving statutory deadlines and timelines for filing andsubmission of any document, payment of taxes, fees andother charges required by law;
• directing all private and public banks, quasi-banks,financing companies, lending companies, and otherfinancial institutions, including the Government Service
Insurance System, Social Security System and Pag-ibig
Fund to implement a grace period of 30 days, minimum,
for the payment of all loans falling due within theenhanced community quarantine without interests,
penalties, fees or other charges;• Provide a minimum of 30 days grace period on
residential rents falling due within the period of theenhanced community quarantine without interest,
penalties, fees and other charges;
The word "bayanihan" is a Filipino word whichmeans communal work; the spirit of communal unity andcooperation. Like other laws that aim to respond tonatural and man-made disasters much focus is given to
rehabilitation of infrastructure and the reestablishmentof the livelihood of the people, but there is no specificprovision on how to help survivors cope with the trauma
and to deal with post-traumatic stress disorder.
Lawmakers are so much into rebuilding bridges, roads,
and buildings, and reenergizing the economy but forget toaddress the "invisible wounds" of the victims. In responseto the COVID-19 pandemic, the Bayanihan We Heal as One
Act, a law enacted in response to the pandemic, did notcontain a provision to address the people's mental health.
It is focused much on the economic and medical aspects,
the effects of which are visible to the naked eye. But
mental health is as important as physical health. The
invisible wounds need addressing as well. The failure toprioritize the treatment of the invisible wounds has led todeath by suicide. Hence, this law, while addressing theconcerns of the pandemic, lacks the specific inclusion ofmental health issues.
Notable responses on mental health during COVID-19
pandemic
The COVID-19 pandemic, as we mentioned earlier, is not
only about physical health. It is also about mental health.
While most of the countries focused on the former, there
were notable responses that included mental health, or atleast led to mental healthcare. In China, a 24-hour online
psychological counselling was offered using online
platforms like WeChat. It was done by mental healthprofessionals coming from medical institutions,
universities, and medical societies (Liu et al., 2020). The
Chinese availed of these services, mainly because thesewere very accessible using their personal gadgets andalso because they needed help.
Germany reaped the benefits of its earlier promotionof digital solutions for healthcare services. As the country
quickly responded to the pandemic, Health Innovation
became one of the most important sources of information
as it listed different trusted telemedicine services, forexample, the Corona-Bot, an application that provides
online chatting services. According to the chairman of
Health Innovation Hub, Corona-Bot allowed patients toaccess relevant information and get advice from experts(Olesch, 2020). They were also protected from fake-news,
which could lead to panic and psychological stress as
experienced by many people around the world.
Vietnam was credited for its effective strategy. No lessthan the WHO praised Vietnam’s response to thepandemic. The Vietnamese did not experience panic,
generally speaking, because of how the government
handled the situation. It was able to get the cooperationof the people, civil society, and government (La et al.
2020). Specifically, the government was able to gain the
support of media in spreading accurate information,
which made the people updated, felt secured, andconfident.

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
New Zealand is a classic example of how people were
helped to feel at ease, at least during the pandemic,
because of the swift response of the government like
lockdown and the timely information they got from thegovernment. For example, the prime minister was seenusing different media platforms, including Facebook Live,explaining the government’s move and how people
should cooperate (Bremmer, 2020).
Appropriate measures towards mental healthIn times of pandemic, mental health should be part of the
programs and services. First and foremost, there shouldbe education and training among the respondents, andgovernment health officials on how to deal withpsychological issues brought about by the pandemic andthe measures by the government on addressing it(Pfefferbaum & North, 2020). These people are crucial in
the fight against the pandemic, but if they are not wellinformed about the issues related to mental health, theiractions are inadequate to serve the overall need of thepeople. There is also a need to debunk the myth of COVID19 because it can also lead to distress (Kar, Arafat, Kabir,
Sharma, & Saxena, 2020). One of these is downplaying the
pandemic's negative effect, especially on thepsychological and mental stress it causes. Thus, theknowledge and wisdom should start from responsible
persons and agencies to be cascaded to ordinary citizens.
Second, mental health should be part of the whole
healthcare services during a pandemic. For example,
mental health experts should be part of the available
personnel in hospitals. For instance, in China, mental
health professionals were stationed in hospitals andavailable for on-site services (Li et al., 2020). In the
Bayanihan We Heal as One Act, there was no clear
stipulation as regards to mental health. It appeared to beneglected or not seen as a priority at all. Fiorillo andGorwood (2020) proposed five important things toaddress mental problems: (1) limit the source of stress,(2) break the isolation, (3) maintain usual rhythm, (4)focus on the benefits of isolation, and (5) ask for
professional help. Of the five, it is the last one that needs
government support. First, the government provides
education on the needs, accessibility, and benefits ofreceiving such help. Second, assistance must be given to
the people in receiving this kind of help. Third, thegovernment promotes the training and professional
education of mental professionals and experts.
In the Philippines, the government shall allocate abudget to make its National Mental Health Crisis Hotline
working and not merely a program. In its advertisement,
the NCMH is supposed to be a 24/7 mental health crisis
phone service established by the Department of Health.
However, there are various complaints that it is not
functional as there is no one to answer calls. This hotline
must be operational, and its existence made known to the
public.
Third, the government should act fast. There is a needfor early intervention to avoid the consequence of mental
illness caused by isolation (Galea, Merchant, & Lurie,2020). Learning from the lesson of the recent pandemic,
the government must be proactive rather than reactive. It

381should include planning for the inevitable effects toloneliness and depression.
Fourth, as effectively done by the mentioned
countries, the government must have an accurate anddependable information dissemination system. Without
proper information, people tend to panic. In the world of
the Internet, so much false information or fake news areproliferated, even during the pandemic. The government
must ensure that people get the right information.
Conclusion
The COVID-19 pandemic is not just a physical healthproblem. It is also a mental problem as evidenced by theeffects to people due to stress brought about by themeasures imposed by the government, particularly
lockdowns. Lessons have been learned, and these include
the specific and deliberate inclusion of mental health in
the whole healthcare program and systems. More
importantly, the government needs to expand its
education and training of front-liners, health officials, andpolicymakers on how to respond to people's
psychological and mental health needs during apandemic. Mental health should be part of the whole
healthcare program and systems. The government mustbe fast in responding, providing early intervention, andusing media platforms to provide accurate and reliable
information to the people. All these measures are crucial
to keeping the mental health of the people during apandemic.
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https://doi.org/10.1177/0020764020915212

Challenges for organ recipients and elderly
persons during the COVID-19 Pandemic-Maria-Keiko Yasuoka, PhD.
Visiting researcher, Graduate School of Health Sciences,
Hokkaido University, Japan
Email: mkya11@let.hokudai.ac.jp

Abstract

All patients and persons with immune health problems require
greater care, in clinical and public health practices, because
infectious diseases such as COVID-19, attack their immune
system. The risk to be a victim increases many-fold compared tohealthy people. Because of increased morbidity and mortality,
they face anxiety of uncertainty every day. In this paper I focus
on informants who are organ recipients and candidates who arein the waiting list, and elderly persons who are in elderly homes
which are associated with current Japan’s rapidly super-aging
society. I argue that during the pandemic period, thegovernment has been struggling how to protect Japanesepeople’s health but not enough for immune-compromised
patients and elderly persons.
Organ recipients have to take immunosuppressant drugs to
avoid rejection of transplanted organs every day, so their bodies
are always immunologically compromised. Organ recipients
have to avoid all kinds of infectious diseases with protective
vaccinations, avoiding raw food, wearing masks, avoiding
people, the cold and dry environment and so on. Among organ
recipient candidates, those waiting for a kidney are dialysis
patients, and their number two killer is infectious disease.
Another high risk group are elderly persons, especially those
who stay in elderly homes. Elderly people whose immune
system is weakened are at risk of care home acquired infections
by residents, caregivers, official visitors and family members. In
the pandemic, most administrators prohibit to bring foods andrefuse all visitors (including families), however, elderly persons’
loss of motor function with being physically separated from theoutside world can produce bedfast elderly people, who progress
to dementia related to isolation, poor communication and social
connections.

Introduction
In Japan, COVID-19 pandemic started in Sapporo city, in
the Northern part of Japan and my hometown, where I live

now. Sapporo is international big city with a population of
two million and it is famous for Snow Festival and WinterOlympics. Sapporo is a sightseeing town and has atourism-based economy. So not only Japanese but also
many foreign tourists visit, especially in winter-time
many foreign skiers stay and sightseeing visitors comefrom all over the world. During “Sapporo Snow Festival
time which is held the same period of Lunar New Yearduring February 4 to 11 every year. Many people from
Wuhan (China) came to Sapporo and the 1st wave (Wuhantype) official pandemic had started in Sapporo and there
was a “Declaration of a state of emergency” from February
28 to March 19. After March 2020 the pandemic spread allover Japan. The official pandemic “Declaration of a stateof emergency has been started all over Japan on April 7
until May 6, 2020. Sapporo started the 2nd wave of
pandemic and the Sapporo governor declared anotherstate of emergency from April 12 until end of May. The
second wave is said to have been from the European type.
As a result, many Japanese had to “Stay Home” for various
periods (Scott 2020).
Broader implications of the stay at home policy:
Emergency Level 3 (20 April – 31 May 2020)
COVID-19 pandemic spread in Japan and we arethreatened by not only health problems but also an
economic recession. Sapporo’s economic situation
become “Business level 3” from 20 April to 31 May. We
have to “stay home” except hospitals and grocery stores.
Also we stay home to 80% reduce to meet others in public
and avoid three “Mitsu” (close), (1) closed spaces, (2)crowded places, (3) close-contact setting, and thegovernment calls for “Zero Mitsu” (close) for all persons
who live in Japan. For example, Hokkaido University (myuniversity) has been closed except for the hospital andsome laboratories which keep animals or having specificreasons, and we have to work at home except professors
who have private rooms. At the start of the new school
year on 1st April no students had live classes and partiallye-learning was provided. Gradually professors preparedonline classes, but there was cancelation of practicaleducation. For many part-time lecturers and otherworkers across Japan there is no work so no payment. It
has been reported that overall 20% of Japanese students
have to give up their universities because their parents
have reduced or no salary, and most student’s lost theirpart-time jobs. As a result, they cannot pay university fees.
The “Stay home” policy is not only losing jobs but also
depriving students’ education opportunity, hope andfuture.
High risk persons and Patients with immunologicalhealth problems
During the pandemic time three categories of persons
who are at high risk include Immunosuppressant andanticancer drug users; Patients with diabetes, heart
failure, breathing problems and dialysis patients; andElderly people. These three categories of people havesome immunological system problems due to diseases or
aging. Immunosuppressant users include organ
recipients (bone marrow, hearts, kidneys and livers etc.)
to avoid both acute rejection and chronic rejection. Also,these drugs are used as treatment for autoimmune
disease patients and those with autoimmune disorders

