eubios journal of asian and international bioethics · balancing autonomy and justice in the u.s....

Eubios Journal of Asian and International 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 pageCOVID-19communitymaskwearing:lessonsfromfoot-bindingandinfibulation-StevenBRothman 354BalancingautonomyandjusticeintheU.S.withacoronavirusoutbreak-AnnBoydandBrandiDavidson 358Nursingstudents’perceptionofmentalhealth,mentalillnessandmentalhealthnursing -AliaNasir,DaiziJafar,AmbreenWasim 363MandatoryCOVID-19vaccinationinAfrica:Thephilosophyofobjectivismonindividualrightsvspublicrightsinacultureboundsociety,Nigeria -FNChukwunekeACEzenwugo,OUJUmeorah,IVIyioke368Turningtragedyintocreativework:experiencesandinsightsofplantloversinDavaodelSurduringCOVID-19pandemic -RPBayod,EJForosuelo,JMCavalida,BBAves 371EthicalissuesofCOVID-19forpersonswithdisabilities -ShahanazChowdhury 376COVID-19andmentalhealth:governmentresponseandappropriatemeasures -GenevieveBandares-Paulinoand-RandyA.Tudy 378ChallengesfororganrecipientsandelderlypersonsduringtheCOVID-19Pandemic-Maria-KeikoYasuoka 382Gaspingforbreath: Is airpollutionormoralblindness theunseenkiller?Areview-AlexanderR.Waller 386Orderinginformation 400Editorialaddress,andallcorrespondenceto:Prof.DarrylMacerEmail:[email protected]

Editorial: COVID-19 and VulnerabilityThe question of autonomy and mask wearing is

discussedinthefirsttwopapersinthisissue.AnnBoyddiscusses how we can balance autonomy and justice.These fundamental medical ethical principles reallyepitomizethedebatesovertheuseofmasks.TheWeCopeCommitteestatementonwhypeopleshouldwearmaskswasreleasedinApril2020,andfortunatelyhasbeenwellimplemented inmostcountries. StephenRothmanalsowritesfurtherontheuseofmaskswithsomeinterestingcomparisons to foot binding and infibulation. Ethicalprinciples have been applied over the millennia indifferent ways and we are still grappling withfundamental issues on the appropriate balancing ofethicalprinciplesincontemporarybioethics.Forthesakeof the vulnerable there should not be any hesitation toexercise solidarity with vulnerable people by wearingmasks,andexercisingphysicaldistancing.

TherearemanytrialsofpotentialCOVID-19vaccinesunderway,andaveryimportantquestioniswhetherornotthevaccinewillbeavailableallaroundtheworld,andhowdowebalancetheinterestsofindividualsoptingoutversustheprotectionthatweneedfromherdimmunity,ThisraisesquestionsdiscussedbyChukwunekeetal. inthe Nigerian context with questions over mandatoryvaccination policies. Shahanaz Chowdhury presentssomeoftheimportantissuesfacedbypersonslivingwithdisability.ThisthemeisonewhichhasbeenaddressedinsomeIPHAconferencesandisbeingtakenupinaWeCopesubcommittee. We invite readers to contribute to thisvery important question of how to balance thevulnerabilitiesofpeoplelivingwithdisability,tocombatsomeoftheharassmentthatpeoplelivingwithdisabilityhavefacedinthepandemic.Forexample,whengoingoutshopping some people with limited visibility need totouchitemsinthestore,orsomepeoplearenotabletowear masks for medical reasons. Other’s may criticizethem.Bandares-PaulinoandTudylookedatsomeofthechallengeswithmentalhealthissues,andNasiretal.,lookat mental health nursing. We need to treat peopleethicallydespitethemanyvulnerabilitiesthatweallhave.Maria Yasuoka looks at organ transplant recipients,cancersurvivorsandelderlypersonswhoareallatriskofseriousconsequencesiftheyareinfectedwithCOVID-19.

ItisnotallgloomanddoomasshowninthepaperbyRogelioBayodetal.wholookatthewaythatplantlovershavebeenabletospendmoretimecultivatingplantsandvegetablesandflowersduringthepandemicshutdown.Maybethiswillalsohelpusallaswegaspforfreshairinaverypollutedworld,asreviewedbyAlexWaller.

This isthefirstoftheextraissuesofEJAIB for2020,and it includes five further papers from the NineInternational Public Health and Bioethics Ambassadors(IPHA)Conferences that have been regularly held overthepastfewmonths,alongwiththreeotherpapers.

TheTenth International PublicHealth andBioethicsAmbassadors (IPHA9) Conference will be held 1-3October2020.Iinvitemanymorereaderstojoin.Pleasekeeponsubmittingyourpapers,and joining thevirtualconferences.-DarrylMacer,Chair,WorldCOVID19EthicsCommitteehttps://www.eubios.info/world_emergency_covid19_pandemic_ethics_committee

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COVID-19 community mask wearing: lessons from foot-binding and infibulation -StevenBRothman,PhDAssociate Professor, Ritsumeikan Asia PacificUniversity(APU),Beppu,JapanEmail:[email protected] Currentscientificevidencepromotestheuseofmasksasaprimarymeasure,inadditiontosocialdistancingandself-quarantine,topreventthefurtherspreadofCOVID-19 from person to person. Despite the importance ofmasks,compliancewithrequeststowearmasksvariesacross cultures around theworld and low compliancemay increase transmission rates among communities.Afterreviewingliteratureonmask-wearing,thisarticlefirst examines twomodelsof socialbehaviorbasedonthe Prisoner’s Dilemma and the Stag Hunt (tippingpoint). Then, combining thisworkwith research fromfoot-binding and infibulation mitigation, this articledemonstrates that social community behavioralcoordination along with game theoretic commonknowledge are important components to increasingmask usage. Finally, the article provides somesuggestionstoincreasemaskusageamongcommunitiesby re-orienting the social culture and increasingcommunitycommonknowledge.Introduction Increasing evidence in epidemiological researchfor COVID-19 suggests the importance of publicmask wearing as a means of preventingexponential spread of the disease (Wang, Ferro,Zhou, Hashimoto, & Bhatt, 2020). Even cursoryexaminationsofthedifferencesbetweentherateofinfection in Western (non-face mask wearinglocations) and Asia (common face-mask wearinglocations) suggests that mask wearing, at leastanecdotally, has a negative effect on spreadinginfection.Despite this evidence,maskwearing inthepublicremainscontroversialasapublichealthmandatedmeasure.PresidentTrumphassignaledseveraltimes,forexample,reluctancefromissuinga national mandate for masks due to theimportanceofindividualchoiceandfreedom(BBCNews, 2020). It is especially difficult forgovernments and authorities to encourageindividuals towearmasks inpublic, especially incultureswheremask-wearingisnotcommonplaceor the sociopolitical costsmay be higher (Utych,2020). Many political officials wear masks whennecessarytosignal to theirconstituencyorwhennecessaryoutsideofthepubliceye,yetdonotweartheminfrontofcamerasduetopublicscrutinyandpossiblecriticismoftheirappearance.Incontrast,otherofficials,suchasPrimeMinisterAbeinJapan,

consistently wears masks in public and duringpublicspeechesandannouncements.

Thispaper generates twopossiblemodels formaskwearingsuggestingaPrisoner’sDilemmalikegame or a Stag Hunt like game representing atippingpointmodel.Usingthetippingpointmodelas a point of particular examination, the paperpresents two other cases of tipping point socialbehaviorchanges,footbindingandfemalegenitalmutilation, to illustrate how social communitychangescanresultinmovingthetippingpointandincreasingmaskusage.Thepaperconcludeswithsomesuggestionsonincreasingimplementationofmask usage in communities where it presents ahigher social cost. The paper proceeds byreviewingbasicinformationontheefficacyofmaskwearingandtheresearchonpublicmaskwearingpractices. Following this brief review, the paperestablishes two common models for socialbehavior related to mask wearing and discussesthe importanceofcommonknowledgeandgroupsignaling to increase socialmaskwearing amongcommunities.Thesepracticesdrawontheresearchrelatedtotwoothersocialpracticesoffoot-bindingandinfibulation.Thepapersuggeststwopoliciestoencourage face mask wearing without therequirementsofstrictmandates.ResearchonmaskwearingduringCOVID-19pandemicThe research on mask wearing consists of twoprimaryareasinregardstoCOVID-19.Oneareaofresearch discusses the importance and use ofmasks inrelation topreventing thespreadof thedisease, essentially the epidemiologicalexamination of masks in relation to disease andCOVID-19. The second area of research involvesthe particular social behavior of individuals formask wearing. Most of the research on mask-wearingconcentratesonthe issueofefficacyandeffectivenessofmaskwearingwhilelittleresearchdiscusses the social practices of mask wearingamong the public,where this paper begins to fillsuchagapinourunderstanding.

Thereislittledoubtthatproperlyfittedmasksworn in medical environments help prevent thespread of infection to patients and to staff(Beckman et al., 2013; Klompas, Morris, Sinclair,Pearson,&Shenoy,2020).TheWHOrecommendsuseofproperandrationalPPEequipmentforstaffdependingontheirrisksofexposure(WHO,2020).Though this is commonlyknownandunderstoodwithin 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


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specificevidencetosuggestthatwearingofmasksbythemasspopulationhasanypotentialbenefit”(Howard,2020).SincetheemergenceofCovid-19,anumberofstudiesemergedexaminingtheeffectsofmasspublicmaskwearingonthespreadofthedisease(Eikenberryetal.,2020;Gandhi,Beyrer,&Goosby, 2020; Pejo & Biczok, 2020; Wu & Zha,2020).Todeterminewhetherandwhenmasksareeffective in preventing the spread of the virus isfundamentaltounderstandingwhetherandwhenindividualsmightbeaskedtouseandwearmasks.However, under uncertainty, many politicaldiscussions advocate the precautionary principlesuch that unless wearing masks are deemeddangeroustoindividuals,itisbettertowearthemas a precaution. Today most officials ingovernments are recommending mask wearingwhen in closed spaces and in close contact withothers to prevent spreading the disease, thoughactualuseofmasksisstillmixedinsomeareasoftheworld.

In the second set of research, there is limiteddiscussion. Although there are some studies onsocialbehaviorandmaskwearing,thereareverylittleconclusionsdrawnfromthisresearchandfewsuggestions for policy makers and communities.This research fills part of that gap by providingboth a social science understanding of maskwearing behavior and suggestions for improvingsocial conformity tomaskwearing. The researchfrombehavioralsciencesisquitescantintheareaof COVID-19. It is clear, however, through somesurvey research in Japan, for instance, that socialfactorspayakeyroleincommunitymaskwearing(JapanLife, 2020).Thoughone researcharticle inparticularpointstoalargenumberoffactorsthatcontributetobehaviorofindividualduringsuchacrisis pandemic, pointing to areas ofcommunication and risk/threat assessment,political and social groupings, zero-sum thinkingand cooperation within groups, moral decisionmaking,leadership,andothers(Baveletal.,2020).Thediscussioniscomprehensive,examiningmanyareas of socio-behavioral variables that influenceindividual behavior, though limited in depth andrecommendations on particulars to improvebehaviorduringthepandemic.ModelingmaskwearingforCOVID-19Game theory modeling is useful to examineinteractionbetween individualswhentheactionsofeachindividualaffectthebehaviorandbenefitofothers in themodel. Game theoreticmodeling iswidely used to examine behavior in socialsituations, such as community mask wearing.Modeling relies heavily on the importance ofassumptions of themodels and the rationality of

actors when comparing the results of the modelwith thegeneralbehaviorof individuals,externalvalidity.

Inthemostbasicmodel,wecansimplifymaskwearing to two individuals with two choices (towear a mask or not to wear a mask). In thissituation,wecanassumethatthereissomecosttowearing a mask, whether that cost involvesbreathingdifficulties,thecostofbuyingorcleaningmasks or social difficulties.We also assume thatthere is some benefit to the wearer of masks inrelation to thedisease,but thebenefit isgreatestwhen theentirecommunitywearsamask.Whenoneindividualwearsamaskandothersdonot,forexample, the benefits are very limited becausewhilethemaskofferssomeprotection,itsgreatestbenefit is in preventing exposure to others(wearingamask).Inotherwords,itwouldbebestfor any individual if everyone else is wearing amask, thus he/she receivesmost of the benefits,whilethatsameindividualdoesnotwearamask,facingnocost(afree-rider).Asageneralguidelineweassumethat if thebenefitsofwearingamaskare greater than the costs, individuals will wearmasks.However,thedifficultyinknowingwhetheronebenefitsfromwearingamaskcomesfromthefactthatone’sbenefitisatleastpartiallycontingenton the behavior of other individuals. Wheneveryoneelsewearsamaskandyouwearamaskthebenefitisgreatest.

There are two general game theoreticmodelsthat might illustrate the situation with maskwearing, the StagHuntmodel and the Prisoner’sDilemma model, depending on the assumptionsmade.Ingeneral,wecanassumethatthecostsofgetting sick are very high and that therefore theinverse, the benefit of avoiding getting ill is veryhigh. Since these benefits are high, we can alsoassume that the costs of wearing a mask aresomewhatsmallrelativetothebenefits.Theissue,then comes to whether wearing a mask actuallyresolves to provide the benefits of preventingillness.Themanifestationof thisbenefitdependsonthebehaviorofotherindividuals.

These two models are quite commonly usedwithin research on social behavior. In particular,thePrisoner’sDilemmaiswidelyusedtoillustratesituations where individuals would prefer toengage in individually beneficial behavior thatleads to sub-optimal social outcomes for thecommunity. The Stag Huntmodel iswidely usedmoregenerallytoillustratethebasicconditionsofa tippingpoint,where twooutcomesarestable–everyonechoosesonehighlybeneficialoutcometosociety or everyone chooses a lower benefitoutcome, individually beneficial but socially sub-optimal.


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For both models, we can illustrate theinteraction of individuals through a 2x2 gametheorymodel(Table1).Themodelrepresentsaninteractionbetween“society”andthe“individual”as twoplayers in themodel.Eachplayerhastwochoices, either to wear a mask or not to wear amask. This creates four potential outcomes, bothwearamask,bothdonotwearmasks,oronewearsamaskandonedoesnot(foreachplayer).Withineachoutcome,wecanillustratetheexpectedvaluefor thatplayerof theoutcomebydesignating theleftnumberfortheleftplayer(individual)andtheright number for the top player (society). Theexpected value represents a measure of benefitrelativetootheroutcomespossibleinthemodel.

IntheStagHuntmodel,wecanassumethatthebenefit only occurs when there is universalcompliance with social mask-wearing. If weassumethatthebenefitofavoidingillnessoccursifandonlyifallotherswearthemask,wegenerateamodel that resembles the Stag Hunt or tippingpointmodel of behavior. Thus, for the StagHuntmodel, the value of the outcome where bothplayerswearamaskis10becausethereisalargebenefitinthiscasewheneveryonewearsamaskinthegroup,comparedtoacasewheretheindividualwearsamaskandnootherpersonwearsamask.Inthiscase,thereisnobenefitbecausethebenefitonly occurs when others wear the mask. Bycomparing these expected values, two NashEquilibriaemerge,whereeveryonewearsamaskor no one wears a mask. Nash Equilibriumrepresents a stable state of the model, whereneitherplayerhasanincentivetoaltertheirchoicewithout incurringaworseexpectedvalue. In thismodel,where thereare twoequilibria, themodeldoesnotpredictwhichoutcomewillemerge,butillustratesthepremiseofatippingpoint.Ifenoughpeople wear masks, the equilibrium will shift toeveryonewearing amask, but if no onewears amask, it is not likely that any individual willunilaterallydecidetowearamask.