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
such as articular rheumatism, myasthenia gravis,
systemic lupus erythematosus, Crohn's disease andulcerative colitis. In addition, inflammatory diseases suchas allergic asthma. These patients are long-term
immunosuppressant users.
Anticancer drug users suppress bone marrow function
and decrease the number of white blood cells and reduce
the ability of white blood cells to fight infection. Diabetes,
heart failure, breathing problem and dialysis patients
have increased susceptibility to infection. Diabetes
patients have high blood sugar, heart failure patients havehigh risk to be susceptible to pneumonia, breathingproblem patients always face a danger from infectious
diseases and for dialysis patients’ one of three majordiseases which are life-threatening complications is
infection. Elderly people have weaker immune systems
than when they were young due to aging naturally.
Organ recipients as immunosuppressant users have totake immunosuppressant drugs every day to avoid
rejection of the transplanted organs. Many people
misunderstand about organ recipient that recipients canget “rose-colored life” with a donated organ (Caplan and
Coelho 1999). Actually, organ recipients can have asecond life with donated organ but it also starts a battlewith organ rejection, so they have to take
immunosuppressant drugs forever (Lock 2002).
Dialysis patients who are mostly kidney organ recipient
candidates (Himmelfarb and Ikizler 2018), are waiting fororgan donation with dialysis to survive for up to a coupleof decades or more (three decades or four decades(Cooper and Cooper, 2014). They commute dialysis withwaiting for organ donation, also dreaming about the life
without dialysis treatment (Yasuoka 2015). Because
dialysis is an artificial kidney and wash their blood bymedical machine, it harms patients’ blood vessels withsuffering life-threatening damage (Offer 2007).
Elderly persons who live in elderly homes have beenbattling with various strategies to protect elderly persons
from clusters of COVID-19 (Matusmoto 2011).
Immunosuppressant Users
Organ recipients’ daily life is tough than we imagine,
because organ rejection is the biggest barrier for themafter transplant of organs. Just after operation, they haveto overcome acute organ rejection with strong
immunosuppressant medical care. After survival, organ
recipients have to avoid chronic organ rejection withimmunosuppressant drugs every day until rejection oforgan or death of transplanted organ itself (this meansthat recipient’s death or re-transplant). Thanks to theimmunosuppressant drug cyclosporin, organ recipients
can survive, and many kinds of immunosuppressantdrugs have been discovered to save recipients’ lives.
However, human beings cannot avoid chronic organ
rejection as a normal reaction by the human body, it has
been occurring five years’ after of organ transplant on
average (great individual variation among recipients). So
immunosuppressant drug postpones rejection of thetransplanted organ from recipients, however they cansurvive several years in average. In addition,
immunosuppressant drugs have severe side effects andorgan receiver’s body is always in an immunological383

disorder situation. It means that organ recipients(immunosuppressant drug users) have high risk ofinfection (Yasuoka 2019).
Organ recipients always protect themselves from
infection through protective vaccinations, prohibit orrecommend not to eat raw food (it depends on kinds oftransplanted organs), wearing masks, avoiding crowded
places, the cold and dry environment and so on. Most oforgan recipients feel what else do we need to do more in
COVID-19 pandemic?
In spite of organ recipients’ daily life in the fight against
infectious disease, most organ recipients feel anxiety
about their safe life and they don’t know what they should
do and how to protect their body during COVID-19
pandemic as a matter of life or death. According to therecipients’ association (Japan Transplant Recipients
Organization website 2020), their safeguard against the
COVID-19 are to strengthened daily protection against
infection, warm themselves (bodies), and “In the case, if
doubt exists, call your doctor, if you have something”.
Many feel that “Is there something new as a strategy?”
These are within the bounds of common sense. Most
organ recipients know about them and they are practicing
in their daily life already. They expect more informationand feel that they need more revolutionary ideas or
strategies for COVID-19 pandemic (Loupy, Aubert, Reese,
Bastien, Bayer, Jacquelinet 2020).
“Please watch my heart transplanted friend’s video…Iwould like to talk about COVID-19 which creates disorderin society now. There are not only weakened immune
system elderly people but also internal disability persons
such as organ recipients whom people can’t be recognizedby appearance. I’m also used to be a kidney recipient and
now dialysis patient. Our immune system are weaken andother physical functions are poor due to dialysis caused
kidney failure. Please for your cooperation such as wearing
mask or stay home.” (narrated by a kidney recipient andhe shared us a heart recipients’ video by facebook).
<https://www.facebook.com/profile.php?id=10000959
5178034&fref=hovercard&hc_location=chat>
Organ Recipients’ Stress
Many organ recipients feel stress during the COVID-19
pandemic strongly because they usually have a risk ofinfection, so they pay attention avoiding infectious
diseases carefully in their daily life. What is worse, there
is no particular strategies to avoid COVID-19 for organ
recipients. However, it is obvious that organ recipientsare high risk people, so their stress and anxiety have been
increasing day by day. A survey found organ recipients’stress levels were high: no stress (6%); a little stress(10%); stress (27%); very stressed (39%); very strong
stress (18%) (Resource: Japan Transplant Recipients
Organization website 2020).
In total 94% of organ recipients feel stress, especially
57% of organ recipients feel strong stress/very strong
stress. During COVID-19 pandemic, organ recipients areforced to live a very stressful daily life. Ironically, stressdecreases organ recipients’ immunological capacity, so
this situation leads to a vicious cycle for them. During
COVID-19 pandemic time, it is so stressful for everyone,
however, pandemic stress brings about death to organ384

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

recipients. The Japan Society for Transplantation (TheJapan Society for Transplantation website 2020)encourages organ recipients’ health care, however, it isnecessary for organ recipients to come up with much
more specific measures.
Dialysis Patients
Dialysis patients are also forced into very tough days
too. Before 1980, most kidney failure patients depended
on dialysis to survive, in other words, dialysis was thelast-ditch effort at survival. But now, dialysis becomes a
bridge medical treatment to wait for organ donation.
Kidney organ recipient candidates are actually kidney
failure patients and they cannot live without dialysis
every another day (3 days/week). Dialysis patients have
weakened immune system due to long term dialysis
therapy, because there are a few organ donations in Japan.
Dialysis have various complications and patients arebattling with dialysis disequilibrium syndrome, bloodpressure variation, bleeding tendency, shunt troubles andcomplications
causedbylong-term
dialysis.
Re(re)transplant candidates are used to being a dialysis
patients and they were lucky enough to be able to receivea donated organ and became an organ recipients once (ortwice).
Several years after the first transplant, unfortunately(or naturally), they faced transplanted organ’s chronic
rejection and remove the rejected organ out of their bodyand these patients also have a compromised immune
system due to taking immunosuppressant drugs over an
extended period of time. After chronic organ rejection,
they have to be back to dialysis again and wait for anotherorgan donation, that is, “retransplant”. Most of kidneyorgan recipients have to repeat this course with fighting
side effects and complications to their last breath. In
addition, thanks to recent medical advance, re-retransplant is available now. Kidney organ recipient
candidates have to repeat dialysis patients andimmunosuppressant drug user patients forever. As aresult, their immune system gets weakened (Kliger,
Cozzolino, Jha, Harbert, Ikizler, 2020).
Another high risk for dialysis patients is their dialysis
facilities problem and it is possible to spark COVID-19
clusters inside dialysis hospitals/facilities. Because
dialysis treatment is provided for the patients in a large
room where many patients have to lie still in their bed for
four hours per day and three days per week. Such a longtime, they have to spend together sharing one room. It ishigh risk for a COVID-19 cluster for the dialysis patientsduring receiving dialysis treatment. In addition,
considering commuting dialysis hospital/facility every
other day is also high risk for patients. It is impossible forthem to “Stay Home” and there are uncountable chancesand risks to catch the COVID-19 more than healthy people
to survive with dialysis therapy. Because dialysis is mass
treatment generally, so Japanese Association of Dialysis
Physicians (Japanese Association of Dialysis Physicians2020) demands special attention for all dialysis
hospitals/facilities. Fortunately, there are no COVID-19
clusters in dialysis hospitals/facilities yet (updated
2020/04/14). Another reason that dialysis patients arehigh risk persons in during COVID-19 pandemic is highrisk people need dialysis therapy. About 50% dialysis
patients have diabetes, who are potentially severe against

COVID-19. Also dialysis users are 70 years old in averageand two third patients are over 65 years old, so they arealso high risk elderly people too.
Dialysis Treatment
There are two kinds of dialysis (blood dialysis andperitoneal dialysis), however most of patients depend on
blood dialysis now. The three major cause of death of
dialysis patients are ①heart failure, ②infection,③cancer. The major infectious diseases which dialysis
patients are susceptible to pneumonia, shunt infection
and urinary tract infectious disease (Refer to an example
picture:https://www.jinlab.jp/basic/img/thumbnail/other_3dis
aster_2ontime.jpg).
The particular factors predisposing to infection of dialysis
patients are low nutrient conditions due to dietary
restriction and nutrition leakage with dialysis, stagnating
urine (decreased urine output and anuria), and infectionof internal shunt.
There are 334,505 dialysis patients in Japan, and they
have increased about 5,000 since 2019 (Japanese Society
for Dialysis Therapy website 2020) and their crude death
rate is 10.1%. In spite of their careful daily activities, a
blood dialysis patient developed COVID-19 in Tokyo on
25 March, 2020. Then the Japanese Society for Dialysis
Therapy released an announcement for medical staffs toprotect COVID-19 cluster in dialysis hospitals/facilities.
They called for: “Make a thorough distinction droplet
infection and contact infection precaution additionally,
with standard precaution. Direct measurement of bodytemperature of dialysis patients every day and grasp thehealth condition of them. Guidance to dialysis patients, inthe case patients have a fever over 37.5℃ or breathingproblems, they have to make a phone communication
before visiting dialysis facilities etc.”
All dialysis
hospitals/facilities have been trying to do the best to
avoid COVID-19 clusters every day.
Elderly People and Elderly Homes
Elderly people also have a high risk to be associated withsevere infectious disease, and the elderly care system isn’t
equipped to cope with COVID-19 pandemic in Japan, as a
rapid super-aging society (Backhaus 2017). Especially,elderly homes face COVID-19 clusters and actually theoutbreak of the COVID-19 clusters in elderly homes has
been announced every week. As of April 2020 about 550
elderly persons who live in elderly homes caught COVID19, and 60 person died. It means that about 10% elderly
persons passed away due to COVID-19 cluster until theend of April. Specialists pointed out “there is a danger that
there will be more and more infected elderly persons andthe death in elderly homes in Japan too”.
Personally, I’m a caregiver daughter for my mother whostays in elderly home now. My mother’s elderly home has
been struggling through various strategies since February2020 and gradually safety guards have been strict. My
mother’s elderly home’s strategies are: closed to visitors,
elderly persons cannot go out except to hospitals; elderly
persons have no recreation. However, these strategies aresafer for elderly persons, the governmental “Stay Home”
Policy risks decline in elderly person’s motor function
while being physically separated from the outside worldEubios Journal of Asian and International Bioethics 30(7) (September 2020)and producing bedfast elderly people seriously (Lock2013).
According to NHK (Japan Broadcasting Corporation
website 2020), 26 COVID-19 clusters broke out in Japanby 31 March 2020, and they have been increasing day byday (See: (https://www.minnanokaigo.com/news/
yamamoto/lesson38/)). The cause may be families bringsome change of clothes, and full-time caregivers assist
changing of clothes for them. Not only elderly persons but
also caregiver staff catch infections too. There are many
chances to touch a potential route of infection for
caregiver staffs to assist elderly persons such as meals,
recreations, baths and toileting (and disposal). The
elderly homes who got infection clusters have a highmortality rate, 8.0% of those aged 70-79 years, and 14.8%
for those aged 80 years and above (Data fromhttps://www.mhlw.go.jp/english/index.html, Ministry of
Health, Labour and Welfare website 2020). In addition,elderly persons have tendency to quickly become severe
after infection of coronavirus and progress to death.
It is also easy for elderly persons to spread infection
from one elderly person to other elderly persons rightaway. Once COVID-19 cluster happens at an elderly home,
it has to temporary close as soon as possible to protect
other residents inside the elderly home. Personally, I’m acaregiver for my mother, and she lives in an elderly home
now and I always visit my mother with her favourite
sweets every Saturday regularly.
However, when I
visited her just before leaving for the US in February, herelderly home prohibited all foods from outsiders. On 28
February, the Sapporo (Hokkaido) governor had started
the first “Declaration of state of emergency”, I learned it
during the conference in the USA. When I came back to
Sapporo and I wanted to see my mother, her elderly homeprohibited all outsiders visit even family members,
especially overseas travellers like me. So I couldn’t giveher favourite Ghirardelli chocolates yet and she missed
me so much. Exceptionally, I can meet my mother, only
when I take her to hospital, so I made a strategy as acaregiver daughter for my mother to reduce her isolation,
keep physical ability and protect her dementia stable toadjust her elderly homes’ strategies for COVID-19 cluster.

Figure 1: Pepper the robot(http://eijyukai-akiyamaen.jp/post/wp-content/
uploads /H28.8pepper①.jpg)385

My strategies as a caregiver to avoid COVID-19 cluster
are to call my mother in elderly home every Saturday, totake her to hospital every time, to bring her favourite
sweets/drinks on hospital day and have together. I also
take my laptop and show her picture. The “Stay Home”
policy for elderly people may progress dementia, which isrelated to isolation, poor communication and social
connections.
No Infection Risk Caregiver; Ai Robot (Pepper)
There are many high risk people in the world during the
COVID-19 pandemic. We have to prepare not only the firstwave of COVID-19 pandemic but also the second wave,
and the third wave, and ever further until we will be able
to prevent COVID-19 infection with a vaccine. However,nobody knows when. We also think about other ways
which protect us from COVID-19 in parallel to vaccine
development. Taking advantage of the COVID-19
pandemic, use of AI robots have been accelerating (Figure
1)
AI robots attract attention from all over the world,
because they can perform various works such as
disinfection and cleaning, delivery service andconversation. It is benefit for us to prevent the spread of
infection and decrease person-to-person contacts.
Actually, there are already some robots which are
working in hospitals for patients and in elderly homes inJapan.
Conclusions
The COVID-19 pandemic has revealed various high risk
people and things in our daily life, and they are much
more diverse than I imagined. In this paper, I focused on
three categories of people: organ recipients, dialysis
patients and elderly persons who are at high risk for
infection, however, there are so many other high risk
persons and things around them in their reality worlds.
Organ recipients (immunosuppressant users) who arealways in a fight against infectious diseases, face strong
threat and stress during pandemic. Dialysis Patients(mostly kidney recipient candidates and in waiting lists)are constantly threatened with infection, and commute todialysis hospitals three days per week to survive. Elderly
persons (residents in elderly homes) have high risk of
bedfast and dementia due to less physical activities andlack of communication.
These people are all battling with stress, fear andisolation. Also we have to pay attention to various
caregivers who provide round-the-clock care for patientsand elderly people in hospitals and elderly homes allaround the world. Although COVID-19 has been making
our daily life chaotic and many people have been forced
into having a hard life, we can feel human love by various
kinds of caregivers who work for others, that is, “Love oflife”. It is necessary to conduct more bioethical researchconcerning issues facing people at high risk for infectionof coronavirus during COVID-19 pandemic time.

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References
Backhaus, P. (2017), Care Communication: Making a home in a Japaneseeldercare facility (London: Routledge)
Caplan, A., and Coelho, D. (1999), The Ethics of Organ Transplants: The
Current Debate (Contemporary Issues) (Buffalo, N.Y.: Prometheus
Books).
Cooper, A., and Cooper, J., (2014), Staying Alive: Dialysis & Kidney
Transplant Survival Stories (London: Rossendale Books)
Himmelfarb, J., and Ikizler, T.A. (2018), Chronic Kidney Disease, Dialysis,
and Transplantation E-Book: A Companion to Brenner and Rector’s
The Kidney (Philadelphia: Elsevier)Kliger, S.A., Cozzolino, M., Jha, V., Harbert, G., Ikizler, T.A., (2020),‘Managing the COVID-19 pandemic: international comparisons in
dialysis patients’ in on behalf of the International Society ofNephrology, Elsevier Inc., 1-5.
Lock, M. (2002), Twice Dead: Organ Transplants and the Reinvention of
Death (Berkeley: University of California Press).
Lock, M. (2013), Alzheimer conundrum : entanglements of dementia andaging (Princeton : Princeton University Press).
Loupy, A., Aubert, O., Reese, P. P., Bastien, O., Bayer, F., Jacquelinet, C.,(2020) ‘Organ procurement and transplantation during the COVID19 pandemic’, in Lancet Vol 395, e95-e96.
Matusmoto, Y. (2011), Faces of aging: the lived experiences of the elderly
in Japan (Stanford: Stanford University Press).
Offer, D. (2007), Dialysis without fear: a guide to living well on dialysis forpatient and their families (New York: Oxford University Press).
Scott, K., (2020) COVID-19 FEAR, SAFEST RISK?: Your anxiety, fear andInformation is killing you before the virus (Tokyo: Amazon Services
International, Inc.).
Yasuoka, K. (2015), Organ Donation in Japan: Medical AnthropologicalStudy (Lanham Lexington: Books).
Yasuoka, K., (2019), Noushi Zokiishoku to mukiau tameni: Iryousha
Recipients Donor families heno kikitori tyousa kara (To face Brain
Death and Organ Donation: Interview Research from Medical staffs,
recipient’s donor family) (Kyoto, Japan: Koyo Shobo).