Inthismodel,illustratedinTable1,weseethattherearetwostablepurestrategyNashequilibria,onewhereallindividualsdonotwearmasksoronewere all individualswearmasks. This representscloselytotheStagHuntgeneralizedmodelorthetipping point model. While both Nash Equilibriaare possible and stable solutions, the preferablesocial optimal Nash equilibrium is one in whicheveryonewearsthemaskandpreventsindividualsfrom getting sick (note that the model ignoresother social costs such as hospitalization andtreatmentfortheill,butthatshouldonlyincreasethebenefitsofwearingamaskandpreventingthespread,thusstrengtheningtheresultsillustrated.)

Table1:SocialmodelsofmaskwearingStagHunt Society

Wear amask

Do not wearamask

Individual

Wear amask

10*,10* 0,2

Donotwearamask

2,0 2*,2*

Prisoner’sDilemma Society

Wear amask

Do not wearamask

Individual

Wear amask

3,3 1,4*

Donotwearamask

4*,1 2*,2*

Anasterisk(*)indicatesapreferredoutcome,whiletwoasterisks in the same cell indicate pure strategy NashEquilibrium.

InthePrisoner’sDilemmamodel,wealterthe

assumptionsslightlysuchthatthebenefitdoesnotdepend on universal compliance but depends onothers’ compliance. Inotherwords, there is littlebenefit to yourself when you wear a mask, butthereisbenefitforotherswhenyoudoso.Similarto the Stag Hunt model, the Prisoner’s Dilemmamodels interaction between an individual andsociety, though the expected values andpreferencesovertheoutcomesdiffer.Themodelisdrawnthesamewayasforthestaghuntexplainedabove.Although in this case, the expected valuesrepresent a relative value preference (ordinal)primarilyandshouldnotbeusedtocompareanymagnitude difference (cardinal) outcome. In thiscase, however, the most preferred outcome iswhere the individualdoesnotwearamask, suchthatit incursnocosts,andeveryoneelsewearsamask,achievingfullbenefit.Thisisessentiallythefree-riderpositionwhereeveryoneelseincursthecost for one’s own benefit. The second mostpreferredoutcomeconsistsofeveryonewearingamask because there is a high benefit for eachpersontodoso,thoughthereissomecostinvolvedinwearingthemasksasassumedinthemodel.Thesecondtoworstoutcomeiswherenoonewearsamask. Insuchacase, there isnocost forwearingthe mask, but also there is no benefit for notwearing a mask. Finally, in the worst case, onebecomesthe“sucker”wherebytheywearamask,but others do not. In this sense, the individualwearingthemaskisincurringthecostforothers’benefit, but not receiving any benefit of his/herown.Inthiscase,weassumethatifeveryoneelsewears amask one can receive the benefit of notgettingillthoughtheydonothavetowearthemaskthemselves. The model is illustrated in Table 1,whichresemblescloselytothePrisoner’sDilemma


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model.Inthiscase,wehaveonepurestrategyNashEquilibriumwherenoonewearsamaskbecausethereisnoadditionalbenefitfromwearingamaskwheneveryoneelseiswearingthemaskbutthereis anadditional cost towearing themask. In thismodel,theonlystablepurestrategyoutcomeisonewhere no onewears amask, but againwe see abettersocialoptimalinwhicheveryonewearsthemask.

Inbothcaseswecanconsiderpoliciesthatwillhelpmotivate individuals towearmaskswithoutmandating such masks. One of the primaryrequirementsformovingfromoneequilibriumtothe other in the case of the Stag Hunt (tippingpoint)involvespubliccoordinationofbehaviorandmaintaining common knowledge among theparticipants. For the Prisoner’s Dilemma, thesituationisonlyslightlymorecomplicatedasitispossible to move from sub-optimal socialequilibriumtotheoptimalsocialequilibriumwithincreased transparency of actions andcommunicationbetweentheactors.Inbothcases,communication, transparency, and coordinationcanshifttheoutcomefromasub-optimalonetoasociallyoptimaloutcome.Inthecaseforthispaper,introducingspecificpoliciesorientedtowardthesevariableswouldhelpmoveindividualsfromanon-wearingmask equilibrium,which is socially sub-optimal, to a more socially optimal situation ofcommonpublicmaskwearing.Oneofthepoliciesusedpreviously inothercases toencouragesuchbehavior increases the social costs of non-compliance,suchasisdemonstratedinthecasesoffoot-binding and female genital mutilation. Thefollowing sections discuss these two cases andillustratethefindingsthatmightapplytothecasesof COVID-19 and mask wearing for individualsaround theworld and implementing governmentpolicies.ChinesefootbindingandinfibulationChinesepracticeoffoot-bindingbeganasapracticedesigned to reduce uncertainty around paternityconcerns during the polygamous period of theChinese elite and to restrict the movement ofconsorts. In order for lower class individuals,fathersinparticular,tohelptheirdaughtersmarryupwardinthesocialhierarchy,theyalsoadoptedthepracticeand thepracticebecamewidespreadamong the population in China. In a sense, if afamilydidnotbindthefeetoftheirdaughters,thedaughterwouldsuffersociallyandwouldnotbeapreferred consort ormarriagepartner forhigherlevels of society (Rosenburg, “How history getsthingswrong”).

Mackie (Mackie, 1996) identified twobackgroundfactorsthatencouragedtheendoffootbindinginChina,intheintroductionofwesternized

culture discouraging the practice and industrialchangesthatselectedagainstthosewhohadtheirfeet bound and restricted movement for work.Thesefactorsalteredindividualpreferences,butinthe larger societal system, foot binding was stillfavored for marriage and consorts. In order tochangethesystem,thetippingpointequilibriumorStagHunt requires a largenumberof individualswithin the same community to change theirbehavior to alter what is “normal” among thatpopulation. As individual families slowly madechanges, the group of individuals and villagesbecamelargerandlarger,changingtheequilibriumfrom foot binding to non-foot-binding practices.Once the group became large enough it becamedisadvantageous socially to have footboundchildren because they were selected against insociety(Mackie,1996).

Similarly,theseprincipleshavebeenappliedtoothersocialpracticesencouragingtheremovalofthose practices, exemplified with infibulation.Similar to footbinding, infibulationemerged in asimilar set of circumstances to control paternityand “enforce imperial male’s exclusive sexualaccess tohis femaleconsorts” (Mackie,1996).Byusingthesamemethodsofcoordinatingbehavioramong a large group, it is possible to generate atippingpoint(Schelling,1973)andshiftbehaviorfromengaginginthepracticetodisengaginginthepractice. It is important to note that the tippingpointmodelusuallyhasoneoutcomewithamuchhigher benefit for society than the other, despitethe fact that both outcomes are stable NashEquilibria. This typeof tippingpoint andmovingthe equilibrium through commonknowledgeandsocial coordination of behavior is so strong thatdifferent organizations and advocates canimplement the policies in local communities(UNICEF, 2005). By applying similar socialcommonknowledgeandcoordinationprinciplestothe mask issue, it may be possible to shift thecommunitieson a local level andeventuallyon anational level to encourage mask-wearing andawayfromthenon-maskwearingequilibrium.

Recommendations Policiesorientedtowardmovingtheequilibriumintheabovemodelsarebestsuitedtoincreasemassmask-wearing among populations andcommunitieswheremask-wearingisnotgenerallyaccepted.Inparticular,basedontheexperiencesoffoot-binding and infibulation practices, suchpolicies includereorientingculturetowardmask-wearing and building community commonknowledge. Although there is some difficulty inaccomplishing these goals, neither requiregovernment forceful implementation of mask-


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wearing and penalties. In both cases, the socialnormsandtippingpointscanpromote theuseofmasks among the community. When a smallcommunityisabletomeettogetherandpromisetowearmasks,wherebyallcommunitymembersgaincommon knowledge that all others within thecommunity also agree to wearmasks, the policycanbemost successful. This commonknowledgerequirementisvitaltoimprovingcompliancewiththenorm.

Of course, other social policies can also bepursued to increase cooperation. This includesrepeated interaction among individuals, whichoccurs within smaller communities and workplaces. When people interact on a regular basis,cooperation becomes more likely based on themodels of repeating Prisoner’s Dilemmaindefinitely,whichisusuallythecaseinmanyworkand social environments where the end of therelationship is unknown to the participants. Inaddition, extending time horizons beyondimmediate gains can also improve cooperationamongthegroup.Orientingpeopletowardlongerterm relationships within the community makescooperationmore likely, just as the institutionofmarriage orients individuals toward long termrelationships and away from one-date or short-termrelationships.

By incorporating social policies such as thosediscussed above, communities can increase thecompliancewithmaskwearingbybuildingsocialnorms among communities and discouragingindividual non-compliance. Rather than focusingonthediseasethemselvesandtherisks involved,social norm compliance works better thanindividual risk assessment. Similar to riskassessmentanderrorinprocessinglongtermrisksof smoking (Slovic, 2001), individuals oftendiscount long-term risks associated with illnessand thus cost benefit analysis often fails toencourageappropriatebehavior.Socialnormsandsocial conformity, instead, allow for greatercompliance and conformity with mass maskwearingforpreventingthespreadofCOVID-19. References Bavel,JJV,Baicker,K,Boggio,PS,Capraro,V,Cichocka,A,Cikara,M, et al. (2020). Using social and behavioural science tosupportCOVID-19pandemicresponse.NatHumBehav,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 inCalifornia hospitals during the 2009-2010 H1N1 influenzapandemic. Am J Infect Control, 41(11), 1024-1031.doi:10.1016/j.ajic.2013.05.006

Eikenberry, SE, Mancuso, M, Iboi, E, Phan, T, Eikenberry, K,Kuang,Y,etal.(2020).Tomaskornottomask:Modelingthepotentialforfacemaskusebythegeneralpublictocurtailthe

COVID-19 pandemic. Infect Dis Model, 5, 293-308.doi:10.1016/j.idm.2020.04.001

Gandhi,M,Beyrer,C&Goosby,E(2020).Masksdomorethanprotect others during COVID-19: Reducing the inoculumofSARS-CoV-2 to protect the wearer. J Gen Intern Med.doi:10.1007/s11606-020-06067-8

Howard,J.(2020).WHOstandsbyrecommendationtonotwearmasks ifyouarenotsickornotcaring forsomeonewho issick. CNN. Retrieved fromhttps://edition.cnn.com/2020/03/30/world/coronavirus-who-masks-recommendation-trnd/index.html

JapanLife.(2020).JapaneseSocialConformityBehindWearingof Face Masks. JapanToday. Retrieved fromhttps://japantoday.com/category/national/japanese-social-conformity-behind-wearing-of-face-masks-amid-pandemic?

Klompas, M, Morris, CA, Sinclair, J, Pearson, M & Shenoy, ES(2020).UniversalmaskinginhospitalsintheCovid-19era.NEnglJMed,382(21),e63.doi:10.1056/NEJMp2006372

Mackie, G. (1996). Ending footbinding and infibulation: Aconvention account. American Sociological Review, 61(6),999-1017.

BBCNews. (2020, July18).Coronavirus:DonaldTrumpvowsnot to order Americans to wear masks. Retrieved fromhttps://www.bbc.com/news/world-us-canada-53453468

Pejo, B & Biczok, G. (2020). Corona games: masks, socialdistance and mechanism design. Retrieved fromhttps://arxiv.org/abs/2006.06674v2

Schelling,TC.(1973).Hockeyhelmets,concealedweapons,anddaylightsaving:Astudyofbinarychoiceswithexternalities.JournalofConflictResolution,17(3).

Slovic,P.(2001).Smoking:Risk,Perception&Policy.ThousandOaks:SAGEPublications.

UNICEF. (2005). Coordinated strategy to abandon femalegenital mutiliation/cutting in one generation: A humanrights-basedapproachtoprogramming.

Utych,SM.(2020).MessagingmaskwearingduringtheCOVID-19 crisis: Ideological differences. Journal of ExperimentalPoliticalScience,1-11.doi:10.1017/xps.2020.15

Wang,X,Ferro,EG,Zhou,G,Hashimoto,D&Bhatt,DL.(2020).Association between universal masking in a health caresystem and SARS-CoV-2 positivity among health careworkers.JAMA.doi:10.1001/jama.2020.12897

WHO. (2020). Rational use of personal protective equipment(PPE)forcoronavirusdisease(COVID-19).WHO.

Wu,J&Zha,P.(2020).Maskisadouble-edgedswordinthefightagainst COVID-19 pandemic. SSRN Electronic Journal.doi:10.2139/ssrn.3563851

Balancing autonomy and justice in the U.S. with a coronavirus outbreak -AnnBoydandBrandiDavidsonHoodCollege,Frederick,MD21701,USAEmail:[email protected] With the emergence of a new respiratory virus, SARS-CoV2,inWuhan,Chinaneartheendof2019,itwassoondeterminedthatpersontopersonspreadcouldleadtoapandemic.Scientistsquicklyisolatedandsequencedthevirusandidentifiedthebasicvirusasacoronaviruswithsevererespiratorypathology(COVID-19).WHOalertednationstotheseriousnessandrapidspreadofthevirusin late January 2020. The Center for Disease Control(CDC)intheU.S.respondedwithpublichealthalertsandlocalpublichealthdepartmentsbeganpreventativebest


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practices: test, isolate, quarantine and treat. However,theresponsewasslowand inconsistentandbyMarch,2020 states were imposing social distancing, closingschools and other social gatherings to reduce spread.Testing was limited in availability and individualsresponded to public health requests with variablecompliance.Inlessthanayear,5.5millioncitizensintheU.S. were infected and 172,000 died. Even as thepandemic continues its natural course, and scientistssparenotimeincreatingavaccine,itisclearthatCOVID-19 reveals conceptual tension between autonomy andjustice. Introduction Thecoronavirusdisease2019(COVID-19)causedby infection with Severe Acute RespiratorySyndrome–Coronavirus2 (SARS-CoV2), anewlyemergent virus, is challenging public health andhealthcaresystemsglobally.Thenationalguidancefrom the Center of Disease Control (CDC) in theUnited States, includes social distancing, self-quarantine, and closure of many businessesincluding schools. The speed of virus spreadpromptedmore dramatic social restrictions thanarecommoninotherpandemicssuchasseasonalflu.Suchactionsarejustifiedinordertoprotectthefunctional capacityof thehealthcare system. It isdifficult to accurately predict the severity of anyone individualcaseofCOVID-19. Individualsmayaccept or reject messages about public healthconstraints.Thepandemicrevealsashift infocusfrom individual patient focused clinical care tocommunal strategies highlighting social justice.Imbedded in the shift is the tension betweenautonomyandsocialjustice.Thegoalofthispaperistoanalyzehowharmonyofautonomyandjusticewouldbenefitresponsetothispandemic.CoronavirusesFourcommoncoronavirusescirculategloballyinaseasonalpatterncausingcommoncoldsymptomsand resolve without medical intervention unlessindividuals have some underlying immunologicalormedicalcompromisingcondition.In2002-2003,a spillover occurred in Guangdong, China. OnNovember16,2002amaninFoshanhadfeverandrespiratory distress, and three weeks later arestaurantchefinShenzhenbecameillwithsimilarsymptoms.Bothmenhadexposuretoseveralwildanimals used in culinary dishes. Symptomsincluded headache, high fever, chills, body aches,severe and persistent coughing, coughing upbloody phlegm and progressive destruction ofpulmonarysystem,oxygendeprivation leadingtoorgan failure and death (Quammen, 2012). Thesevere acute respiratory syndrome (SARS)describesthemedicalsymptoms,butthecausativeagentwasunknown. Scientists tested specimens

for antibody and searched for nucleic acid (RNAandDNA)matches by polymerase chain reaction(PCR)usingprobestoknowninfectiousagents,e.g.H5N1, Hanta virus, pneumococcus. Nothing wasfound in the known agent collection that couldproduce such symptoms. The interpretation wasthat a virus had crossed from some animal tohumans,anemergingzoonosis.