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Caregiver AI robot, <http://eijyukai-akiyamaen.jp/post/wpcontent/uploads/H28.8 ｐ ｅ ｐ ｐ ｅ ｒ ①.jpg>, accessed
29/04/2020.
2) COVID 19 corona virus spread in japan begin from Hokkaido vector
illustration<https://www.shutterstock.com/ja/imagevector/covid-19-corona-virus-spread-japan-1658883610>,
accessed 04/29/2020.
3) Japanese Association of Dialysis Physicians, Home page,<http://www.touseki-ikai.or.jp>, accessed 05/25/2020.
4) Japanese Society for Dialysis Therapy, Home page,<https://www.jsdt.or.jp/index_e.html>, accessed 05/25/2020
5) Japan Transplant Recipients Organization Home page,< http://www.jtr.ne.jp/index.html>, accessed 05/04/2020.
6) Jin Lab, <https://www.jinlab.jp/basic/other_3disaster_2ontime.
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14/04/2020
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1 The Global Burden of Diseases, Injuries and Risk Factors (GBD)

figure of 6.7 million air pollution related deaths is quoted in theeditorial of The Lancet, Lancet Neural (2018) 17: 103
2 This is reported from various studies in the UK and USA andare reviewed in Conticini et al (2020) who recognize that there is

Gasping for breath: Is air pollution or moral
blindness the unseen killer? A review- Alexander R. Waller, PhD
AUSN Visiting Professor of Environmental Ethics andEducation, Thailand
Email: arwaller1@hotmail.com
Abstract

Air pollution causes millions of deaths globally every year. The
cause is largely, but not solely, from fossil fuel combustion in theelectricity generation and transport sectors as well as various
agricultural and waste management practices. This pollution in
the form of ground level ozone, particulate matter and acidic
gases such as nitrogen oxides and sulfur dioxide causes
respiratory, cardiovascular and neurological problems inhumans. These health concerns tend to have a greater impact on
more vulnerable sectors of societies, including street vendors,
agricultural workers and school children. There is a growing
body of evidence that the pollution has equally devastating
impacts on other organisms including plants, which may harm
whole ecosystems. As humans are integral to rather thanindependent of nature, then this will have further reciprocal
effects on us. A survey of people in rural central Thailand
indicates that people are largely unaware of the main causes of
and, to some extent ambivalent of, the risks associated with air
pollution. An absence of policy to address this throughmechanisms such as taxation akin to tobacco, alcohol or the UK2017 sugar tax and compulsory environmental education
programmes could be viewed as evidence of moral blindness. In
light of some events of the Covid-19 pandemic, the importanceof developing united policies to cope with worldwide air
pollution is never been more apparent. There is good news inthat data on local air quality is becoming increasing available inuser friendly apps, which creates an opportunity to develop
participatory education programmes that could emphasise
personal responsibility, to address both the twin pandemics of
air pollution and environmental moral blindness.
Keywords: Air pollution, Global Burden of Disease, Moral
Blindness, SDGs, Participatory Education

Introduction
Air pollution-related diseases claim approaching sevenmillion lives each year 1 . Furthermore, in 2018, studies
linked air pollution to a wide range of diseases anddisabilities from millions of cases of diabetes to lower
intelligence levels. The World Health Organization (WHO)Director-General Tedros Adhanom Ghebreyesus referred
to air pollution as “the new tobacco”. The WHO has longcalled air pollution a public health emergency, attributing
7 million deaths (including 600,000 child deaths) to
exposure to unhealthy air, which 90 per cent of theworld’s population breathes, UNEP (2019). It has also been
linked to increased death rates from COVID-19 in somecountries2.
The combustion of coal causing smog in major cities like
London and vehicle emissions being the primary cause ofphotochemical smog in cities like Los Angeles has been
well documented since the middle of the last century. By
a correlation between air quality and higher death rates. They
conclude that this is likely due to air pollutants such as PM2.5, SO2
and NOx impairing defence of upper airways. They call forfurther research.

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
the end of the 20th century legislation such as the US
Ambient Air Quality Standards had identified six criteria
pollutants: PM10, ozone, nitrogen dioxide, sulfur dioxide,
carbon monoxide and lead as well as nearly a further 200
Hazardous Air Pollutants (HAPs) that need control, Turns(2006). The growing awareness of the economic impact of
air pollution has meant that combatting it has risen insustainable development agendas. For example, it wasemphasized as thematic sustainable development priority
by UNESCO member states, Wals (2009). A focused review
for the Forum of International Respiratory Societies
Environmental Committee by Schraufnagel et al (2019)concludes that:“Air pollution is largely an avoidable healthrisk that affects everyone, although the most vulnerable—
the ill, the elderly, children, and the poor—facedisproportionate risks. Urban growth, expanding
industrialization, global warming, and new knowledge ofthe harm of air pollution are among the factors that raisethe degree of urgency for pollution control and stress theconsequences of inaction. Fortunately, reducing air
pollution can result in prompt and substantial healthgains”.”
The agenda of the Sustainable Development Goals(SDGs) is an action plan to ensure a healthy andsustainable planet for people and other living organisms.
The European Environment Agency (2017) report on air
pollution illustrates how twelve of the SDGs areconnected with air pollution. Tackling some goals such as
SDG 3 health and wellbeing, SDG 7 clean and affordable
energy, SDG 11 sustainable cities and SDG 13 climate
action will directly mean addressing air pollution. Other
goals will be more easily achieved if there less air
pollution: as pollution reduces crop yields this will impact
on SDG 2, zero hunger; SDGs 14 and 15 relate to natural
ecosystems that are affected, which will be discussed
later. Even SDG 4 to ensure inclusive and equitable quality
education opportunities for all relates to air pollution, as
in some cities schools are closed when air quality, due toPM2.5 and other pollutants, is excessively low. Worse stillsome schools are located in close proximity to roads thatcarry heavy traffic. High levels of pollution affect thehealth of students and hinders their capacity to learn,
King (2019).
Scale of the problem
Ambient air pollution causes millions of premature
deaths every year. Exact estimates vary yet worldwide
studies by Lelieveld et al (2020) and The Lancet
Commission on Pollution and Health (2017) both agree
that, for all types of pollution, this is over 8 million per
year. A headline from the WHO (2018) report Air pollution
https://www.who.int/airpollution/infographics/Air-pollutionINFOGRAPHICS-English-1.1200px.jpg?ua=1 Accessed 2-3-20
4 UN News 2014 More than half of world's population now living
in urban areas, UN survey finds [Accessed online 2-4-20 available
fromhttps://news.un.org/en/story/2014/07/472752-more-halfworlds-population-now-living-urban-areas-un-survey-finds]
3387

and child health: Prescribing clean air was: “More than 90%of the world’s children breathe toxic air every day.” This
paper reviews the extent that air pollution has major
human health and some environmental impacts, outlines
some of the causes of outdoor air pollution and thendiscusses the barriers and suggests ways forward to
improve air quality. The focus is on outdoor air pollution
and the application of ethical principles to clarify therights and responsibilities of various agents. It isessentially a review paper and useful primer for further
research into the need and potential benefits ofenvironmental ethics education to tackle one of the mostpressing global health concerns. It aims assist in somesmall part to reduce the moral blindness that surrounds
the problems of air pollution and similar environmental
issues.

Air pollution the silent killer from WHO3
CitiesOver twenty years ago Rogers (1995) wrote that cities
produced around 75% of global pollution. Since the last
decade of this century more than half of the global
population lives in cities 4, so the problems of urban air
pollution are even greater. As urban traffic is a major
source of air pollution and the concentration is closer tothe source and has greater impact on the health andwellbeing of the inhabitants it must be a priority toaddress this avoidable health burden. Many of these cities
are in the northern hemisphere notably eastern Europe
across Asia, and particularly South Asia: Wang et al (2017)
report serious winter particulate pollution in
Ulaanbaatar, Cichowicz and Wielgosinski (2018) relatechanges levels of air pollution in selected German andPolish cities to changes in global industry, services andtrade and the AIRQUAL IQAir website regularly identifies
many cities in India5 as being the in the worst 20 cities for
air quality globally. The IQAir 2019 World Air Quality
5 BBC world service podcast The Real Story: India’s Pollution

Problem puts this figure as being 15 of the worst 20 polluted
cities as Indian. They attribute only 15% of this urban pollution
to agricultural sources.

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Report lists nineteen Asian capital cities having thepoorest air quality.
Indoor / outdoor pollution
This paper deals primarily with the issues related to
outdoor air pollution. However, many of the principles
that WHO (2000) reference to determine a right to healthy
indoor air are equally relevant to outdoor air pollution.
Legislation and public awareness of the right to clean air
indoors has been significantly improved in many
developed countries since that time. Some of the pollutant
chemicals are the same in both indoor and outdoor
pollution, although indoor air pollution largely relates to
products from tobacco smoke, radon build-up fromradioactive underlying rocks and / or building materials aswell as carbon monoxide from incomplete combustion oforganic fuels. In less developed and rural communities
indoor air pollution can be caused from solid fuel burningand even mosquito coils that release substantial levels offormaldehyde and PM2.5, Tharaphy and Chapman (2010).
With regards to outdoor air pollution, the scale, causes
and effects are much broader compared to indoor air
pollution. Lelieveld et al (2015) calculated that at least 3.3
million premature deaths per year worldwide could be
attributed to high levels of outdoor PM2.5. They found that
this was complicated by varying particulate toxicity, but
premature deaths were more prevalent in Asia. Jerrett(2015) comments on further findings from Lelieveld
saying that the high levels of pollution in parts of Asia
require significantly more attention than relatively lower
levels in other parts of the world. PM2.5 is just one fractionof outdoor, but its visibility as well as it causing somerelatively immediate health effects and noticeable
reductions during the COVID-19 pandemic has given it
greater media profile recently in comparison to otherpollutants such as ozone and nitrogen oxides.

dioxide, nitrogen oxides, ozone and particulate matter.
Carbon dioxide and methane are also gases that cause
environmental concern due to their being greenhousegases, but the focus of this paper is on more the direct
effects on the health humans and other organisms.

Figure 1: Air pollution within the transport sector from
European Environment Agency (2019)6
Figures 1 and 2 illustrate the contributions from various
sectors. Aviation transport, although having a high carbon
footprint per passenger mile, actually only accounts for
3% of the global air pollution, whereas road transport
accounts for 20% of PM2.5 pollution.