Efforts tocultivatevirus frompatientsamplessucceeded and the publication cautiouslyannounced a new coronavirus as the “possiblecause” of SARS. Itwas the first coronavirus everfoundto inflictserious illness inhumans. Familyand health workers attending these cases wereinfectedandthevirusspreadtoHongKong.Whena grandmother visiting family in Hong Kong,returnedtoherhomeinTorontoinfected,thevirusbecame an outbreak but good public healthinterventionpreventeditfromcausingapandemic.Eight thousandcasesweredocumentedwith774deaths.Thescopeof theoutbreakwas limitedbygood laboratory diagnostics, finding andidentifyingthevirus,coupledwithefficientpublichealthinterventions:caseswereisolated,contactswere traced and quarantine measures wereinstituted in southern China, Hong Kong, andToronto(Quammen,2012).

In 2012 another coronavirus emerged in themiddleeastcausingasimilarrespiratoryillnessin2494 confirmed cases with 858 deaths. Thisoutbreak was called MERS for Middle EastRespiratory Syndrome. Scientists identified thevirussequenceandmappedbothMERSandSARS-CoV to a phylogenetic tree of coronaviruses. Thespike glycoprotein is the outer most structuralprotein on the virus and is responsible forattachment to cells through the angiotensinconvertingenzyme(ACE2)inthecaseofSARSbutMERSusesadifferentreceptorandantibodydoesnot cross react between SARS and MERS.Furthermore,antibodythatneutralizesSARS-CoV1doesnotneutralizeSARS-CoV2(Ou,X.etal.,2020).

SARS-CoV2wasnamedaninternationalpublichealth emergency by World Health Organization(WHO)on30January2020,followingisolationandsequencingofthevirusinJanuary2020inWuhan,China. The announcement was preceded byscientificdata indicatingcommunalspreadof therespiratory pathogen and reports of person toperson spread. By February 2020, cases wereconfirmedinEuropeandtheUS.Incubationof2-14dayswithanunknowncasefatalityratemadeitdifficult to limit exposure especially amongasymptomatic infected persons. In addition tointensestudyof thevirus, its complexpathology,scientists andmedical personnel sought ways to


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treat the infectionandresearchescalated towardcreatingavaccine(Rabi,F.etal.,2020).

Every known vaccine creation strategypreviouslyusedandseveralnewapproachesareindevelopment with over 140 trial vaccines beingdevelopedandfourteenoftheminhumanclinicaltrials. The leading vaccines currently inPhase IIItrialsincludeAstraZenecaandUniversityofOxfordvaccine made from a weakened version of acommon cold virus (adenovirus) as vector andexpressingSARS-CoV2spikeprotein.ThePhaseIIItrials are taking place inBrazil and SouthAfrica.Thedevelopingcompanyhaspromised to supplymore than 2 billion doses globally anticipatingdelivery of 400 million doses before the end of2020.ModernainpartnershipwiththeNIHbeganphase III trial July 27, 2020 with 30,000 adultvolunteers.ThevaccineismRNA-1273thatcarriesinstruction for cells to produce the viral spikeprotein. BioNtech, Pfizer and Fosum Pharmacollaborativelyaretestingfourvaccineseachusingmessenger RNA in different combinations totargetedantigens.TheUSgovernmenthasplacedaninitialorderfor100milliondosespaying$1.95billion (Doheny, 2020). Lacking a thoroughknowledge of immunological requirements forprotectionagainstinfectionifexposed,itisdifficulttoassesseachvaccinecandidate’sworth(AmanatandKrammer,2020).

SARS-CoV-2 pandemic and US response:Abidingby thepublichealthguidelines toreduceriskofcoronavirusinfection,peoplewereaskedtorestrict activity, many businesses closed, schoolsandchurchesandotherplacesofgroupgatheringsceasedmeeting.Self-quarantineandstayathomeorders were variously enforced by local officialsand by state authorities. Hourly wage workersweremoreseverelyimpactedthanemployeeswhoeitherhadpaidleaveorcouldworkremotelyfromhome. The economic toll was immediate andserious.Whiletherateofinfectionsteeplyroseinsomeareas, otherswereminimally affected.Thisled to some skepticism about whether therestrictionswerenecessary inrelationship to theeconomic hardships. In some cities, groupsprotested the shut-down, arguing the economicimpactwasdisproportionate to thepublic healthmeasures. Individuals expressed concerns thatautonomyandlibertywasbeinginfringedwithoutsufficientjustification.Itisdifficulttomeasurethenumberofinfectionsthatdidnothappenduetotheshut-downandmobilityrestrictions.Ifapersonisyoung,healthy,anddependentonincomebasedonhoursworked,itishardertodemonstratethattherisk to one’s health is more important than thedeprivations causedby lackof income. For thoseliving paycheck to paycheck, the hardships were

amplified, risking housing, food, and other life -essentials.Herecommunication that isconsistentandtransparentanduniformlyappliedwouldhelpbutperhapsnotsatisfyeveryone.Desperationanda highly valued individual autonomymade someindividuals defy precautionary restrictions.Refusing to stayhome,gather ingroups,orwearmaskswereexpressionsofindividualfreedomthatwouldnotmeetthestandardofarelationalconceptof autonomy. Individual risk-benefit assessmentsreflectedmanyconfoundingvariablesintheirlives,from socio-economic, trust in public healthprotections, and perception of seriousness ofinfection.Manychoosesurvivalofthefamilywithits accompanying risks in working jobs thatexposedthemtoinfection.

Autonomyistheexerciseandprivilegeofself-governance, advocated by people across a widespectrum of political philosophies. The Westernethicalandphilosophicalnotionofautonomyisthecognitive ability and freedom, values and reason.Eighteenth century philosophers such asImmanuel Kant emphasized autonomy as anethicalexerciseofreason.Anypersoncouldapplya reasoned analysis to a situation and create adefensibleplanofaction.Kant isclearthat inthereasoningprocesstheactiondecideduponwillbeonethatallotherscouldactonsimultaneouslyandwould never use others as a mere means. Anautonomous agent then recognizes his intrinsicvalue as a rational being and sees no relevantdifference between persons, accepting all otherrationalbeingsasequals.

Conditionsinoursocial,physicalandemotionalenvironment influence exercising the will set byautonomous reason. In the midst of a pandemicwithrapidspreadofvirusfrompersontoperson,how many people can exercise the freedom toignorepublichealthguidancewithoutdoingharmto others? In the more traditional context of adoctor-patient conversation regarding treatmentofadiagnosedillness,thefreedomtoapplyreasontodecidehowtomedicallyproceedwithtreatmentisaverydifferentscenariothanhavingavirusandspreading it to others. Autonomy recognizesindividualsasmoralagentsbutanticipatesalevelofmoralresponsibilitythatisimportant.

Moralresponsibilityreferstotheaccountabilityof anagents’ voluntary choiceand to a judgmentabout the rational justification of the agents’choice. Inbothways,amoralagent,while freetochoose according to reason, is neverthelessresponsiblefortheweightofconsiderationsgiventotheeffectofanactiononothers.Apersonwhoacceptsresponsibilityforactingasamoralagentissubject to the critique of the community. Thewillingness to take responsibility for our own


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characteraspersons–toknowwhoweare–andtocareabouthowourchoicesaffectothersismoralresponsibility(Gauthier,2000).Justice: Individuals live within communities,families, and societies. Recognizing the unfairdistributionoftalents,abilitiesamongindividualswithinasocietyledRawlstoproposeasystemthatwouldgivespecialadvantagetothedisadvantagedbywayofcompensatingadjustments.Developinga fair and just system could be obtained byimaginingahypotheticalpositioninsocietywhereour talents and position is unknown and can beanyonewithinthecollective.Thissocalled“veilofignorance”awakensasensitivitytoeconomicandsocialinequalitysothatifwewereatthe“bottom”of the social construct, we would advocate for adecent minimal assistance to be contributingmembers of society. By elevating the worst-offmembers of a social group, the entire societybecomes more attractive and socially stable(Rawls,1971)

In the current context of a virus pandemic,justiceinhealthcarewouldexpectequivalentandequal medical treatment for persons infected bytheviruswithoutlimitationsimposedbyinsurancecoverageandaffordabletreatment.Forthebenefitof the community in which a COVID-19 patientresides, treatment and confinement of the sickindividualbenefitsthesickpersonandallwhoarepotentiallyexposedtothevirusthroughhim/her.Equalitywould support a system inwhich everyworkercouldrecoverwageswhilesociallyisolatedfor the benefit of others (MacKay, 2018). Toachievefairdistributionofrisksandbenefits,ifweask hourlyworkers to keep the subwaysmovingand the nursing homes staffed, some protectionshouldbeprovidedthroughregulationsorpolicies(Rawls,1993). It isclearly inthebest interestofsociety to make it possible for an infectedindividualtoquarantine.Likewise,itisreasonableforpublichealthauthoritiestoimposerestrictionson behaviors contributing to virus spread, beingparticularlyprotectiveofthemostvulnerable.

Public health is defined by the Institute ofMedicine (IOM) as “what we, as a society, docollectivelytoassuretheconditionsforpeopletobehealthy.”Toaddresstheproblemsspawnedbypandemics,publicofficialsarerighttoconsiderthecollective benefits of population health overindividual interests. It is tempting to stress thetensionbetweenindividualandcollectiveinterestsand ignore the synergies. Without ignoring theimportanceofindividualliberty,freedomofchoice,and the importance of autonomy, public health’scharge is the health andwell-being of thewholecommunity. Prevention of harm is prioritized inpublic health. The “harm principle” in bioethics

insists competent adults have freedom of actionunless they pose a risk to others. Just as statesrequire seat-belt use through legalmeans, publichealth authorities with the support of stategovernorscanandshouldactinpaternalisticwaystolimitspreadofadeadlyvirus.

Local public health agencies in high impactareas struggled in thebeginningof thepandemicwith allocation of personal protective equipment(PPE).Frontlineworkersinhealthcare,essentialworkers whose exposure to the public increasetheirriskofinfectionareduetheprotectionofPPEand should have first priority in distribution(Gostin,2016).Asvaccinesclearclinicaltrialsandare approved, it is likely that distribution of thefirst available batches will be another seriousdistribution dilemma.Will the same priorities asforPPEserveforvaccine?

Some states mandate vaccination for specificinfectious diseases for all school children,providing exceptions on medical grounds. Theproponents of mandatory vaccination prioritiesthe collective welfare and health of communityoverindividuallibertyclaimingbeneficenceastheguiding principle. A public health mandate orpolicyshouldclearlyarticulatethejustificationandthemessageneedstobedeliveredconsistentlyandclearly.Carefulanalysisisrequiredtoensurethatsuch policies don’t infringe upon some groupsmoreheavilythanonothers.

Asadexampleistheshortageofventilatorsthatcaused rationing decisions in some hospitals. Arecommendation to limit elective surgeries wasintendedtopreservehighvalueresourcesforcareofCOVID19patients.Physicianswererequiredtomake a rapid transition from patient centeredpracticetotriageoflimitedresources(Dunhametal.,2020;DeBruinandLeider,2020).

VulnerableGroups:Ageisoneofseveralcriteriaused to allocate beds in the intensive care units(ICU) in assessment of likelihood of survival. Inearly weeks of the outbreak, younger peopleappearedtonotdevelopseriouscomplicationsbutthat turned out to be only partially true. It isactuallyveryhardtopredictwhowillandwillnotbenefitfromICUintervention.Personsaged50orolderrepresent35%oftheUSpopulation,accountfor 40% of the gross domestic product andcontribute 43% of tax revenue according toAmericanAssociationofRetiredPersons (AARP).Respecting each person, regardless of age, andevaluatingbesttreatmentoptionsisthemostjustapproach (Carrieri, et al., 2020). The rates ofseveresymptomswereobservedtoincreasewithage and among those hospitalized early in thepandemic more than half were age 60 or older(Powell andEhrlich,2020).Preventing infections


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among frail older adults with comorbiditiesmayhave been better if the distribution of PPE tonursinghomeattendantsanduniversaladherencetopublichealthbestpracticeshadbeenenforcedearlyandconsistently.

African American and Hispanic communitiesbear a disproportionate burden of disease thatrevealsystemicinjustice.CDCdatarevealthatonein three people sick enough to requirehospitalization from COVID-19 were AfricanAmericanwhomakeup13%oftheU.S.population.Underlyingmedicalconditionsandhigherratesofjob exposure to virusmay account for increasedincidence.Toprotectolderadultsand thosewithunderlying medical conditions is the mainjustificationforpreventivemeasures.

Applying these principles and the RawlsiansocietytotheSARS-CoV2pandemic,itisclearthatRawls would be concerned about vulnerablegroupsandhowtheywouldbeimpactedbysocialdistancing, stay at home orders, or otherrestrictionsaimedatcurtailingvirusspread.Somepeople have greater share of responsibility forkeeping society functioning, such as healthworkers, first responders, essential businesses.Closingschoolsanddaycarecenterscreatedmoredifficulty for families wherein the parents wereessential employees. Childcare became a sharedsocial,expandedfamilyresponsibility, inordertoprotect children from exposure to the virus byparentswhowereprofessionallyexposedtovirusdaily. Children who receive free meals, stayinghome could mean hunger, so efforts to providemealsatacommonlocationwereeffortstoaddressthe inequalityofaffect the imposedpublichealthmeasureshadondifferentfamilies.

CompetingprinciplesConflict and controversy arose after weeks ofimposed restrictions, with people expressingconcernsabout lossofhumanfreedomor liberty.Asfreehumanbeings,libertycannotbetakenawaybutitcanberestrictedtemporarilyasthesecondprincipleofRawlssuggested:unequaldistributionisallowedaslongasitisadvantageoustoall.Underthe conditions of restricted movement to limitspread of a seriously pathogenic virus, socialdistancingandself-isolationarethemosteffectivecontrolmeasuresavailable.BecauseSARS-CoV2isanewlyemergentvirus,thereisnoknowneffectivetreatmentotherthansymptomcontrol.Giventherapid spread of infections globally, the mosteffective public health intervention was to limitspreadbyquarantine(LeiandQui,2020).

Liberty infringingmeasures tocontroldiseaseare justified if the risk of harm to others can besignificantly reduced. Government authorities

havearesponsibilitytoactandruleinfavoroftheircitizens.Theyareresponsibleforthewell-beingofcitizensandforprovisionofaframeworkinwhicheveryperson canpursue their self-directedgoals(autonomy). Sadly, mistaking limited, temporaryrestrictionstomobilityasanassaultonindividualfreedom and liberty could contribute to the factthatconfirmedcasesofcoronavirusinfectiongrewfasterintheUSthananyothernation(Nace,2020).

Healthcare coverage is a patchwork in whichsome benefit more than others. Whereas theAffordableCareAct(ACE)providedmoreMedicaidcoverage,andexpandedaccesstohealthinsurance,opponents consistently chip away at the law,seeking to either amend or repeal it. TheUS hasdiscussed universal health care since TheodoreRoosevelt was President and we still lackconsensustomakeitanationalpolicy.PandemicslikeSARS-CoV2remindusagainthatthefailuretocoverallcitizenswithadequatehealthcareaccess,leads to inequalities that call forth social justiceconcerns.Itmaybeautonomouschoicetohaveornothavehealthinsurance,butwhenyourinfectiongoesuntreatedandyouexposemetoapotentiallylethal virus, theethical issuequicklymoves fromautonomy to justice. Larry S Tempkin remarks:“manybelievethatitisunfairwhenfundamentallydecentpeopledon’tfarewell…andsincereasonsofjusticeapplytoeveryone,therewouldbereasontoprovide equal and high quality health care to allfundamentally decent peoplewhose 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 andacknowledgehumansufferingandtointegratethatknowledge into the decisionswemake. Commonhumanity is a bridge to moral maturation and aleveler in mutual respect. The implication ofempathymovesus to seeothersasequivalent toourselves, deserving of healthcare if ill, andrespectfulactionsthatlimitexposuretoinfectiousvirus. Leaving subpopulations without medicalinsurance,vulnerabletohigherratesofinfection,isdifficulttoreconcilewithcommunalgood.Itisinsuch limited choices where autonomy isconstrainedbysocialinequalities.Theautonomouschoice of individuals to not wear masks or self-isolate puts others at risk especially those invulnerable groups. Disproportionate sharing ofburden of disease by some suggests that socialjustice needs more emphasis. Understandingautonomy as moral responsibility helps createharmonywithsocialjusticerequirementsinpublichealth. Where these two principles are out ofbalance, people suffer. Careful rebalancing is


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needed to avoid more harm and to protect thehealthandwellbeingofeveryone.References Amanat, Fatima and Florian Krammer, (2020) SARS-CoV-2Vaccines:statusreport,Immunity52:583-589.

Carrieri, Daniele, Fedro Alessandro Peccatori, and GiovanniBoniolo, (2020) COVID-19: a plea to protect the olderpopulation,InternationalJournalforEquityinHealth19:72-76.At:@https://doi.org/10.1186/s12939-020-01193-5

DeBruin,DebraandJonathonLeider,(2020)COVID-19:theshiftfromclinicaltopublichealthethics,JPHMP26(4):306-309.

Doheny, Kathleen, (2020) COVID-19 Vaccine: latest Updates,accessed August 25, 2020. at:www.WebMD.com/lung/news/20200610/covid-19-latest-updates.

Dunham,AexandraM.,TravisN.Rieder,andCaseyJ.Humbyrd,(2020) A Bioethical Perspective for Navigating MoralDilemmas Amidst the COVID-19 Pandemic, J. Am. Acad.Orthop.Surgonline2020Apr10.Doi:19.5435/JAAOS-D-20-00371.

Gauthier, Candace Cummins. 2000. Moral responsibility andrespectforautonomy:Meetingthecommunitarianchallenge.KennedyInstituteofEthicsJournal10:337-352.

Gostin,LawrenceO.andLindsayF.Wiley,(2016)PublicHealthLaw: Power, Duty, Restraint, 3rd edition, University ofCaliforniaPress.

KathrynMacKay, (2018)Utility and justice inpublichealth, J.PublicHealth40(3):e413-e418.

Lei, Ruipeng and Qui, Renzong, (2020) Report from China:EthicalQuestionsontheResponsetotheCoronavirus”fortheHastings Center. At:https://www.thehastingscenter.org/report-from-china-ethical-questions-on-the-response-to-the-coronavirus/

Nace,Trevor(2020),Confirmedcoronaviruscasesaregrowingfaster in the United States than any other country in theworld. Forbes magazine, at:https://www.forbes.com/sites/trevornace/2020/03/20/coronavirus-is-growing-faster-in-the-united-states-than-any-other-country-in-the-world/#6cfa3a87e72e.

Ou, Xiuyuan, et al., (2020) Characterization of spikeglycoprotein of SARS-CoV-2on virus entry and its immunecross-reactivitywithSARS-CoV.NatureCommunications.at:https://doi.org/10.1038/s41467-020-15562-9www.nature.com/naturecommunications.

Powell,T,Bellin,EandEhrlichA.(2020)OlderAdultsandCovid-19: the most vulnerable, the hardest hit, Hastings CenterReport50(3):62-63.

Quammen, David, (2012) Spillover, W.W. Norton & company,NY.

Rabi,Firas,etal., (2020)SARS-CoV-2andcoronavirusdisease2019:Whatweknowsofar,Pathogens9:231-245.

Rawls,John.(1971)ATheoryofJustice.CambridgeMA:HarvardUniversityPress.

Rawls, John. (1993) Political Liberalism, NY, ColumbiaUniversityPress,p283.

Tempkin,LarryS.(2014),UniversalHealthCoverage:Solutionor Siren? Some Preliminary Thoughts. Journal of AppliedPsychology31:1-22.

Nursing students’ perception of mental health, mental illness and mental health nursing -AliaNasirAssociateProfessor,MohiuddinIslamicUniversity,CollegeofNursing,AzadKashmir,Mirpur,Pakistan-DaiziJafarSr.NursingInstructor,MohiuddinIslamicUniversity,CollegeofNursing,AzadKashmir,Mirpur,PakistanEmail:[email protected],ZiauddinUniversity,Karachi,PakistanAbstract Theshortageofhealthcareprovidersinpsychiatrybothin mental health nursing and psychiatrist is evidentglobally.Multiplefactorsleadtomakingthedecisiontowork inapsychiatric setup.Theperceptionofnursingstudents and other health care providers play anessential role. This study was aimed to identify theperceptionofnursingstudentsregardingmentalhealth,mental illness and mental health nursing. A cross-sectionalstudywasconductedwith73nursingstudentsenrolled in BSN 3rd year. Participants completed aquestionnaire of demographic and clinicalcharacteristics on mental health, illness and mentalhealthnursing.Purposive samplingwasusedanddataanalysiswasdone throughSPSSversion23. A totalof13.7%(n=10)malestudentsand86.3%(n=63) femalestudentswithameanageof19years(SD±5)participatedinthisstudy.76.5%participantsbelongedtoruraland23.2%tourbanpopulation.90.4%ofnursingstudentsreportedapositivecontributioninprovidingservicestoindividuals suffering frommental problems. However,only43.9%respondedthattheyareneutraltoapplyinmental health nursing. On the other hand, 52% ofstudentsshowedhighanxietydealingwithmentally illpatientsincontrastto50.6%participantswhoreportedthey are self-confident at work with mentally illindividuals. On stigmatization, 71% of participantsresponded thatmentally ill patients areunpredictable.Thisstudyhighlightstheknowledgeandskillsofnursingstudents in mental health, mental illness and mentalhealth nursing and may serve to encourage nursingstudentstopursueacareerinmentalhealthnursing.BackgroundMental health is satisfactory functioning in dailylivingactivitiestowardsindividual’sfullpotential.Mental illnesses are health circumstances thatinvolvealterationinemotion,thoughtprocessandbehavior, and mental health nursing is aboutpromotingandsupportinganindividualsufferingfrommentalillnesstorecoveryandtoenablethemtohavemoreparticipationandcontrolovertheir


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disorder1.Globally,theleadingcauseofdisabilityismental illness and approximately 450 millionsuffer frommental illness.Unfortunately, there isscarcity of healthcare providers including wellprepared nurses and physicians to look aftermentallyillpersons.AWHOreportshowsthatlessthan1psychiatristand7.7nursesareavailableper100,000 population2,3,4. In Pakistan, 10% of thepopulation(20million)sufferfrommentalhealthissues5.InastatesummaryofPakistan,10-16%ofindividualssufferfrommildtomoderate,and1%suffer from severe mental health conditions.Mentalhealthillnessinstitutes11.9%oftheentireworldwide illness burden and adds to the 1,607DisabilityAdjustedLifeYears(DALYs/100,000)ofthepeopleinPakistan6.Thealarmingstatisticsinprovinces, Sindh 16%, Punjab 8%, Baluchistan40% and Khyber-Pakhtunkhwa 5% indicate thatimmediatemeasuresareneededtopreventfurtherriseinmentalillnesses7.

In order to deal with the alarming burden inhealthcare system of Pakistan, manpowerdevelopment is required and nurses and otherhealthcareworkersshouldbetrained.Inordertopreparenursesrelatedtomentalhealth illnesses,nursing education facesmany challenges. Nursesbelong to the same racial, religious and socialbackgroundwheretheconceptofmentalillnessesis stigmatized. In order to prepare nurseseffectively, we need to identify their perceptionrelatedtomentalhealth,mentalillnessandroleofmental health nurses. That is why this cross-sectionalstudywasdesigned.Thepurposeofthispaper is to highlight the burden of disease, itscauses and share the perception of nursingstudents related to mental health, mental illnessandmentalhealthnursing.Authorsshallproposerecommendationsbasedontheresults, limitationandconclusionofthestudy.

Teaching nursing students to deal withindividuals with mental disorders is verychallengingwherestudentsneedtocollaborateinteaching. After entering the psychiatric setup,nursing students feel nervous and incapable tomake therapeutic interactions8,9. The learningprocess for nursing students in a psychiatricsetting is very complicated.Anxiety is a commonresponse of many students as they becomeprejudiced by media publicity and communityabout individualswithmentaldisorders.Anotherconcern in nursing students is poor attitudestoward mental illness and consumers of mentalhealth facilitiesmay be accountable for a lack ofattention in mental health nursing. This leadsnursingstudentsawayfromseeingacareerinthefieldofmentalhealth10.

Mental illness is considered negatively inPakistanicommunity;individualssufferingmentalillnesses become stigmatized and this causes abarrierinrecoveryofmentalhealth11,12.Evidenceshowsthat70-80%populationdonotseekmentalhealthcareservicesduetostigmaandthatisoneofthe major barriers13,14. These stigmas includeviews that individuals with a mental illness arehazardous, impulsive, more likely to commitviolence, and are somewhat responsible for theirillness. Previous research has recommended thatattitudes toward mental illness by healthcareprofessionalsareveryaliketothoseoftheoverallpublic. Nursing students ‘attitudes reflect thepredominantobservationoftheoverallpopulation,towardindividualswithmentalillness15,16.

Research proposes that students’ stereotypesand 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 andmentalillnessandtheirmanagementintheirthirdyear of training, so that they can develop goodunderstandingabouthealthsituationandrelevantbaseline knowledge. However, preparing nursingstudentsformentalhealthandillnessissomewhatchallenging due to their pre-conceivedperceptions,beliefsandattitudes.Whentheyenterthe clinical phase, this causes anxiety andhindrances to developing therapeuticcommunicationwiththeclients,patientsandtheirfamily members. The consequences of firstinteractions with mentally ill patients can beparticularly distressing18. Furthermore, thesemisunderstandingscanleadtoalackofacceptanceof individuals in the psychiatric setting withundesirable opinions and attitudes held towardsthem1.Therefore, thisresearchstudyattempts toidentifythenursingstudents’perceptionstowardsmental health, mental illness and mental healthnursing.

Methodology A cross-sectional research study was planned toachieve the research objective. This study wasconductedataprivateuniversitycollegeofnursinginKarachi,Pakistan.Purposivesamplingofatotalof 76 students enrolled in BSN-3rd year nursingprogramwasdonewhoweregoingtotakeMentalHealth Nursing course. Data was collected usingMHN-I questionnairewhich is pre-testedbyFurr(2014) in his study about perceptions ofundergraduate students. The questionnaire wasdistributedtoallnursingstudentsafterconsentingtothestudy.Studentswerebriefedaboutthestudyandwereassuredofanonymityandconfidentiality.


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DatacollectionandinstrumentThestudyparticipantswereexaminedwithMHN-Ipretestquestionnairewhichisaneducationaltoolandisself-descriptiveoriginatedbyWynaden,Orb,Mcgowan and Downie to measure the specificperceptions towards mental health, illness andmental health nursing. The instrument wasadministeredtonursingstudents.Theinstrumentconsistsof24responses.Thesubscalecontainsthelevelofpreparednessforthementalhealthsetting,understanding of mental illness, beliefs onstigmatization; pursue it as a career, courseefficacy, anxiety about themental conditions andimportantcontributions.

The responses 1, 4, 7 and 10 refer to level ofpreparednesswhileresponses9,18,19,and23areabout knowledge of mental illness. Anothersubscale about stigmatization consists ofresponses8,21and24.Thesubscaleofpursuing

career in mental health is 6 and 12. Courseeffectiveness included responses from 14 to 17.Thesubscaleonanxietywasresponses3,5and22.The subscale about valuable contribution forprovidingservicestomentallyillwasinresponses2,11and20.DataanalysisData was analyzed using SPSS version 23.Descriptive statistics were formulated such asfrequenciesandpercentages tocomputerelevantsociodemographic characteristics. Fordescriptiveanalysis all responses of mental health nursingeducation survey were grouped. The responseitems were grouped into three categories as“strongly agree”, “agree” and “somewhat agree”combined to form agree category while neutralremained on its own and another category wasmade as disagree with combination of “stronglydisagree”, “somewhat disagree” and “disagree”.Interpretationswereagreeduponbytheauthors.

EthicalapprovalApprovalwas granted from college of nursing toconductthestudyaspartoffacultydevelopment.Nursing students were briefly informed of theirvoluntary participation and consent form wasfilled.Results Atotalof76questionnairesweredistributedand73questionnaireswerereturnedcompletely(96%responserate).Respondentsweremainlyfemales(86.3%n=63)withameanageof19years(SD=5).Theprovincewisepercentageof theparticipantswas Sindh (27.7%), Punjab (1.4%), Baluchistan(1.4%),KPK(56.2%)andGilgitBaltistan(13.7%).Participants were taken from BSN year threebecause they were taking mental health nursingcourseandneedtoattendtheclinicofmentallyillpatients as course requirement. 43.9% ofparticipants responded neutralwhether to applyforgraduateprograminmentalhealthwhile28.8%disagreed. On the issue ofmental health nursingmakes a positive contribution, 90.4% of nursingstudents agreed, 52% reported that they feelanxiousworkingwithindividualssufferingmentalhealth problems and 50.6% reported they areconfidentworkingwithmentallyillpatients. Discussion Inexpressionsofgeneralperceptionaboutmentalhealthnursing,studentsshowedmainlyapositiveperception, which is consistent with previousresearchstudiesconductedacrosstheworld.