Figure 2: What are the sources of air pollution? From
WHO website7

Causes of air pollution
The WHO website emphasizes that outdoor air pollution
has causes, from both natural and anthropogenic sources.
Maduna and Tomasic (2017) further classify emissions
depending on whether they are from point, line, surface
or diffuse volume sources. Some of the anthropogenic
causes are outlined below. Point sources includes
factories and power plants, whereas roads are line
sources. The usefulness in classifying in this way is thatthe impacts of pollution to wind patterns and climate
conditions can be more reliably be assessed or predicted.
The fractions of each sector of the global economy that is
ultimately responsible for causing air pollution indifferent regions depends on the type of pollution as eachfuel and the combustion conditions produce uniqueblends of waste gas products. For this paper thesubstances of main concern are carbon monoxide, sulfur

Traffic and transport
According to Lelieveld (2020) toxicology reports indicatethat particles from diesel engines are more toxic thanthose from petrol engines and that both are more harmful
than biomass burning. Air transport requires very highlevels of fuel consumption and releases waste gases
directly into the high atmosphere where many molecularand radical species are involved in secondary reaction
pathways that produce a further spectrum pollutant andnon-pollutant chemicals, however as shown in Figure 1,
apart from NOx it accounts for little of the total.

6 European Environment Agency: Contribution of the transport

and-maps/indicators/transport-emissions-of-air-pollutants8/transport-emissions-of-air-pollutants-8]
7https://www.who.int/airpollution/infographics/Air-pollutionINFOGRAPHICS-English-4-1200px.jpg?ua=1]

sector to total emissions of the main air pollutants [Accessed
online 25-7-20. Available from: https://www.eea.europa.eu/data-

Household energy and electricity generation
The global “consumption” and use of domestic electricity
is still rising exponentially as more and more economies
become more affluent. Yet the majority of this electricity
is not generated from clean or renewable technologies.
The generation of electricity is still heavily reliant uponEubios Journal of Asian and International Bioethics 30(7) (September 2020)
fossil fuel including coal combustion. The sulfur in the coalproduces sulfur dioxide, which in addition to nitrogenoxides is a major contributor towards acid rain. The cause,
effects and abatement measures relating to acid rain havebeen known for many years and in more developed
countries a great deal of technology and legislation havebeen successfully implemented to address this.
Agriculture and crop residue burning
Although some agricultural practices, notably forest
clearances by “slash and burn” and waste residue or
stubble clearances receive attention in the press,
Lelieveld et al (2015) found that agricultural sources are
the second-largest contributor to global mortality from
PM2.5. This is due to releases of ammonia from livestockand fertilizers that lead to atmospheric formation ofammonium nitrate and sulfate particles. He also called for
greater research on the contributions by agricultural
practices. Jerrett (2015) comments on the potential importof Lelieveld’s findings saying that; “much more attention
needs to be paid to agricultural sources, by both scientists
and policymakers”. More recent work by Lelieveld et al(2020) reports that over 5% of mortality is due to biomassburning. The burning of crop residues, slash and burnagriculture and forest clearance frequently makes
headline news in South Asian and South-East Asian media,
especially when this is seen to worsen air quality in large
cities 8 . The area influenced by agricultural processes
depends on many factors according to Prato and Huertas(2019), but they found that when comparing carbon
monoxide, nitrogen dioxide, PM10 and PM2.5 fromsugarcane burning in the USA, it was the PM2.5 that had thegreatest area of influence due to its low mass andlongevity in the atmosphere. PM2.5 is of great cause
concern to impacts on health. Dioxins are also a concern
from agricultural waste burning, Canadian Commission
for Environmental Cooperation (2014), more researchneeds to be done to access their impact globally.
Forest fires and Transboundary issues
Notman (2019) observes that it was 40 years ago that Paul
Crutzen had identified biomass burning as a significant
source of trace gases in the global atmosphere. Notman
reports that the 2017 Californian fires released ten
million kg of fine particles into the atmosphere. The firesin Australia in 2019 – 2020 were covered widely and theglobal media and brought images of devastation alongwith stories of economic and environmental tragedy. Yet
less attention was paid to the long term health impacts offires such as how far reaching or long term these effects
might be. Peat fires produce significant levels of carbon
monoxide and other species that have been linked to
8 Biswas, S. (2018) reported for the BBC that Delhi’s smog was theresult of India’s farming revolution. Ellis-Petersen (2019) wrote
in The Guardian that vulnerable Indian farmers claim to be
scapegoats for urban smog. Confounding factors include
demand for cheap food, poor enforcement of environmental

389

health issues, Neitzel et al (2009), Weinhold (2011), Page
and Hooijer (2016) and Cassou (2018). Johnston et al (2016)
point out that the diversity of the constituent mix inlandscape fires depends not only on the substrate, butalso on the water content and the temperature intensity.
Recent studies using satellite evidence have clearlyshown the extent of which aerial particulate matter has
no respect for national or geographical boundaries. For
example Chakrabarti et al (2019) used satellite and healthsurvey data to estimate the burden of disease from crop
fires in India and within a few months BBC News reports
were questioning whether this was the cause of poor air
quality in Pakistan.9 Extance (2020) relates that now thereis the potential to track sources of pollution throughremote isotope ratio mass spectrometry, which provides
evidence rather than mere hearsay. He illustrates how
this technology has been used to distinguish between
local and transboundary PM2.5 pollution in Korea thatoriginated in China.
Types of air pollution
A large number of texts provide thorough accounts ofdifferent compounds in the air pollution mix. A usefulsummary is available in Maduna and Tomasic (2017). In
this paper however I focus more of two main constituentsthat both have significant impacts on health, namelyozone and particulate matter (PM), which is present insmoke in various sizes. The size is of relevance in as muchas it affects the time the particles remain airborne andhow deep they can penetrate into the lungs, alveoli or
pass into the blood stream. PM has serious effects onhuman health and also on global climate change, withincreasing evidence of its contribution to arctic melting,
Baron et al (2010). PM2.5 small size, large surface area andlong residence time in the air, which makes it likely toadsorb contaminants such as metals that could lead tobrain damage; King (2019). These can not only come fromdiesel exhausts, but also brake, tyre and road surface
abrasion and wear making PM2.5 considerably more toxic
than would otherwise be so.
In addition, various chemical species including
levoglucosan, methoxyphenols (MPs) and polycyclicaromatic hydrocarbons (PAHs) add to the complexity andprovide signatures to the carbon soot mix; Neitzel et al(2009) and Weinhold (2011). Agricultural burning has
been estimated to be responsible for 20% of particulatematter and 50% of PAHs released into the wider global
environment, Kambis and Levine (1996).
Ozone is formed from various atmospheric reactions
involving the photolysis of nitrogen dioxide, carbonyl andhydroxyl radicals. Agricultural burning can also be asignificant source of dioxins, CEC (2014). The rate of ozone
protection laws, and contributory pollution form traffic andfactories.
9 Is India’s crop burning polluting Pakistan’s air? Reality Check:
BBC News 8 November 2019 [Accessed online 20-2-20. Available
from: https://www.bbc.com/news/world-asia-india-50333985]

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production depends on both the concentration ofhydrocarbons and NOx. The complicated chemistry has
meant that as some legal frameworks, such as the US 1970
Clean Air Act, were based upon limited understanding
and focused on hydrocarbon emissions then they had less
impact on air quality than was anticipated; Jacob (1999).
Gadde et al (2009) say that open burning of crop stubble
results in the emissions of harmful chemicals like
polychlorinated dibenzo-p-dioxins, other dioxins andPAHs. These air pollutants have both carcinogenic andtoxicological properties. Many are stored in fatty bodytissue and accumulate over time.
Other harmful or toxic gases include carbon monoxide,
sulphur dioxide SO2 and various nitrogen oxides NOx. The
acidic oxides are major contributors to acid precipitation
causing harm to a number of terrestrial and aquatic
ecosystems.
Problems caused – human health
While air pollution is often ignored as a health risk factor,
the 2018 Lancet Commission on pollution and healthestimated that approximately nine million excess deaths
worldwide can be attributed to degraded environmental
conditions, and that approximately half of these are due
to significant ambient (outdoor) air pollution. The maincauses of death are lung and heart disease, lung cancer,
and stroke as shown in figure 3. Lelieveld et al (2019)
estimates 8.79 million in 2015. This agrees well with theglobal estimate of 8.9 million by Burnett et al (2018). To
put this into perspective, the WHO estimates that theexcess death rate from tobacco smoking is 7.2 million per
year; hence air pollution is now rated as the larger risk
factor.
Lung cancer and other lung diseases such as
emphysema, asthma and bronchitis are all strongly linked
to air quality. There is growing evidence that higher levelsof air pollution also inhibits the growth of children’s
lungs, which leads to poorer health in later life and areduction in life expectancy. The lungs are the mostvulnerable organ in the body to damage from all types of
air pollution, but they are not the only organ to suffer.

Figure 3: The fractions of fatalities caused by air
pollution10
The WHO infographic in figure 3 states that 24 % ofstrokes are related to long term exposure to poor air
quality. However, the brain is also subject to more direct
https://www.who.int/airpollution/infographics/
invisiblekiller2_all4_2018.jpg?ua=1
11 A caution is raised that to date although there is a growing
body of epidemiological evidence, there is little direct evidence
10

harm from several pollutants. BBC Science editor David
Shukman (2019) reports that there is the possibility that
PM2.5 is small enough to be transported to and enter
nerves in the brain and thereby cause plaques to develop,
which are associated with dementia. King (2019) provides
an illustration that being close to a congested road could
expose children to 100 million magnetite nanoparticles
per cubic metre. These can go directly to the brain throughthe olfactory nerve. King also draws attention tosuggested links between exposure air pollution during
pregnancy and the development of autism in children.
Lelieveld et al (2019) found that within Europe thefigures for death by ischaemic heart disease far exceeded
other specific fatalities related to air pollution. In fact,
these together with cerebrovascular disease account for
approaching 40% of the 650 000 plus deaths they
attributed to air pollution in Europe. The detailed study
accounted for other contributory factors.
In addition to physiological disease are people’s general
wellbeing. Few studies have been undertaken to
determine links between mental health and air
pollution11, but recently Vienne (2020) published resultsfrom a 17-source database that combined individual
survey data, air pollution data at the city and country
level, climate information and macroeconomic indicators,in Latin America. One of her statistical analyses showedthat on average, an increase in 1 μg/m3 in the mean annual
concentration of PM10 there is an associated reduction ofself-reported happiness level. Rocha et al (2020) foundassociations between air pollution and Alzheimer’s
disease, dementia and migraines amongst otherneurological conditions, from 52 PubMed articles. Khan etal (2019) demonstrate that in both the US and Denmark
there is a clear association between pollution andpsychiatric disorders including bipolar, schizophrenia,
depression and epilepsy.
Moral pollution
Lu et al (2018) review evidence that indicate the ability to
predict unlawful and unethical activity in environmentswith higher levels of air pollution. They demonstrate thatas poor air quality raises anxiety levels, then this in turncan lead to behaviours which are intended alleviate
anxiety. They note that various alternative mechanisms
for this link need further research, such as the brokenwindows theory by Keizer et al (2008), which argues that
moral concerns are diminished in degradedenvironments. A further alternative theory that lower
light levels in smog induces a sense of anonymity thatlowers inhibitions against engaging in unlawful orunethical behaviour as shown by Zhong, Bohns and Gino
(2010).

of causal links between neurological disorders and air pollution,in the editorial of The Lancet, Lancet Neural (2018) 17: 103. A
possible pathway for toxins to reach the brain is via nerves fromthe nasal cavity.