The level of preparedness reported throughattendingmentalhealthclinicandalsoknowledgeofmentalillnessisreportedwithpositiveregardasshown in table-I. This is consistent with otherresearch study findings of encouraging nursingstudents exhibiting their competence in terms ofskills, knowledge and their abilities in mentalhealth nursing19,20. Stigmatization is an issuewhereindividualscannotworkuptothepotentialforprejudicewhich is anegativebehavior and isreportedwithhighpercentagewhichisconsistentwithotherresearchstudiesbecausestigmaisbeliefaboutmentally ill that they are dangerous,moreprone to violence and are responsible for theirillness.Thesebeliefsareduetolackofknowledgeofcommunity21,22,23.

Pursuing a career inmental health nursing isnotafavorablechoiceasshownintable-1whichisseen in other research studies where lack ofinterest in mental health services is highlightedduetopoorattitudestoindividualssufferingfrommentalconditions.Thesenegativeattitudesdirectnursing students not to choose mental healthnursingascareer.

Table1:DescriptiveanalysisofdemographicindicatorsAgeMean±SD 19±5

No.%

BelongsRural 56 76.5Urban 17 23.3

GenderMale 10 13.7Female 63 86.3

Province

Sindh 20 27.7Punjab 1 1.4Baluchistan 1 1.4KPK 41 56.2GilgitBaltistan 10 13.7


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Table2:Descriptiveanalysisofdemographicindicators Strongly

disagree Disagree Somewhatdisagree Neutral Somewhatagree Agree Stronglyagree

n(%)

levelofpreparednessaboutMHN1 Ifeelwellpreparedformentalhealthclinicalplacement

- - 3(4.1)

8(11.0)

8(11.0)

35(47.5)

4 Ihaveagoodunderstandingoftheroleofpsychiatricnurse

19(6.0)

1(1.4)

5(6.8)

7(9.6)

22(30.1)

18(24.7)

7 Ifeelconfidentinmyabilitytocareforpeopleexperiencingmentalhealthproblems

20(27.4)

10(3.7)

11(15.1)

7(9.6)

8(11.0)

12(16.4)

12(16.4)

10Theoreticalcomponentsofmentalhealthhavepreparedmewellformeclinicalplacement.

13(17.8)

- - 2(2.7)

7(9.6)

14(19.2)

23(31.5)

knowledgeofmentalillness9 Mentalillnessisnotasignofweaknessinaperson 11

(15.0)10

(13.0)8

(11.0)5

(6.8)16

(21.9)12

(16.4)11

(15.1)18SomeoneIknowhasexperiencedamentalhealthproblem

1(1.4)

3(4.1)

9(12.3)

18(24.7)

14(19.2)

14(19.2)

14(19.2)

19Whenapersondevelopsamentalillnessitisnottheirfault

2(2.7)

5(6.8)

4(5.5)

7(9.6)

11(15.4)

16(21.9)

28(38.4)

23Thewaypeoplewithmentalillnessfeelcanbeaffectedbyotherpeople’sattitudestowardsthem

1(1.4)

- 3(4.1)

8(11.0)

20(27.4)

17(23.3)

24(32.9)

Stigmatizationinmentallyillpatients8 Peoplewithmentalillnessareunpredictable - 2

(2.7)6

(8.2) 8

(11.0)18

(24.7)26

(35.6)21Peoplewithmentalillnesscan’thandletoomuchresponsibility

13(17.8)

2(2.7)

4(4.5)

3(4.1)

4(5.5)

14(19.2)

26(35.6)

24Peoplewithmentalillnessaremorelikelytocommitoffencesorcrimes

20(27.4)

2(2.7)

2(2.7)

6(8.2)

8(11.0)

14(19.2)

28(38.4)

pursuingcareerinMHN6 Iwillapplyforgraduateprogramsinpsychiatric/mentalhealth

1(1.4)

8(11.0)

12(16.4)

20(27.4)

17(23.3)

11(15.1)

4(5.5)

12Iintendtopursueacareerinpsychiatric/mentalhealthnursing

1(1.4)

8(11.0)

12(16.4)

20(27.4)

17(23.3)

11(15.1)

4(5.5)

Courseeffectiveness14Mycoursehaspreparedmetoworkasagraduatenurseinamedicalgraduateprogram

- 2(2.7)

6(8.2)

8(11.0)

18(24.7)

26(35.6)

13(17.8)

17Mycoursehaspreparedmetoworkasagraduatenurseinanagecaregraduateprogram.

2(2.7)

3(4.1)

13(17.8)

2(2.7)

20(27.4)

23(31.5)

10(13.7)

Anxietyattendingmentallyillpatients3 Ifeelanxiousaboutworkingwithpeopleexperiencingamentalhealthproblem

3(4.1)

7(9.6)

7(9.6)

18(24.7)

7(9.6)

22(30.1)

9(12.3)

5 Iamuncertainhowtoacttowardssomeonewithamentalillness.

5(6.8)

4(5.5)

12(16.4)

22(30.1)

21(28.8)

7(7.6)

2(2.7)

22Ifeelsafeaboutthispsychiatric/mentalhealthplacement

3(4.1)

7(9.6)

7(9.6)

18(24.7)

7(9.6)

22(30.1)

9(12.3)

valuablecontributionforprovidingservicestomentallyill2 Mentalhealthnursingpositivelycontributestopeopleexperiencingamentalhealthproblem

- - 7(9.6)

- - 30(41.1)

36(49.3)

11Placementinmentalhealthnursingwillprovidevaluableexperienceformynursingpractice.

- - - 3(4.1)

13(17.8)

25(34.2)

32(4.8)

20Mentalhealthservicesprovidevaluableassistancetopeopleexperiencingamentalhealthproblem.

1(1.1)

1(1.1)

2(2.7)

2(2.7)

12(16.4)

29(39.7)

26(35.6)


367

Thesenegativeperceptionsofnursingstudentsaboutthe field of mental health nursing unfavorably affectsthemasnot topursuemental healthnursing as career.24,25,26.Ontheresponsesaboutanxietyrelatedtodealingwithmentallyillclients,studentsreportedfearwhichissimilar to the other research findings because nursingstudentsencounterissuesofmentaldisordersduringthebachelorprogram innursing.Research showednursingstudents to have fear and anxiety about mentally illpatientsthusitisveryimportantfornursingstudentstohavecommunicationbeforeencounteringrealpatientstoreducetheir levelofanxiety.Fearisacommonreactionafter entering the psychiatric area because of negativemediaaboutmentaldisorders.Thisbecomesachallengefor nursing students to provide teaching and dotherapeutic communication with patients.27, 28, 29.Valuablecontribution in termsofrecovery frommentalillnessisamajorfactorwhichisenhancedthroughgroupvolunteer services; alsogoodphysicalhealth is amajorcontributorinrecoverythroughprovidingservices30,31. Conclusion Thisstudyfoundthatnursingstudentsshowedpositiveperceptions 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 byattendingtheclinicnursingstudentscanmakeapositivechange towards selecting mental health nursing as acareerchoice.LimitationsThisstudywasconductedatoneprivatecollegesosamplesizewas only from one classwhich is not enough representation.Throughthesefindingsitisrecommended,toconductaquasi-experimentalstudyonthesamegroupandmakeacomparisonaftertheycompletethecourseofmentalhealthnursing.AcknowledgementsThe authors would like to acknowledge all nursing studentsenrolled in BSN-III year for providing their contribution andcommitment. The study data was collected after havingpermission by the research committee of College of Nursing.Written consent was taken from the study participants afterassessing the confidentiality of participants. Autonomy rightwasgiventothestudyparticipantsofwithdrawalanytimefromthestudy.References 1. Ranna Parekh (2018) https://www.psychiatry.org/patients-families/what-is-mental-illness,AmericanPsychiatricassociation.

2. Samari,E.,Seow,E.,Chua,B.Y.,Ong,H.L.,Lau,Y.W.,Mahendran,R.,…Subramaniam, M. (2019). Attitudes towards psychiatry amongstmedical and nursing students in Singapore.BMC medicaleducation,19(1),91.doi:10.1186/s12909-019-1518-x

3. Gustavson,K.,Knudsen,A.K.,Nesvåg,R.,Knudsen,G.P.,Vollset,S.E.,&Reichborn-Kjennerud,T.(2018).Prevalenceandstabilityofmentaldisorders among young adults: findings from a longitudinalstudy.BMCpsychiatry,18(1),65.doi:10.1186/s12888-018-1647-5

4. Dickens, G. L., Ion, R.,Waters, C., Atlantis, E., & Everett, B. (2019).Mentalhealthnurses'attitudes,experience,andknowledgeregardingroutinephysicalhealthcare:systematic,integrativereviewofstudiesinvolving 7,549 nurses working in mental health settings.BMCnursing,18,16.doi:10.1186/s12912-019-0339-x

5. Nisar,M.,Mohammad,R.M.,Fatima,S.,Shaikh,P.R.,&Rehman,M.(2019). Perceptions Pertaining to Clinical Depression in Karachi,Pakistan.Cureus,11(7).

6. AliTM,GulS.(2018).CommunitymentalhealthservicesinPakistan:ReviewstudyfromMuslimworld2000-2015.

7. Ansari I. Mental health Pakistan: Optimizing brains. InternationalJournalofEmergencyMentalHealth.2015;17(1):228.

8. Maddineshat,M.,Hashemi,M.,Besharati,R.,Gholami,S.,&Ghavidel,F.(2018).Theeffectivenessofclinicalteachingofmentalhealthcoursesin nursing using clinical supervision and Kirkpatrick'smodel.Electronicphysician,10(1),6265–6272.doi:10.19082/6265

9. Furnes,M.,Kvaal,K.S.,&Høye,S.(2018).Communicationinmentalhealthnursing -BachelorStudents' appraisalof ablended learningtraining programme - an exploratory study.BMC nursing,17, 20.doi:10.1186/s12912-018-0288-9.

10. Ganzer CA, Zauderer C. Structured learning and self-reflection:strategiestodecreaseanxietyinthepsychiatricmentalhealthclinicalnursingexperience.NursEducPerspect.2013;34(4):244–7.

11. Furr, Susan, "Nursing Students' Perceptions of Mental HealthPatients and Mental Health Nursing" (2014). Nursing Theses andCapstone Projects. 17. https://digitalcommons.gardner-webb.edu/nursing_etd/17

12. Martensson,G.Jacobsson,W.&Engstrom,M.(2014).Mentalhealthnursingstaff’sattitudetowardmental illness:ananalysisofrelatedfactors.Psychiatricandmentalhealthnursing.21,782-788.

13. StuartH.(2016).Reducingthestigmaofmentalillness.Globalmentalhealth(Cambridge,England),3,e17.doi:10.1017/gmh.2016.11

14. DamaniS.S.(2018).MentalillnessinPakistan:AsubjectofStigma,ridicule,andculturalinsensitivity.

15. Wei,Y.,McGrath,P.J.,Hayden,J.,&Kutcher,S.(2015).Mentalhealthliteracymeasuresevaluatingknowledge,attitudesandhelp-seeking:ascopingreview.BMCpsychiatry,15,291.doi:10.1186/s12888-015-0681-9

16. Kane,J.C.,Elafros,M.A.,Murray,S.M.,Mitchell,E.,Augustinavicius,J.L.,Causevic,S.,&Baral,S.D.(2019).Ascopingreviewofhealth-relatedstigmaoutcomesforhigh-burdendiseasesinlow-andmiddle-incomecountries.BMCmedicine,17(1),17.doi:10.1186/s12916-019-1250-8

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31. Dickens GL, Ion R, Waters C, Atlantis E, Everett B. Mental healthnurses’ attitudes, experience, and knowledge regarding routinephysical healthcare: systematic, integrative review of studiesinvolving 7,549 nurses working in mental health settings. BMCnursing.2019Dec1;18(1):16.

Mandatory COVID-19 vaccination in Africa: The philosophy of objectivism on individual rights vs public rights in a culture bound society, Nigeria -ChukwunekeFN,MPH-EzenwugoAC,MPH-UmeorahOUJ,MPH-Iyioke,IV,PhDCollege of Medicine, University of Nigeria Ituku-OzallaCampus,EnuguState,NigeriaEmail:[email protected] Abstract Themandatetoensureandprotectthehealthofthepublicisaninherentmoralpursuitof any responsiblegovernmentwhoseobligation is tocareforthewell-beingof itscitizens.Throughwell planned prevention of ill health, individuals can spendmoreoftheiryearsingoodhealthandcontributemeaningfullyto the development of the society. Because of the concern inbalancing respect for individual autonomyand liberty, ethicaljustification for government intervention to promote publichealththroughvaccinationdeservesrenewedscrutiny.Acaseinpointisthesuggestionforamandatoryvaccinationnecessitatedby the latest COVID-19 pandemic. Vaccination campaignsaimingtoeradicatediseasehavebeendeployedinthepasttocreateherdimmunitywithinagivenpopulation.Dependingontheepidemiologicalsituation,vaccinationsmaybevoluntaryinsome countries but mandatory in others, with mandatorypolicies sometimes leading to resistance against thegovernment.Acceptanceofvaccinationforpreventablediseasesisoftenhighatvariousplaces.However,inAfrica,asitsoftenthecasewithmanydevelopingcountries,asignificantnumberoftenrefuse vaccinationdue to various concerns, including culturaland religious perceptions, ideological differences, or starkignorance or misinformation about vaccines. Proponents ofmandatoryvaccinationarguewithjustificationthatundersuchepidemiologicalconditionthestateisrighttoactintheinterestof public health. But the complexity of African society withvarying cultural and religious practices also reflects on thepeople’sperceptionandunderstandingoftheirhealthmatters.ManyAfricancultureshavedifferentnotionsandunderstandingofthecausesofdiseasesandmaythusrejectvaccinationforadiseasetheybelieveisspiritualorevennon-existent.Weareofthe opinion that mandatory vaccination for COVID-19 forAfricans given its heterogeneous and complex nature andsignificant uncertainties in both the pathophysiology andmanagement of the virus calls for intentional and robustcommunityengagementanddialogue.Thispaperwillexploreanyethicaldilemmaandpresentaplatformtoaddressconcernsaround safety, access and dissenting opinions as well assustainabilitybeforeanyformofimplementation.

Introduction Thehistoricaljourneytoprophylacticvaccinationasoneof the least costly andmost effective forms of medicalinterventionstartedfromEdwardJenner’sworkin1796(Dohertyaetal.,2016).Jennerisconsideredthefounderofvaccinologyafterheinoculateda13year-old-boywithvaccinia (cowpox)virusanddemonstrated immunity tosmallpoxthatledtothedevelopmentofthefirstsmallpoxvaccine in 1798. Today several vaccines are producedbased on new knowledge and better understanding ofmolecular biology and have led to a reduction in themortality rate of many infectious diseases. In the 18thcentury they used the vaccinia virus while in the 19thcentury,LouisPasteurandÉmileRouxdemonstratedthatinactivated or attenuated organisms could provideprotection (Dohertya et al., 2016). The 20th centurywitnessed an accelerated development of new vaccinesinvolvingmanynewtechnologieswhichbecameavailablefor immunization against many diseases with highmortality.Despitebeingoneofthemostwidespreadandsuccessfulofallhealthinterventionsaftertheprovisionofsafedrinkingwater,immunizationhasbeencontroversialsince its introduction, with opponents claiming it wasunnatural or contaminating (Schwartz,2012) and couldbe harmful. Because vaccines are different from mostmedicines and are administered to large and mostlyhealthypopulationsincludinginfantsandchildren,theremaybelowtoleranceforpotentialrisksorside-effects.Inaddition, the long-term benefits of immunization inreducing or eliminating infectious diseasesmay inducecomplacencyduetotheabsenceofcases(Di-Pasqualeaetal.,2016).Insomecases,theremaybeassociatedvaccinescares.