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
Pressure on health care systems
The global Covid-19 pandemic has seen unprecedented
pressure on many national healthcare providers aroundthe world. The annual impact of air pollution already had
a tremendous cost and consumed an enormous
proportion of national budgets. An initial study in four
European countries demonstrates that there is acorrelation between nitrogen dioxide exposure anddeaths from Covid-19, Carrington (2020). Another study in
America showed an association between PM2.5 and deaths
from the virus, Wu et al (2020). Neither of these studies
claimed that there was a direct causal link, but there is apossible indication that long-term exposure to high levelsof various pollutants weakens people resilience tosubsequent infections. Furthermore, as the population
demographics in many countries shows aging
populations there will be a growing burden on healthcare
to treat and care for patients suffering from long-term
exposure with progressive illnesses such as mental
health, lung and cardiovascular diseases. As further
pandemics are also likely in the future, it would be
prudent to take action now to minimalise the effects of air
pollution and plan and prepare so that health caresystems have sufficient capacity.
Problems for nature beyond humans
King (2019) discusses reports that autopsies on dogs fromheavily polluted streets Mexico City revealed that were
found to have brain inflammations and protein clumpingthat are indicative of Alzheimer’s disease in humans.
Canaries were traditionally used to test for toxic gases incoal mines. Many ornithologists are encouraged byreports such as Drewitt (2015) who describes theresurgent growth of peregrine numbers in city centres in
the UK as they feast on abundant pigeon populations. In
this time of hearing more and more reports of declining
numbers of predators due anthropogenic activities this issurely good news. Yet if these awesome birds are exposed
to damaging high levels of pollution directly and throughthe consumption of polluted prey, then sadly thisresurgence may be short-lived. Sanderfoot and Holloway(2017) provide a review of literature regarding the effectof air pollution on avian species. They note that several
studies comparing the populations of the same species inpolluted and less polluted environments does indicate apattern, however they acknowledge that several
confounding factors such as habitat degradation and foodavailability make it impossible, at this stage, toconclusively prove that air pollution is the main driving
factor in population declines. Their review does
nonetheless report in vivo physiological studies on birds’lung tissue that do strongly indicate pollutant damage.
Ejaz et al (2014) recorded increases in toxin levels of vitalorgans in some birds. This could potentially lead tobioaccumulation in predators or scavengers. It is often
assumed that amphibians are modern day indicators ofpollution as they possess highly permeable skin. However,Kaplan (2009) reports in Nature that amphibians,

391

surprisingly, often appear more resilient to air pollutionthat would be expected.
The effects of ozone on plants has been known for many
years and lichens are well known pollution indicators.
Rich (1964) refers to studies on germinating seeds as far
back as the late mid-19th century. Rich lists well over fifty
species that had already been identified to suffer fromozone. Over the last half of the 20th century to date thegrowing list of and extent of this damage to agriculturally
important crops has been identified. Van Dingenen et al(2009) provide two models to make predictions of global
staple crop losses by 2030 due to surface ozone. Bothmodels show significant impacts that would makeachieving SDG 2 more of a challenge.
Less work has been done to identify the effect of air
pollution on whole ecosystems but Lovett et al (2009)
studied the impact of fur pollutants, sulfur, nitrogen,ozone, and mercury in eight North American ecosystems
and concluded that: “Effects of air pollution wereidentified, with varying levels of certainty, in all theecosystem types examined. None of these ecosystem
types is free of the impacts of air pollution, and most are
affected by multiple pollutants.” The US Environmental
Protection Agency (2017) says that the impact on thephotosynthetic ability of plants slows their growth, makes
them more prone to insect damage and ultimately leads
to decreases in biodiversity, contributing to changes inhabitat quality and ecosystem cycles.
How does ethics help?
In extreme moral blindness individuals cannot perceive
an ethical issue. In the case of air pollution, it seems thatwhole societies if not morally blind are taking a blind eyeor are experiencing a form of analgesia to the situation.
Bauman and Donskis (2013) refer to this as adiaphora –implying an attitude of indifference or moral numbness.
Cliffe (2017) compares attitudes towards tax on sugarwith acceptance of tax on alcohol, which is a much lower
health risk in the UK. Taxation is an accepted approach to
tackle the global smoking epidemic. Does an absence ofspecific tax allocation on fossil fuels suggest moral
blindness or visual impairment by governments? Or is it
merely that taxes are politically unpopular and thatenergy providers are a powerful lobby? The range ofsources and causes of air pollution indicates that no one
sector or industry is solely responsible. Governments
alone cannot realistically enforce changes that are
essential to improve air quality. It is therefore largely
down to individual choices and actions. As de Paula andCavalcanti (2000) argue: “Therefore, it is important that
individuals are aware of themselves and others. That is tosay, they evaluate the effects of their actions in relation to
those whom they live with, to society as a whole and to thenatural environment.”
This raises a key to moral agency and ethical decision
making – it cannot be made in isolation from, or
independent of, other people and organisms who havemoral interests even if they do not have agency. An392

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

assumption is that all people are able to make therequired evaluations –requiring not only fully available
information, but a prerequisite is having higher order
thinking skills. This makes it vital that educational
programmes and programmes provide opportunities forstudents and participants “to open their eyes” toenvironmental ethical issues through exercises todevelop their ability to critique, appraise and makejustified recommendations through participatory
activities such as group discussions or data gathering andanalysis. The use of guiding ethical principles is a usefulapproach to aid discussion and a systematic approach tounpack complex and controversial issues. It is also arequirement to make informed ethical choices that people
have access to and an understanding of the wider
scientific information, as well as socioeconomic andpolitical factors that are relevant. This means thatcomprehensive educational programmes must be
developed.
Principles
Twenty years ago a WHO (2000) working group produced
a report, based on nine principles of human rights,
ecological sustainability and biomedical ethics, arguingthe case for a right to healthy indoor air. These principles
included:• Right to human health• Respect for autonomy• Non-maleficence• Beneficence• Social justice• Accountability• Precaution• Polluter pays
• Sustainability
In the COMEST (2004) report on ethical use of waterreframed some of these principles in terms of solidarity
between upstream and downstream communities, water
as being a common good, stewardship, participation andempowerment. Liu et al (2011) apply principles from the
UDBHR (2005) to develop refined principles such as theduty of care bestowed upon people who are fortunate tolive in the vicinity of abundant water sources. Arguably
this could be applied to people who live in rural areas withlittle traffic or industrial air pollution; a duty to notpollute as they are living in a “privileged” position.
Polluter pays – this may be possible to enforce for point
source pollution emitters such as factories or throughtaxation on vehicle emissions or fuels, but it would benearly impossible in the case of wild and forest fires. The
issues of corruption and poor law enforcement
additionally confound this approach. In a similar way toplastic bag littering: is the responsibility of the producer
or the consumer? Several countries do enforce car
emissions controls, but there is still scope for these to gomuch further if global air quality is to reach acceptablelevels, as has been shown to be possible during the COVIDhttps://www.who.int/airpollution/infographics/Air-pollutionINFOGRAPHICS-English-3-1200px.jpg?ua=1 Accessed 2-3-20
1219 lockdowns around the world that have beenaccompanied by improvements in air quality.
Preemptive action – Notman (2019) recalls how the 2009
wildfires in Australia promoted a change in policy to start
more deliberate fires to reduce the fuel load. This
however, had a negative effect on air quality. With climatechange in mind, this becomes a viscous circle as drought
periods renders large areas tinder dry increasing the
likelihood of extensive wildfires. Further preemptive
action would be to ensure infrastructure is in place forelectric vehicles, mass transport systems and clean
renewable electricity generation systems to reducereliance on fossil fuels.
WHO (2017) reports that tobacco kills in excess of 8
million people per year – comparable to Lelieveld et al(2020) figure for ambient air pollution. WHO argues thatbans on advertising and pictorial health warnings have
proven to be significant deterrents. There is potential for
extending this to combat air pollution such as displaying
prominent images at fuel stations, on electricity bills or on
fertilizer packaging for example. Bennett (2020)encourages students to explore, through computermodeling, how trees can be used to reduce urban
pollution. This has added environmental ethical benefits
as students develop a greater understanding of ourrelationships with the biota around us. The potential fortrees to combat air pollution is discussed by Barwise andKumar (2020), Yang et al (2015) and UK Department forEnvironment, Food and Rural Affairs (2018). As trees takedecades to grow this is a form of preemptive action interms of planning. UNEP (2019) produced a report on 25
science based solutions to improve air quality in Asia.
Many of these are preemptive such as legislation
regarding fertilizer use, land clearance and energy
efficiency standards.

Figure 4: Who is most impacted by air pollution? From
WHO website12
Remedial action – in this situation governments must be
prepared to have health systems with the capacity to copewith what is a growing burden of disease from poor air
quality. The long term nature and progression of many ofEubios Journal of Asian and International Bioethics 30(7) (September 2020)393

the associated diseases, does allow a timeframe forcountries to be prepared. Maybe this will be one of thelessons from the COVID-19 pandemic, that although apandemic was forewarned for several little preparations
had actually been done. The 2019 UNEP report for Asia
identifies industrial process, vehicle and post combustion
emission controls as being of the greatest and mostachievable immediate benefit.
Environmental justice issues – outdoor air pollution
often has greater impacts of poorer and more vulnerable
people, as shown in the WHO infographic in Figure 4, insociety such as farm workers, street vendors, and those
who do have access to clean energy. There is a vast andgrowing body of evidence to support this such as Serya etal (2019) who identify poorer respiratory health in female
street vendors in Egypt and Kongtip et al (2010) who
reported on a pilot survey of similar workers in Bangkok.
This is closely related to the principle of not putting
people at risk from harm or health and safety at work
protection. Firefighters are on the frontline when
combatting wildfires that may be started accidently, as
part of controlled burning or either deliberate acts ofarson. For example, in April 2020 the Bangkok Post 13
reported that there had been seven deaths of people
fighting forest fires in the North of Thailand already thisyear. However, this does not reflect the longer term healthrisks to these workers. Neitzel et al (2009) found higher
levels of low molecular weight methoxyphenols (MPs) inurinary samples from firefighters. They correlated thesefindings with CO, PM2.5 and MP exposure to wood smoke
in controlled burns. They noted that the MP mix was
different in angiosperm and gymnosperm combustion,consequently the toxicity depended upon the fuel. As
outlined above many individuals, and generally more
vulnerable groups, are exposed to high risks from air
pollution during travel to or at work yet they do notreadily have the health monitoring and protection
afforded to employed workers. This highlights how inpractice it is often the polluted rather than the polluter
who pays.
Non-maleficence - King (2019) highlights the findings ofa study of approximately 3000 school children inBarcelona published by Sunyer et al (2015), which
reported that those in proximity to greater levels of traffic
pollution had slower cognitive development. King lists
evidence of a link to Alzheimer-like amyloid plaques,attention deficit-hyperactivity disorder, autism in
addition to respiratory illnesses such as asthma. Worsestill is that there is growing body of evidence that links
later developmental is detrimentally impacted by in utero
exposure to increased levels of air pollution. Surely, it is ofparamount importance to protect innocent unborn andyoung school children from the harms propagated andsustained by the actions of adults.

Sustainability - The cost of air pollution in economic
terms amounts from increased health care, the reduction
in crops, the added costs of “cleaner” technology. However,sustainability as a principle encompasses more than justeconomics – it demands that current practice does not
impinge on the potential needs of future generations.
Therefore, care for the natural environment is essential as
we are inextricably linked with nature and natural cycles.
Air pollution that harms other organisms will impact onfood chains and webs, this in turn may alter some cycling
processes and ultimately lead to whole ecosystemdeclines. The consequences of some gases causing acidic
precipitation are already well documented and in many
ways technological and legal measures have been taken toaddress this. However, prolonged exposure to PM2.5 is far
less clear. The impact on human health is only recently
becoming known, but further studies must be performed
to see how this harms a wider range of other organisms
and what happens as these particles are transferredthrough food webs and ecological energy pathways.
Bioaccumulation could well lead to unforeseen
complications in the same way as pesticides are now wellknown to do. If these particles can reach the heart andbrain, are they also able to enter gamete cells?

13 “Youth dies in bid to douse wildfire” Bangkok Post, 23 April

https://www.bangkokpost.com/thailand/general/1906105/volunt
eer-dies-in-bid-to-douse-wildfire

2020

accessed

online23-4-20

available

from

Solutions and barriers
Since the 1950s many governments introduced
legislation to combat photochemical smogs largely causedby burning coal for domestic purposes. This legislation
gained public support as the public were well informed of
the acute health risks and benefits of legal protection.
There is growing body of reports that the general public
are losing trust in politicians and wary of scientists being
unbiased or impartial when presenting data or employing
models. In a survey in rural Thailand Waller (2020) foundthat only 1% and 2% of respondents were in support ofraising fossil fuel taxes or using electric vehicles
respectively. Yet 25% were in favour of planting more
trees in cities and 20% community education programmes
regarding air pollution. Therefore, key to successful
strategies, advocated by WHO in Figure 5, is education to
gain raise awareness of health risks with comprehensive
and detailed information sharing. Other strategies involve
technical developments in transport, power generation
and waste management sectors as well as taxation andreform of agricultural practices and domestic fuelefficiency improvements.
William Logan (2012) observes that during the 1996
Olympics in Atlanta traffic flow into and out of the city was
restricted, resulted in a reduction of emergency hospital
admissions. Following the competition events the traffic
was allowed back in and the level of hospital admissionrose accordingly. Schraufnagel et al (2019) also reportsthat a significant number of studies have shown that, oncevarious environmental policies were put in place, air394

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

pollution fell. When air pollution was reduced at national,
local or even domestic levels there were health benefits
that were “almost immediate and substantial”, andcontinued long term. The key for gaining public support
for such initiatives is through raising awareness andeducation of the health and pollution links.
Air quality is a universal and fundamental entity for ahealthy environment. Marks (2012) reviewed theeffectiveness of three different approaches to address
climate change and finds them all wanting. He argued thatthe hegemony of capitalism rendered human rights anddevelopment approaches important, yet saw potential
capacity in adopting a revised view of human security as
greenhouse gas emissions, as like particulate emissions,
are trans-boundary issues. The human security
perspective highlights environmental threats to fromenvironmental degradation. Marks refers to several
reasons for adopting this perspective, amongst which isthat this approach could be more likely to engage
cooperation between states and policy makers thandemanding rights or measuring up different degrees ofdevelopment.

Figure 5: Strategies for tackling outdoor air pollution14
However, there is scope and value to investigate theextent to which human rights are restricted by the impactof air pollution. The right of the unborn child to a healthy
life. The rights of women subjected to poor indoor air
quality from solid fuel cooking, which limits their ability
to maintain good health. The economic impact on street
vendors and their right to work. The rights of children tomeaningful education and protection from harm. Right ofaccess, by less advantaged communities, to affordable
medical care. As previously stated, WHO proposed thehttps://www.who.int/airpollution/infographics/Air-pollutionINFOGRAPHICS-English-6-1200px.jpg?ua=1Accessed 2-3-20
15 WHO (2018) Exposure to household air pollution for 2016
[Accessed
online27-2-20.
Availablefrom:https://www.who.int/airpollution/data/HAP_exposure_results_fin
al.pdf?ua=1]
16 The BBC (2017) reported that rising air pollution at Buddha's
birthplace in Nepal is causing alarm for monks and pilgrims as it
is 10 times the safe level. Accessed online 30-4-20. Available
14

application of nine principles to inform policy andpromote healthy indoor air. However, the 2018 version of
the WHO Exposure to household air pollution for 2016
webpage states that: “Globally, 41% of the world population
is exposed to household air pollution resulting from cooking
with polluting fuels and technologies in 2016.”15
This suggests that the time is right to revisit what are
the barriers to achieving greater progress in improving
air quality, suggest how these barriers can be overcome
and to explore the potential of alternative solutions. The
media have the potential to play a major role in raisingawareness and in education. However, stories may
sensationalise, mislead, misinform, or cherry pickprominent events or locations16 and not relate the wider
global scale of the problem. Media reports may focus on
populist opinions, such as hill tribe agriculture causing air
pollution.
Access to data
2020 saw the launch of the world’s largest air quality data
platform by UNEP, UN-Habitat and the Swiss company
IQAir 17 . Access to data, particularly positive trends, is asource of great encouragement. For example, initialdespondency following the Chernobyl tragedy of 1986
has been turned to one of hope as it has been shown thediversity of life that is now thriving within the exclusionzone. In the words of Wood and Beresford (2016), “Whenhumans were removed from an area, nature has aremarkable ability to reclaim that space.” The timely
launch of the IQAir system has enabled regular
discussions in the media of reductions and subsequent
rises in air pollution during and post lockdown
restrictions, Watts and Kommenda (2020) and Newburger(2020). This was accompanied by some reports inincreased wildlife activities during lockdown, althoughwhether this can be attributed to short term air quality
improvements rather than the reduction in humanactivity has not been confirmed. Nonetheless, access todetailed, accurate and real time data is vital for
researchers, quality education and policy makers alike.
Political considerations
Wolinsky (2006) argues that there could be a case to saythat if UNESCO and WHO had worked morecollaboratively on the UDBHR it may have carried greater
standing. His diagnosis may be given some credence in thelight of predictions of countries disregarding Article 3
when taking measures to curb disease epidemic, such as
the Covid-19 pandemic. Wolinsky winds up his analysis byidentifying the overall benefits of the UDBHR, but greaterfrom:https://www.bbc.com/news/av/science-environment39865269/air-pollution-at-buddha-s-birthplace-is-10-times-thesafe-level
17 This was announced on 10 February 2020 on the UNEP
website. [Accessed
online3-3-20. Available
from:https://www.unenvironment.org/news-and-stories/story/whatsair-world-urban-forum-2020-launches-worlds-largest-real-timeair]