Thelargelyunprovenrelationshipofmeasles-mumps-rubella (MMR) vaccine with autism, and whole-cellpertussis vaccines with encephalopathy, can result inreduced vaccine uptake and consequent diseaseresurgence(Di-Pasqualeaetal.,2016).Vaccinationshavehad an enormous impact on population health and thepreventionofdiseaseandhavebeenoneofthegreatestpublichealthachievementsofthelastcentury.However,over the past decade, acceptance of vaccines has beenchallengedby individuals andgroupswhoquestion thebenefitandsafety(KristinandSarah,2017).Ethicalissuespertaining to mandatory vaccination activities and thepublic health versus individual rights debates areimportant in the implementation and the public'sresponse to vaccination programs. The debates willcontinue,andashealthcareprofessionals,ourdutyistoempowerandeducateconsumerssothatdecisionscanbemade with the best interests of all in mind (Luke etal.,2014).Notwithstanding,acomprehensivevaccinationprogramisacornerstoneofgoodpublichealthandwillreduce health inequities and the universal diseaseburden.

From a human rights perspective, vaccinationequitablypromotesandprotectspublichealthwhenthefocusisonitspublicgood.Ontheotherhand,individualrightsissuescomeupwherethereishesitancyandrefusaltobevaccinatedbasedonsomereasonssuchasreligion,personal belief and culture. The ethical principles ofbeneficence,non-maleficence,justiceandautonomytendto provide a morally justified basis for mandatoryvaccination,eventhoughtheautonomyoftheindividual


369

becomes restricted. The final goal of a mandatoryvaccination program, to prevent disease, disability anddeath,isnobleandmoralbothfromthedeontologicalandutilitarian perspectives (Umeora et al., 2012). Thephilosophy of objectivism and distributive justice isbetter served by mandatory rather than voluntaryvaccinationprogramswhendealingwithaknowndiseasethat has demonstrated success in control with knownvaccines.

ThismaynotbethecasewithCOVID-19vaccineuntilthe safety and efficacy are determined through clinicaltrials.COVID-19isanofficialrecognizednameforanovelcoronavirusfirstisolatedfrompersonswithpneumoniainWuhancity,China(WorldHealthOrganization,2020).The virus can cause a range of symptoms, from mildillnesstopneumonia.Symptomsofthediseasearefever, cough, sore throat and headaches. In severe casesdifficultyinbreathinganddeathcanoccur.Atthemomentthere is neither a definitive cure for COVID-9, nor aneffectivevaccine. Methodology We carried out Internet search of articles, conferenceproceedings,mediareports,andtextbooksonvaccinationwithfocusonmandatoryvaccinationandhumanrights,publichealthethicsandculturalnormspublishedlocallyandgloballywithoutlimitationoftimespanandlanguageusing Google search, Google Scholar, PubMed, AfricanJournal Online, Medknow, Hinari and NIH.gov,ResearchGate, and Elsevier. We also searched forpublished papers and technical reports on the noveldiseaseCOVID-19andbiomedicalcareinAfricafromtheInternet and university libraries. The search enginesyielded25relevantpublicationswhich,inadditiontotheauthors’knowledgeandexperienceinpublichealthandbioethics,supportedtheinformationaspresentedinthisarticle. Mandatoryvaccination:individualrightsvspublicrightsIndiscussingthisissue,somepertinentquestionsmustbeaddressedandtheyinclude;v Are the rights of individualmore important than therightsofthesociety?

v When should an individual right be sacrificed for thecollectivegood?

v When should a collective concern be eliminated toprotectanindividual'srights?

v Do governments have the right to determinewhat isbestforeveryonewithintheirdomains?

v Should people surrender their autonomy to getvaccinated at the cost of probably having adversereactions to the vaccine for a novel disease such asCOVID-19thathasnotyetbeenproperlyunderstood?

There is no doubt that ethical challenges abound inmakingvaccinationmandatoryespeciallyinapluralisticsocietywithdifferentculturaldispositions.Becausemostof the diseases being vaccinated for prevention aretransmitted from person to person, there is a need toprovidebothindividualandpublicprotectionagainstthedisease. A mandatory vaccination in Africa for a novel

diseasesuchasCOVID-19will inevitablypresentstrongethicalconcernswhenweighedagainstarisk–to-benefitratio. This is because the immunogenicity is not yetproperly understood and despite clinico-pathologicalsimilaritieswiththeseasonalinfluenzaviruses(flu),itismuchmorecontagiousand fatal. Insub-SaharanAfrica(with the exception of South Africa and parts of theMaghreb)fluvaccinationisrare.Nigeriadoesnothaveavaccination program against flu because it is rare andwhen it occurs, it runs a mild course with or withoutmalariaorothercommoninfectiousdiseaseliketyphoid-fever.

RespectingindividualconcernsandtherighttoacceptorrefuseCOVID-9vaccinationaswellasacknowledgingexemptionsseemsagoodethicaldecisioninthelightofthe present outbreak. When an adequately largeproportionof individualsinacommunityis immunized,those persons serve as a protective barrier against thelikelihoodoftransmissionofthedisease,thusindirectlyprotectingthosewhoarenotimmunized(KevinandAlan,2007). Thismeans not everyonewill be vaccinated forseveral exemption reasons such as medical conditionswhichgovernmentsmayacceptasawaiverirrespectiveof the individual autonomy to opt out due to personal,culturalorreligiousbeliefs.Exemptionshouldnotonlybebasedonmedicalgrounds;peoplehavearighttodecidewhether they should be vaccinated or not based onvaccinesafetyconcernsandriskstheymayfeeloutweighthebenefits.

In children, proposals for vaccination requirementsoften precipitate vigorous discussions of ethical issues,especially among parents. Some parents do not acceptexisting safety evidence. Others oppose the concept ofmandatory vaccination for specific reasons such asreligious or philosophical beliefs that conflict withvaccinations (CDC, 2015). Because several scientificstudieshavefoundthatindividualswhoexercisereligiousorphilosophicalexemptionsfrommandatedvaccinationsareatagreaterriskofcontractingdiseases,whichputsthemselvesand theircommunitiesat risk,publichealthadvocates often struggle to balance the ethics ofprotecting individual beliefs and the public's health(DavidandSaad,2006).Asocietyismadeupofnumerousindividuals without which, the society does not form.Individualright isaperson's justifiableclaim,protectedby law, to act or be treated in a dignifiedmanner thatprotects the liberty and right to decision making.However,inreality,theindividuals’rightsaregroundedin relativismwhen the issues of collateral damage andpublic harm are envisaged by the state especially onissues of epidemic and pandemic disease outbreak. Insuchasituationanindividualrightmaybesacrificedforthe collective good so as to avoid group harm andcollateraldamage.

Autonomyandrighttopersonallibertymeanthatanindividualdeserves the right to takedecisionsaffectinghim/her inall issues includingright toreceiveorrejectanyformofhealthcare,preventiveortherapeutic(Laveryetal.,2007).Amandatoryvaccinationpolicy impliesnoconsentistobesoughtbeforethevaccineisadministeredtoan individual.Thisobviouslynegates the individual’srights to liberty and autonomy and could therefore be


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argued on this basis as illegitimate irrespective of theintended outcome (David and Saad, 2006). Thegovernmenthas themandate toensureandprotect thehealthofthepublicinitsmoralpursuitsandobligationtoduty in caring for the well-being of its communitiesthrough vaccination but governments cannot alwaysdeterminewhat's best for everyonewithin the society.Forced vaccination against a person’s right to decision-making may in certain cases lead to serious harm orpossible death following vaccine reactionswhich on itsownviolatesthefundamentalrighttolifeofanindividual.VaccinationinNigeria:anoverviewThecomplexityofAfricansocietywithdifferentculturaland religious practices often reflects on the people’sattitudeandunderstandingof theirhealthmatters.Theinfluence of culture on the health-seeking behavior ofAfricans cannot be underestimated as many Africancultureshavedifferentnotionsandunderstandingofthecausesofdiseases(Chukwunekeetal.,2012).Anecdotalevidence suggests that a significant percentage ofNigeriansandindeedmanyAfricans,believethatCOVID-19 does not exist or is aWestern disease. This defaultpositionhasplacedAfricansonthequagmireofdealingwiththeimpendingcatastropheaspredicted(Zhaoetal.,2020). InNigeria,vaccination(immunization)began in1956whensmallpoxwasseverenationwide.Thenationalexpandedprogramofimmunization(EPI)startedin1979to combat deadly childhood diseases, which wereregarded as the cause of high infant morbidity andmortality inNigeria (Endurance et al., 2014).Nigeria isdividedintosixgeo-politicalzones:NorthCentral,NorthWest,NorthEast,SouthEast,SouthWestandSouthSouth,that make up 36 states and the Federal Republic ofNigeria.Themostpopulouscountry inAfrica,Nigeria isestimatedtohaveapopulationof167million(NationalPopulationCommission,2008).

The Expanded Program of Immunization (EPI),introduced in 1979 with the aim of providing routineimmunizationtochildrenlessthantheageoftwoyears,recorded initial but intermittent successes (Odusanya,2008). Immunization has always been a very difficulthealth project in Nigeria becausemany families do notalwaysallowtheirfamilymembersincludingchildrentobeimmunizedmostlyduetoculturalandreligiousbeliefs.Some studies have shown Nigeria as the worstimmunization defaulter in theWestAfrican sub-region,onlybetterthanSierraLeone(Green,2004).ThevisionofEPI in Nigeria was to improve the health of Nigerianchildren by eradicating all the six killer diseases: polio,measles, diphtheria, whooping cough, tuberculosis, andyellowfever(Enduranceetal.,2014).Asoutlinedinthenational health plan between 1985 and 1990, theobjectives of EPI were to strengthen immunization,accelerate disease control and introduce new vaccines,relevanttechnologiesandtools(Enduranceetal.,2014).However, these objectives were hampered by somechallenges such as rejection of selected vaccination byparents or on religious ground. Many decision-makersand caregivers reject routine immunization due torumors,incorrectinformation,andfearofcomplicationsthatmayfollowthevaccination(Enduranceetal.,2014).Inthepast,someNigeriansobjecteddosoduetofearsandworries regarding routine vaccination because of little

knowledgeorlimitedinformationandmistrust.SomeareoftheopinionthattheWesternworldisindirectlyusingvaccination to reduce the population of the Africans astheyaredetermined toregulateand imposepopulationcontrol especially in Northern Nigeria (Feilden, 2005;Yola,2003).Thislackoftrustandconfidenceinroutineimmunization is also found in many parts of Nigeria(BabalolaandAdewuyi,2005). Ethicalconsiderationsandrighttopersonalliberty:Amandatoryvaccinationprogramimpliesthatnoconsentfromtheindividualistobesoughtbeforethevaccineisadministered. This obviously negates the principle ofpersonallibertyandownershipofone’sbodybecauseanindividualdeservestheabsoluterighttodeterminewhathappenstohisorherhealth includingvaccinations.Fortheminors,thisautonomyresideswiththeparentorlegalguardian.Mandatoryvaccination is thereforeanaffronton autonomy as it negates the protestations of parentsand the voluntariness that should follow informedconsent (Colgrove, 2006). The principle of autonomydemands that each individual has a competent right toself-determination(Belmontreport)andbetreatedasanend in itself, never to be used as a means whileconsideringamandatoryCOVID-9vaccinationprogram.MandatoryCOVID-9vaccinationbearsthehumanrightsand ethical burden of relegating informed consent,restrictingautonomyandlibertyagainstthepopulation.

TheproponentsofmandatoryvaccinationofanoveldiseasesuchasCOVID-9mayarguethatsuchvaccinationprogrammay provide the requisite herd immunity butthis could also be interpreted in terms of using theindividualasameansandnotasanendforadiseasenotyet clearlyunderstood.A further concernwouldbe theachievable goals of the mandatory program since theeffectiveness of the immunization in poor developingcountriessuchasNigeriawillbehamperedbychainsofreactionofevents:lackofgoodinfrastructureforeffectivemovementofhealthpersonneltomostruralareas,erraticpowersupplywhichcancompromisetheintegrityofthevaccinecoldchain, lackofadequatemanpower,povertyandignoranceespeciallyamongsttheruralpopulace.Atthe end, not everyone willing can be vaccinated,mandatoryprogramnotwithstanding.

Some proponents (Chukwuneke, 2020; Alberto andJulian,2017)ofmandatoryvaccinationhavearguedthatitisethicallyjustifiedbecausepeoplehaveamoraldutynotto harm or risk harming other people especially whenavoidingharm,orriskofharmcomesatasmallcost toindividuals. Apart from moral obligation, mandatoryvaccination is justified based on the fundamentalprinciple 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-19pandemicmayposeahealththreattomanypeopleacrosstheglobe,we suggest that theremayevenbea greaterthreattopersonallibertybymandatoryvaccination.Withrespect 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


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withoutmandatoryvaccination,wouldthatofCOVID-9benecessarysince it isyetunclear that thevaccine (whenoneisdeveloped)mayprovidelastingimmunitysuchasseeninthecommonflu. Conclusion Mandatory vaccination policies apart from moralobligationwouldguarantee thateverybodymakes theirfaircontributiontoanimportantpublicgoodsuchasherdimmunity. However, in the case of a mandatoryvaccination for a novel disease whose vaccine has notbeen fully developed and clinically tested on risks andbenefit ratio, it is fraught with many ethical concerns.Peoplearealsoconcernedaboutproposalsfromcertainquarters for a mandatory vaccination without anyevidenceofclinicaltrialoutcomeofthevaccine.WeareoftheopinionthatmandatoryvaccinationforCOVID-19forAfricansisparticularlyworrisome.Effortsmustbemadetoaccountforthenumerousculturalbeliefsofthepeople,andpropercommunityengagementandethicaldialogueto address different concerns and dissenting opinionsbeforeanyformofimplementation. References Alberto G. Italy has Introduced Mandatory Vaccinations – othercountries should follow its lead.https://theconversation.com/italy-has-introduced-mandatory-vaccinations-other-countries-should-follow.June2,2017

AlbertoG, Julian S (2020).Vaccination,Risks, andFreedom:The SeatBeltAnalogy"https://blog.oup.com/2020/04/why-vaccines-should-be-compulsory/.AccessedJune28,2020.

BabalolaS,AdewuyiA(2005).FactorsInfluencingImmunizationUptakeinNigeria:ATheory-basedResearchinSixStates.Abuja:PATHS;2005

BelmontReport(Accessed,2020:http://www.hhs.gov/ohrp/humansubjects/guidance/belmont.htm.Accessed,May27,2020.

CDC(2020)."StateSchoolImmunizationRequirementsandVaccineExemptionLaws’PublicHealthLaw.https://www.cdc.gov/phlp/docs/school-vaccinations.pdf.AccessedJuly10,2020

Chukwuneke F (2020). COVID-19 vs. Childhood Immunization: ABioethicsPerspectivefromNigeria.BioethicsintheNews:CenterforBioethicsinHumanitiesandLifeScience,MichiganStateUniversity.https://msubioethics.com/ 2020/06/25/childhood-immunization-covid19-nigeria-chukwuneke.June25,2020.

ChukwunekeFetal.(2012).CultureandBiomedicalCareinAfrica:thein-fluence of culture on biomedical care in a traditional Africansociety,Nigeria,WestAfrica.NigJMed:Vol.21No.3;pp331-333.

Colgrove J (2006). The ethics and politics of compulsory HPVvaccination.NEnglJMed.2006;355(23):2389–2391

Di-PasqualeaA,BonannibP,GarçonN,LawrenceR.MostafaS(2016).Vaccinesafetyevaluation:Practicalaspectsinassessingbenefitsandrisks.Vaccine;Volume34,Issue52,20December2016,Pages6672-6680

David AS, Saad BO (2006). "Individual Freedoms versus CollectiveResponsibility: Immunization Decision-Making in the Face ofOccasionallyCompetingValues,"EmergingThemesinEpidemiologyonline journal.https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1592474/(accessed03/05/2020).

DohertyaM,BuchyP,StandaertaB,GiaquintoC,Prado-CohrsdD(2016).Vaccineimpact:Benefitsforhumanhealth.Vaccine.Volume34,Issue52,20December2016,Pages6707-6714.

Endurance A.O, Musa YT, Precious EI (2014). Current Trends ofImmunizationinNigeria:ProspectandChallenges.TropMedHealth.24June,2014:42(2);67-75.

Feilden (2005). Batters by Analysts. Design of Routine ImmunizationInitiative—TripReportforDFID.BathUK:2005.

Green C (2004). Demand for Immunization and IMCI in Nigeria: Anissues paper. Background paper prepared for the PATHSImmunizationandIMCIroundtable.FinalVersion.Abuja:PartnershipforTransformingHealthSystems(PATHS);2004

KevinMalone, and Alan Hinman (2007). "VaccinationMandates: ThePublic Health Imperative and Individual Rights," in Law in PublicHealth Practice, eds. Richard Goodman et al. (New York: OxfordUniversityPress,2007).

KristinVOandSarahB(2017).GlobalPublicHealthThreats-TheRoleof Vaccinations. Health Progress. Journal of The Catholic HealthAssociationoftheUnitedState.January-February2017.

Lavery JV, Grady C, Wahl ER, Emmanuel EJ (2007). Ethical Issues ininternationalbiomedicalresearch.NewYork:OxfordUniversityPress2007.

Luke ET, Amy S, Guy E (2014). "Vaccines Are Not Associated withAutism:AnEvidence-BasedMeta-AnalysisofCase-ControlandCohortStudies," Vaccine 32, no. 29 (June 17, 2014): 3623.www.sciencedirect.com/science/article /pii/S0264410X14006367(accessedNov.30,2016).

NationalPopulationCommission(NPC)[Nigeria]andICFMacro(2008).Nigeria Demographic and Health Survey 2008. Abuja, Nigeria:NationalPopulationCommissionandICFMacro;2009.

Odusanya OO, Alufohai EF, Meurice FP, Ahonkhai VI (2008).Determinants of vaccination coverage in ruralNigeria. BMC. PublicHealth2008;8:381.[PMCfreearticle][PubMed][GoogleScholar]

SchwartzJL(2012).Newmedia,oldmessages:themesinthehistoryofvaccinehesitancyandrefusalVirtualMentor,14(2012),pp.50-55,10.1001/virtualmentor.2012.14.1.mhst1-1201.

UmeoraOUJ,OkontaPI,ChukwunekeFN,UmeoraMC(2012).IsthereaplaceformandatoryHPVvaccinationinNigeria?Publichealth,humanrights and ethical considerations. Nigerian Journal of Clinical &BiomedicalResearch(Jun.2012)Vol.6No.1:5-11

World Health Organization (2020). https://www.who.int/maldives/news/detail/31-01-2020-updates-on-novel-corona-virus-(COVID-19).AccessedJune28,2020

YolaAW(2003).ReportonChildImmunizationClusters(CICS).2003;4:1–3

Z.Zhao,X.Li,F.Liu,etal(2020).PredictionoftheCOVID-19spreadinAfricancountriesandimplicationsforpreventionandcontrols:acasestudyinSouthAfrica,Egypt,Algeria,Nigeria,SenegalandKenya.SciTotalEnviron(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

- RogelioP.Bayod-ErikkaJuneForosuelo-JeanM.Cavalida-BernadetteB.AvesCorJesuCollege,thePhilippinesEmail:[email protected] Abstract The Covid-19 pandemic has resulted in disruption ofworkandothersocialactivitiesofsomanypeople.Somewereforcedtostayathomeandmanydecidedtostayathome for fear of being infected with the virus. Thisphenomenonbroughtdifferentreactionsandevenmentalstresstomanypeople.However,therewerepeoplewhoturnedthiskindoftragedyintocreativework.Thispaperdiscusses the experiences and insights of known plantloversinDigosCity,DavaodelSurPhilippines.DigosCityisoneoftheheavilyaffectedplacesduringtheseriesofearthquakes that jolted Davao del Sur last year. Whilepeoplearestillrecovering,COVID-19addedanadditionalburdentotheresidents.Inthispaper,wearguethattheirdecision to focus on gardening was not only to fightboredomand todivert their attentionduring lockdownbutthiswastheirwayofmaintainingtheirwell-beingbyparticipating in the on-going work of creation and re-creationandtorise fromthetragedy.Wefurtherargue


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that it might be good that this creative work will gobeyond home gardening and beyond pots and slowlyextendtocreativeworkforenvironmentalprotectionandpreservation through more active engagements intoreforestationactivities. Introduction The COVID-19 pandemic created several unforeseenchallengesandhas takena significant tollonpeopleallacross the world. Our daily routines have beeninterrupted, work has been displaced, school time forchildrenandadultstoppedandtheoncebusystreetsatnight turned into peaceful paths. All these we arecurrentlyembracingaswegraduallyfacetherealityofthenewnormal.Butthiscircumstancealsoignitescharacterformation. According to (Rashid, n.d), character is thevirtueofhardtimes.Individuals,despitemanyset-backsinlife,trytoutilizetheirstrengthtodealwithchallengesadaptively.Itissaidthatapplyingourstrengthhelpsustoreframeandreappraisechallenges,andprovidesuswitha steady dose of well-being to build positive copingmechanisms.Research,informedbypositivepsychologyconcepts (Southwick, Satodiya&Pietrzak,2016) showsthattappingontoourstrengthshelpsustotackletoughchallenges(Niemiec,2018;Niemiec&Mcgrath,2019).Tosome, strengthmeans resorting to plant collecting andplantgrowing.Apersonwholovesplantsandflowersiscalled an anthophile. Plant and flower growing andcollecting have been proven to stimulate the mind,improving focus and concentration. Bringing naturalelementsindoorsandoutdoorshelpsmemoryretentionandproductivityintheofficeandtheenvironmentwearein.

Aswegatheredstoriesandexperienceofpeoplewhoare into home gardening, plant growing and plantcollecting, we argue that the reason that they are intogardening isnot only todo awaywithboredomduringlockdown and quarantine, but because it is theirmechanismtomaintaintheirwell-beingthroughactivelyparticipating in the on-going work of creation and re-creationandtoalsoriseabovetheseriesoftragiceventsthey have experienced.We also further argue that thiscreativepastimeneedstogobeyondpotsandgardensoil,and shall extend to creative work for the purpose ofprotectingandpreservingourenvironmentandmoreso,activeengagementswithreforestationactivities.

We asked our participants the following questions:What is your main reason you resorted to gardeningduringthistimeofpandemic?Howdoesgardeninghelpyouduringthistimeofpandemic?Whatlessonscanyougetfromengagingintogardening?Reasons why they resorted to gardening: Homegardeningcanbeveryexhaustingandtimeconsumingifitisnotconsideredasapassionorapastime.Inthistimeof pandemic, when there are government mandates tostayathomeforsafety,wecanactuallysustainforaweekoramonthbutaddingmoredaysandweekswouldresultto boredom, depression and worse, laziness andprocrastination.AccordingtotheCenterforDiseaseandControl Prevention (2018), well-being is a positiveoutcome that is meaningful for people and for manysectorsofsociety,becauseitshowsthatpeopleperceive

theirlivesasgoingwell.Thisistruetotheindividualswhoresorted into home gardening, plant growing andplantcollecting.Theyperceivetheseactivitiesasmeaningfulinthe midst of the strains brought about by COVID-19pandemic; to themthere is stillhope that their livesgowell by taking care and growing plants and flowers intheir gardens. There is no consensus around a singledefinitionofwell-being, but there is general agreementthat at minimum, well-being includes the presence ofpositive emotions and moods (e.g., contentment,happiness), the absence of negative emotions (e.g.,depression,anxiety),satisfactionwithlife,fulfillmentandpositive functioning (Andrews &Withey, 1976; Diener,2000;Ryff andKeyes,1995citedbyCenter forDiseaseand Control Prevention, 2018). These ideas also arelikenedtoGeorgeKelly’sPersonalConstruct(1963)whichstatedthatanyeventhappeninginourlivesisopentoavariety of interpretations and it is the individuals’perceptiononhowtheymakesenseofit(Engler,2010).Ifindividualsperceivedgardeningasawayofcopingwithstress and fear of being infected with the virus, thenindividuals create their own way of understanding theevents in a positive manner. Instead of becomingparanoid to the situationandhysterical to thenegativeinformation, they do something to make their livesproductive.Thus,whenaskedaboutthereasonswhytheyareintohomegardening,thesepeoplesaytheyengagedintothisactivitybecauseofthefollowing:Torelievestress,strengthenfamilybonding,andtofocusonpositivethingswhilestayingathome.

To relieve stress. It cannot be denied that COVID-19pandemichascausedsomuchstress topeople inmanycountriesintheworld.StressaccordingtotheUSNationalLibrary ofMedicine (2020) is a feeling of emotional orphysicaltension.Itcancomefromanyeventorthoughtthatmakesyoufeelfrustrated,angry,ornervous.Inorderto release the stress brought about by COVID-19, ourparticipants resorted into home gardening because iteases out and relieves the stress they are feeling. Oneparticipant said: “gardening is fun and removes stress”.Anotherparticipantsaid:“forashorttimeIdonotworryabout the healthcare; instead, doing gardening workrelaxesme and easesmyworries”. In otherwords, theyengagedintogardeningbecausetheyexperiencedasenseof happiness and fulfillment and that gardening takesaway their worries about what is happening in thesociety.Itisthereforeimportanttolearntomanagestresswhich includes avoiding stress and taking actions todecreasestressasitoccurs.Humanbeingsaregiftedwithpowerfuldispositionsanditisuptoustomaximizethispotential tobeabletoadjusttovariousadversitiesthatwegothroughinourlives.

This is very true to peoplewho engaged into homegardening during this pandemic. They experienced andtheybelievethatbyengagingintogardening, theywereable tomanagethestressbroughtaboutby thecurrentpandemic.Asidefromtakingawaytheirstress,gardeninggives them a feeling of enjoyment and relaxationwhenthey see their plants and flowers growing. In short,gardeningenhancestheirwell-being.Gardeningrelievestheirstressandsinceplantsarelivingbeings,itservesascompanyinthehouseandplantownersdonotfeelalonewhile staying at home during the pandemic.They take


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control of the situationbymanaging theirmentalwell-being andholdon to thehope that growingplants andcollecting its varieties divert their attention from thetoxicitybroughtaboutbythepandemic.

To focus on positive things while staying at home.Anotherreasonthatmotivatesourparticipantstoengageintohomegardeningisthattheywanttofocusonpositivethingswhilestayingathome.Duringthe interview,oneparticipantsaid:“stayathome,workfromhome,lockdown,quarantinecausedmetothinkaboutwhatotherthingstodo during this period”. Another participant said: “I finddiversion from the negativities that our environment isexperiencingatthemoment”.Thetragiceventsthattheyexperiencedallowedthemtofocusonpositivethingsandto enhance their capabilities to rise above the tragedy.The capability approach purports that the freedom toachievewell-beingisamatterofwhatpeopleareabletodoandtobe,andthus,thekindoflifetheyareeffectivelyable to lead (Sen 1992: 48; Robeyns, 2005: 94–96;Qizilbash,2008:53–54;Sen2009a;Robeyns,2016).Itissaid that optimists find opportunity in every difficulty.This implies that despite the negative situation, peoplechose to findwaysandmeans to livewithpositivitybytakingcareofplantsandflowersandengagingintohomegardening.Andthus,quarantineandlockdownallowourparticipantstothinkofotherbeneficialthingstodoandbecausetheyalreadyhaveplantsathome,theydecidedtopropagatethemandcultivatetheirsoil.

Cultivating the soil is cultivating life. For Kumar,(2013)ascitedbyBayod(2020),“soilisthesourceofalllife, literally andmetaphorically and that, all life comesfrom themother soil and returns to her”. Thus, Kumarloves soil as his mother and takes care of her (Bayod,2020). Kumar even made a beautiful analogy of theinterconnectednessoflifewhenhesaid:“Ifmyouterbodyissoil, thenmyinnerbeingisthesoul.AsIcultivatethesoiltogrowfoodforthebody,Itakecareofthesoulandcultivatelove,compassion,beautyandunitytorealizetheharmonywithinandwithout. When I am at ease within, I am at easewithout. I am at ease with the whole of humanity.Throughcaringforsoil(land)IamamemberoftheEarthcommunityandthroughcaringforsocietyIamamemberofthehumancommunity.”(Kumar,2013,p.10).According to Bayod, (2020), Kumar’s new trinity of

“Soil,Soul,Society”isawayofsayinginthreewordstheinter-relatedness, inter-connectedness and inter-dependenceof livingorganismsonearth. Indeed, it isatrinityofwholenessandunityoflifeinitsmyriadforms(Kumar,2013).