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)
synergy between UN divisions (UNESCO, UNDP, UNEP,
WHO and FAO) is surely needed to promote more rapid
improvement in air quality. This is after all the aim of SDG
Goal 17: Partnerships for the Goals. The role of WHO in the
COVID-19 epidemic has been questioned by many
political leaders. However, many of these leaders, who
generally have short term political interests, have tried toshift blame away from themselves. This illustrates thevital need for unified action on pervasive global andpersistent issues such as air pollution. Blame shifting is
also seen in the media as farmers, in some countries like
India, Cambodia or Thailand are often reported as being
the main offenders as air polluters18. Apportioning blame
largely on rural communities is a distraction anddiversion of the real issue. Policies must be regionallybased, with specific targets to reduce all sources andevery type of pollutant in a holistic and integrated
approach. It also illustrates a limitation of the short term
rule of elected leaders as often they are concerned withimmediate results to impress voters rather than long term
action and less popular strategies such as increased
taxation.
Congestion charges and alternative transportsystems
Pandita (2004) explored how a civic society organisation
was instrumental in producing reports, convening
meetings between various experts and raising publicawareness of the severity and impact of urban air
pollution in India during the late twentieth century, whichlead to court judgments that in turn induced changes inlegislation of transportation systems as well as
compulsory environmental education programmes, Wals(2009). In many countries vehicle use changes have been
introduced under other initiatives such as congestion
charges, subsidies on clean biofuels or greater taxes ondiesel as part of strategies to promote renewable energy,
infrastructural support for electrical vehicles andexpansion of mass transit systems that have all beenrolled out as part of development programmes rather as
explicit health agendas to tackle air pollution. Yet manyurban planning projects do aim deliberately to improvehealth and general wellbeing, such the expansion of green
spaces, Baines (2014) and cycle lanes or building schools
away from busy roads, King (2019). If revenues fromcongestion charges or additional fuel surcharges wereused to fund mass transport initiatives or community
education programmes this may gain a degree of public
support or at least acceptance. Noree et al (2015) propose
a similar approach to support national healthcare in
Thailand by taxing medical tourism.
Education curricula
Dodds (2007) observes that over the last century many
governments developed nationalistic curricula for school
18 In a survey of 466 respondents in rural lower north and northeastern Thailand 57% stated that they believed agricultural andforest burning were the main cause of PM2.5 air pollution, and395

education. This does not mean that universal values were
not taught, but it does illustrate that ultimately that
ultimately citizens are programmed to consider nationalrather than global issues first. But even within countries
educational quality and experiences vary within regions.
For example, Umavijani (2019) claims there are large gaps
between urban and rural healthcare in Thailand, andmakes recommendations that education and training
through government initiated traditional broadcasting
and contemporary social media should be used for
information sharing to help people take preventative
measures. A possible benefit of the Covid-19 school
closures is that due to online learning there has been apossible leveling of the access to quality education forstudents attending different schools, if an assumption ismade that all had equal access to the internet.
Education of disadvantaged communities
Dorevitch et al (2008) identified limited internet access byless advantaged people as a barrier to long term
participation in a community air quality education
programme. UNESCO (2019) still states that rural poverty
as a particular barrier to participation in adult learningand education. Buchanan and Russo (2015) provide
evidence that if collective action takes place then someparticipants will to some extent compensate for noncompliance of others regarding energy conservation.
However, if people can identify clear and achievable
positive impacts on their lives this does help to increase
participation. In Thailand, for example, a high level ofcompliance to government lockdown restrictions, could
be attributed in no small part, to information sharing at
village and community levels by locally elected council
and administration officers. The benefits of community
education programmes must be made clear from theoutset to promote and sustain involvement through tocompletion. Furthermore, the show casing of model
communities that have had substantial improvements inhealth, nature conservation and even economic benefits
should be endorsed to encourage uptake of “courses” byproviders in other locations. Neitzlel et al (2009) reported
problems in collecting real time urinary data to monitor
air pollution. Now however, with more readily available
apps and greater mobile coverage in the 2020s theconditions are more conducive for public engagement,
which may encourage more disadvantaged communities
to participate in data gathering and engage in education
events.
Economic energy policies
WHO (2017) concludes that taxes are effective in reducing
tobacco use. One of the MPOWER measures, adopted bymany countries to address the global tobacco epidemic, is
to increase taxation on tobacco. When it comes to taxing
there is an ethical issue of whether it is a regressive tax
19% said that enforcing legislation against this should be one of
the top three priorities to improve air quality, Waller (2020)

396

Eubios Journal of Asian and International Bioethics 30(7) (September 2020)

that has disproportionate impact on the wellbeing of
economically vulnerable people. Chitiga et al (2012) foundthat in South Africa overall fuel taxation was progressive.
However, some fuels for specific purposes such astransport and paraffin use in homes was regressive.
Mkenda et al (2012) had similar findings in Tanzania,
where taxation on basic fuels like firewood and kerosene
was regressive but progressive on more luxury fuels suchas electricity, or diesel and petrol. Kosonen (2012) foundsimilar results in Europe. Regressive taxation ontransport does not induce public endorsement ofcongestion charges mentioned earlier unless the revenue
from them is used transparently to good effect inimproving mass transport systems.
WHO (2017) recognises that tobacco users need help tobreak their dependency. Similarly, for farmers to embrace
alternative agricultural practices in poor rural areas, theyneed assistance in the form of education, development
and conservation funding: not being imposed with further
taxation. However, there may be a case that if tied toeconomic subsidies to trail and adopt new practices thena tax added to inorganic fertilizers could be used to fundthe aforementioned programmes.
Technological
The wider acceptance of the use of face masks has been apositive outcome from Covid-19, but the efficacy of somemasks needs to be improved and the limited benefits need
to be fully understood. They are, at best, only able toaddress the effects rather than the causes of pollution. The
development and use of electric vehicles, especially if theelectricity is generated via renewable technology such as
wind turbines and solar cells would ensure a massive
reduction in air pollution from fossil fuels. Meanwhile it isessential that flu gas scrubbers or desulfurization, vehicle
exhaust catalytic converters and reducing coal and diesel
consumption will all bring immediate benefits. Farming
practices can also be improved such as limiting theapplication of fertilizer and applying at the optimum
times as well as increasing the use of composting oralternative processing rather than burning residues.
Barwise and Kumar (2020) review the use of what theyterm Green Infrastructure - trees - as air pollution barriers
and Yang et al (2015) rank various species, finding thesilver maple, London plane and honey locust as having
above average ability at PM2.5 removal. These were also
found to be in the top ten of most commonly planted
urban trees in 60 cities across the world. There is scopefor more research into the capacity for other tree species
to improve urban air quality, and to determine which willsurvive and thrive best in local climatic conditions.
Legislation
Many nations have laws that address air quality, forexample the UK banned stubble burning in 1993. This andlegislation regarding coal combustion and flu gas
19 “Toxic haze alert for 4 provinces” Bangkok Post, 17 April 2020

accessed

online23-4-20

availablefromemissions were drawn up as UK was criticized as being
the “dirty man” of Europe and a major contributor
towards the acidification of Scandinavian lakes andforests. Important as national legislation is, this illustrates
the need for regional and international legislation tocombat this invisible killer. With satellite technology andimprovements in chemical sampling and analysis
technology this makes holding offenders to account more
possible. The next step is to enforce the laws. Notman(2019) notes two significant issues relating to forest
clearance in South East Asia for palm oil plantations.
Firstly, that banning laws are variably (at best) enforced
and that as the forests are on peat soils that these produce
greater quantities of smoke compared to non-tropicalforest fires. The smoke from such forest fires crosses
boundaries between Thailand and Cambodia, Singapore,
Malaysia and Indonesia or India and Pakistan. This isclearly a regional issue and tackling it needs a cooperative
approach. Cheong et al (2019) conclude that:
Epidemiological studies on the disease burden andsocioeconomic cost of haze exposure would alsobeuseful to guide policy-making and international strategy
in minimizing the impact of seasonal haze in Southeast
Asia.
What can be done now and at reasonable cost?
Alternative uses of crop residues include: mushroom
farming, feedstock for biogas generation and oils fromgasification or pyrolysis, cattle bedding material, paper
making, construction material production, or reincorporation into soils, which improves soil quality
through raising soil carbon content, Kumar et al (2015).
Some of these measures will produce a supplementary
income for farmers if there is a local market, others may
improve the long term viability of agricultural land. Thereis some good news for example; the deputy governor of
Chiang Mai, Komsan Suwan-ampa has said19 that there areplans in place for the education of local communities
regarding agricultural, waste and forest fires causing air
pollution in Northern Thailand, after Covid-19 restrictions
are lifted. Education must not be restricted to ruralcommunities – it needs to address all causes of air
pollution and meet the needs of the whole of society.
Urban programmes could be include participatory
activities such as planting suitable trees that would allow
students to feel empowered to take positive actions, havepsychological benefits, improve wellbeing and promote
cooperative sustainable behaviour within communities aswell as improve urban air quality, as explored in Zelenski
et al (2015) and Bennet (2020).
Conclusion
Several pressing environmental concerns receive wide
attention – global warming or climate change, biodiversity
loss, deforestation, plastic pollution, ozone depletion andacid rain are typical examples of issues that are regularly
discussed in the media and addressed to some degree by
https://www.bangkokpost.com/thailand/general/1901515/toxichaze-alert-for-4-provincesEubios Journal of Asian and International Bioethics 30(7) (September 2020)
many governments and explored in numerous education
curricula. Although various reports such as the GBD and
The Lancet Commission on Pollution and Health (2017)
have been widely available, a survey of rural generalpublic in Thailand shows significant gaps in knowledge ofand some ambivalence towards air pollution. Recent
events of the global COVID-19 pandemic have raised the
profile of air pollution as reductions were observed in
lockdowns and correlations with death rates to pollution
levels were reported. Yet the deaths from that pandemic
and even the prolonged HIV/AIDS pandemic, are so far,dwarfed by the year on year accumulated deaths due toongoing air pollution. So now the time is ripe to sustain
momentum into further monitoring, research,
participatory education, and policy development withaccompanying economic and legal enforcements toaddress both pandemics: air pollution and environmental
moral blindness. In the medium term these actions will
help towards reaching a number of the SDGs and in thelonger term will contribute towards making sustainable
practices become routine.
Acknowledgements

Phayung Morgan for her time and insights shared regarding
village level information sharing meetings run by local councils
in Wichianburi district, Phetchabun Province, Thailand. Also
thank you to Sutharat Suksangthong and Phayung Morgan forcollecting survey responses in Pak Chong and Wichianburi
respectively.

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