How gardening helped them during this time ofpandemic:Inthisnewnormal,peoplegotsomuchcrazeinbuyingpots,plants,flowers,andsomeevenpropagatedmore plants by growing seedlings at home. Friendlyneighbors, office friends and even social media vlogssharedtipsonhowtogrowhealthyplantsthrivinginaneverchanging environment. People were happy andexcitedbecauseoftheseactivitiesdespitethepresenceofthe pandemic. In her capabilities’ theory (Nussbaum,

2002, citedbyKleist, n.d) she emphasized: “if a personlives a life where she is unable to exercise her humanpowers(forexample,self-expressivecreativity)thensheislivingherlifeinmoreofananimalisticmannerthanasahumanbeing”.Nussbaumseeksacapabilities’approachthatcanfullyexpresshumanpowersandnotjustprovideopportunitiesforpeopletoperformcertainfunctions.Ashuman persons we are gifted with capabilities andchoices which transcend us from the rest of the livingcreatures.Wecandosomethingtoturntryingtimesintoa worthwhile undertaking and these activities help ussustainduringthepandemicthatstrippedusofthingsweareaccustomedwith.Theanswersofourparticipantsfallinto the following themes: Provides relaxation andcalmness; Enhances self-esteem and well-being; Providessourceofincome.Provides relaxation and calmness.To relaxmeans tocalmthemind,thebody,orboth.Relaxingcanquietourmindandmakeusfeelpeacefulandcalm.Infact,ourbodyreactswhenwerelax.AccordingtotheAmericanInstituteof Stress (2019), one is lucky to live in a home thatprovidesitsowngardenorgreenspacebecauseonecanfeel a sense of tranquility. For our study participants,gardening helps them to slow down, be calm andreflectiveaboutlife.Italsoprovidesthemenjoymentandcomfortwhile seeing theplantsgrow.Asmentionedbyoneofourparticipants:“Homegardeningmakesmeslowdownthepaceofmybusylifebecauseplantsandflowersbring calmness and serenity. I found comfort with theplantseverytimeIseethem.Theyareimmediatemedicinetomyworriesinthistimeofpandemic”.Mentalfocusandmindfulness are popularways of combatting the stressandanxiety causedby theCOVID-19pandemic. Indeed,gardeninghelpsthemtoslowdown,relaxandbecalm.Italso provides them with enjoyment, relaxation andcomfort while they nurture their plants. Certainly,spendingtimeinthegardenisagreatwaytorelaxandcalm.Plantsandflowershavemagicalpowertorelaxourmindandbody.Thatiswhyinmanyretreathouseswherepeople are expected to pray and be still, they aresurrounded with plants and flowers. Aside from theoxygenthattheyprovidetohelppeoplebreathnormallyandcomfortably,gardensarealsopleasingtotheeyesandhelpyoustaycalmandrelax.

Enhances self-esteem and well-being. Due to theincreasingdemandofplantandflowervarieties,severalsocialmediagroupsarecreatedtoanswertheseneedsofplantgrowers.Averygoodexample isaFacebookpagethat allows people to sell, barter and introduce plantvarietiesanddiscussmattersrelatedwithplantgrowingandhomegardening.Ourparticipantswereveryproudtoexpress their thoughtson the fact thathomegardeningenhances 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 offocusingontheproblem,gardeninghelpsmere-alignmyenergies tobemoreproductive in the society.Every timepeoplecomeandseemyplants,theyarehappyandI’malsoproudofmyself”.Anotherparticipantmentioned:“Itgives


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mepositiveoutlook.Iloveseeinglittleonesgrowing.Anditgives me a very wonderful experience, especially onknowingplantnamesandpropagationprocessthatmakesmemoreexcitedwakingupeachday”.Thesameconceptwas shared by another participant when she said:“Gardeningmakesmehappyanddevelopsmyself-pride.Itbuildsmypatience,clearsmymindandchallengesmetoenjoy simple things in life without spending too much”.Seeingtheirplantsgrowenhancestheirself-esteemandthey are affirmed of their capabilities to nurture life.Sharing these experiences with their fellow gardenersalso allows them to establish and develop friendshipswith them. According to Scott, Masser and Pachana,(2020), gardening groups offer a way for people toconnect with nature and each other, allowing socialbenefits toaccrue.Connectingwithothermembersofagardeninggroupallowspeopletoreceivesocialsupportand to contribute positively to the lives of others, animportant protective factor against isolation andloneliness(Haslametal,2019).Asexpressedbymajorityof the study participants, they think and feel thatgardening really enhances their self-esteem and well-beingastheyenjoysimplethingsinlife.Gardeningmakesthemfeelexcitedtowakeupeachdayasitprovidesthemwithapositiveoutlookinlife.

Provides source of income. A lot of people have beendisplacedduetothepandemic.Somelosttheirjobsandothersareforcedtostopgoingtoworkbecausetheyaredirectedtohavehomequarantine.Withmeageramountofincome,thesepeoplelookedforwaysandmeanstolivebyandtosustainespeciallythattheyhavemouthstofeed.This is one of the major reasons why home gardeningbecameasourceofincometoplantandflowersgrowers.Accordingtooneparticipant:“Istartedmyinvestmentincollectingdifferentvarietiesofplantsforfutureplanslikehaving a nursery/farm as additional income”. Anotherparticipantsaid,“Foreconomicsurvival,gardeningreallyhelpsme.”Itrevealsthathomegardeningprovidedthemanopportunity toearnmoneyespecially in this timeofpandemic.AccordingtoWallin(2019),flowersareamongthemostprofitableplants,producingoneofthehighestreturns of any specialty crop. One can get startedwithverylittle, justenoughforseedsandsupplies,andmostnewflowergrowersmakemoneyinthefirstyear.Thereareplantandflowergrowersespeciallyduringthetimeofpandemic,whoonlycollectforhomebeautificationatfirstand later turn their love of plants and flowers intoprofitableventures.Theymakemoneyoutoftheirhobbywhichbecomesanadditiontotheirincome.

Lessons they get from engaging into gardening.Plantingflowersandvegetablescanreapgoodharvest.AsstatedbyFrost(n.d):“Beyondtherewardofhomegrownproduce, gardens provide health, environmental andenjoymentadvantagesforthegardener”.Itisafulfillingjob and it also bring us back to commune with thewonders of nature. Asmentioned by our participants,the lessonstheyget fromengaging intogardeningare:To be patient and to treat and enjoy life properly;Promotesphysical,mentalandemotionalhealth;Tofocusongratitudeinsteadofcompetitionandtolettheflowersbloom in its perfect time; To go beyond backyardgardeningtotakecareofourenvironment.

To be patient and to treat and enjoy life properly.Patience is a virtue especially when it comes togardening.According toKinzler (2017), gardening isarefreshing throwback to a quieter, more patient time,which ispart of its charm.And sinceplant and flowergrowersareveryexcitedtoseetheirflowersbloomandtheir plants produce, there will always be strides inquickeningthepacebecauseplantstakeallthetimetheyneed 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 thelikelihoodofstress-relateddepression.Accordingtooneoftheparticipants:“Ilearnedthatyouhavetobepatientinlifebecauseyoucannotrushyourplants’growth.Theyhavetobetreatedproperly,tendedregularlysothattheycangrowright”.Anotherparticipantsaidthat“It taughtmepatience,toleranceandendurance.Itmademerealizethesimplethingsinlife.Thatjoycanbeattainedbysimplylookingatyourplantsbloomingandgivingbackthelove”.Indeed,gardeningreallydevelopsyourvirtueofpatienceinwaiting.Butwhilewaiting,youare fullofexcitementandjoyfulanticipationofthedevelopmentofyourplants.Gardeninghelpsustoreflectaboutlifeingeneral–thatweneedtobepatientaswejourneyandineverystepoftheway,letusjustenjoythejourneyandembracewhatlifehastooffer.

PromotesPhysical,MentalandEmotionalHealth.Asemphasized by (Eliades, 2013), gardening promotesphysical and mental health through relaxation,satisfactionandbetternutrition.Thereisnogreaterjoythan seeing the plants thrive well, healthy and green.According to Ellison Chair in International Floriculture(n.d),flowerscanhelpachieveamoreoptimisticoutlookinlife,whichpleasesvisualstimulationandhelpsincreasethe perceived happiness of the planters. Researchersoftenfindintheirstudiesthatsubjectswhoparticipateingardening have a positive mental outlook (Lombard,Forster-Cox, Smeal,O’Neill, 2006;Armstrong, 2000).Asoneofourparticipantssaid:“homegardeninghelpsmetobementallyandemotionallyhealthy”.Anotherparticipantexpressed:“Plantsareouroutletandonethatboostsourenergytocontinuelivingwithgraceandenthusiasminthischallenging time”. Studies reported in the Journal ofHealthPsychology in2012showthatpeoplewhofeelaconnection to nature are indeed happier (Cervinka,Roderer&Hefler,2011).

Tofocusongratitudeinsteadofcompetitionandtoletthe flowers bloom in its perfect time. It is said thatpeoplewhospendextendedlengthsoftimearoundplantstend to have better relationships with others. As theysharestoriesoftheirplantvarietiesandtheirexperiencesin home gardening; these people also have expressedgratitude to friendsandneighborswho share seedlingsandotherplantmaterialsthatcanbeaddedtothehomegarden.Asoneparticipanthappily said: “Despiteall thenegative things happening around us, there is alwayssomethingtobe thankful forandto look forwardto. Justlike plants, we all bloom in our own ways and in God’sperfecttime”.Throughoutgenerations,plantshavebeena


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beautifulmedium throughwhichwe can learn some oflife’svaluablelessons(ClickandGrow,2019).

Togobeyondbackyardgardeningandtotakecareofour environment. Gardens are not just aestheticallypleasing,theyareabuildingblockofahealthyspaceandareductionincarbonfootprints(Throne,2018).Gardenshelp keep the environment healthy and strong. Theabsenceofplantsandflowersinourgardenscanincreasepollution,globalwarming,carbondioxide,andunhealthylifestyles.Asmentionedbyaparticipant:“Itwouldbegoodtoplant trees. Iwish Ihadabigareahere. Iamstillnotenergeticenoughtoclimbupmountainstoplanttrees.ButI can just plant few trees or fruit trees here in ourbackyard”.Andanotherparticipantsaid: “IrealizedthatGodhasareasonforlettingusexperiencehomequarantine,notonlytovaluethepresenceofourlovedonesandpetsbutalso to help mother earth revive its beauty throughplanting/gardening.”Themorepeopledecidetoengageinhomegardening,theywillnotonlybehelpingthemselvesto improve their well-being but also help protect andnurture the environmentwe live in.Manyof our studyparticipants have the desire to go beyond backyardgardeningandtogetinvolvedinlarge-scaletreeplantingactivities to really protect the environment if given thechance.

Conclusion Ourenvironmentisanimportantpartofourexistence.Aswejourneytogetherinfacingthetremendouseffectsbrought about by the COVID-19 pandemic, people areabletoturntragedy intocreativeworkbydoinghomegardening and by growing plants and flowers. Theseplantloversresortedintogardeningduringthistimeofpandemic to relieve stress and to focus on positivethingswhile staying at home. Furthermore, gardeningprovidesrelaxationandcalmness,enhancesself-esteemandwell-beingandprovidesasourceof income.Thus,peoplewhoengage ingardeninghavenotonlyearnedadditional incomebutalsogain lessons in life thatarepriceless.Theylearntobepatientandtotreatandenjoylife properly. Gardening also helps them to promotephysical,mental andemotional health and to focusongratitude insteadof competitionand to let the flowersbloom in its perfect time.Whilemomentarily they arejust doing gardening in their own backyard, many ofthem also share that they are willing to go beyondbackyardgardening to take careof theenvironment ifgiventhechancetodoso.Itmightbemorenobleifthiscreativework that is discoveredand transpired in thetimeofpandemiclikehomegardeningandloveofplantsandflowersshallgobeyondthegardensoilsandpotsinthe gardens (including projects for greening ofbackyardsathome)andleadtoactiveparticipationandinvolvement in activities on environmental protectionand preservation. It is already established that loss ofbiodiversity and deforestation will result in virusoutbreaks (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 ourailingenvironmentthroughreforestationandgreening

projectsmaynotonlypreventafuturepandemicbutwillalso give, nurture and protect life not only for thepresent generationbut for thenext generations yet tocome.

Thepresentpandemicalsoallowsustochannelourenergyinenhancingourcapabilities.AsdiscussedbytheStandford Encyclopedia of Philosophy (2016): “thecapability approach is a theoretical framework thatentailstwocorenormativeclaims:first,theclaimthatthefreedom to achieve well-being is of primary moralimportance, and second, that freedom to achieve well-beingistobeunderstoodintermsofpeople'scapabilities,that is, their real opportunities todo andbewhat theyhavereasontovalue”.Accordingtomanyphilosophers,the best description of the capability approach is aconceptualframeworkforarangeofnormativeexercises,includingmostprominentlythefollowing:(1)assessmentofindividualwell-being;(2)evaluationandassessmentofsocial arrangements; and (3) design of policies andproposalsaboutsocialchangeinsociety.Inotherwords,thecapabilityapproachprioritizesthecapacity,freedomandopportunity of people todo important actions thatwill also enhance the core of their personhood.MarthaNussbaum (2011) has described the general capabilityapproachas consistingof twoclusters:one focusingonthecomparativequalityoflifeandtheotherontheorizingaboutjustice.Whilemostexperiencesofourparticipantsarestillcenteredontheirownwell-being,wecangleanfromtheirinsightsthatsomeofthemarewillingtoextendtheiractivitiestoamuchbroadercontextandissuessuchasenvironmentalprotectionandclimatejustice.

It has been said that great things start from smallbeginnings. This gardening venture of many people,while primarily intended only to help themselvesphysically,emotionallyandspiritually,mustextendintogreaterinvolvementintothedifferentcollectiveactionstowardstakingcareoftheenvironment,protectingourremaining forests and even restoringdenuded forests.Whileweneedtotakecareandmaintainthebeautyandbounty of our home, let us be reminded that we arecitizensofthisonebighome–ourplanet.Thus,weneedtotakecareofourcommonhomebyestablishingadeepreciprocal relationship with our planet and all that itcontains.Whilewetakegoodcareofourplanetandallthat it contains, it shall take good care of us. Indeed,thereisnotragedy,nomatterhowbigandterribleitis,ifpeoplecontinue tosingourSONG–ourrelationshipwithSelf,Others,NatureandGod. References AmericanEncyclopediaofPhilosophy(October3,2016).TheCapabilityApproach. Retrieved July 30, 2020 fromhttps://plato.stanford.edu/entries/capability-approach/#Bib

Andrews FM, Withey SB. Social indicators of well-being. NewYork:PlenumPress;1976:63–106.

Armstrong,D.(2000).AsurveyofcommunitygardensinupstateNewYork: implications for health promotion and communitydevelopment.HealthPlace,(4):319-27.

Bayod,R. (2020). CommuningwithMotherEarth: IndigenousWay toCare and Manage the Ecosystem. Social Ethics Society Journal ofAppliedPhilosophy,Vol.6,No.1,April2020.

Cervinka, R., Röderer, K. & Hefler, E. (April 2012). Are nature lovershappy?Onvariousindicatorsofwell-beingandconnectednesswithnature. JHealthPsychol17:379-388, firstpublishedonAugust22,


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Center for Disease and Control Prevention (October 31, 2018).Well-being concepts. Retrieved July 30, 2020, fromhttps://www.cdc.gov/hrqol/wellbeing.htm

ClickandGrow(March07,2019).7Amazinglife’slessonsplantsteachus. Retrieved July 30, 2020, fromhttps://asia.clickandgrow.com/blogs/news/amazing-life-lessons-plants-teach-us

ClimateCouncil. (2020). “Infographic:howdoes climate changeaffectbushfires?” https://www.climatecouncil.org.au/resources/infographic-how-does-climate-change-affect-bushfires/

Diener,E.(2000).Subjectivewell-being:thescienceofhappinessandaproposalforanationalindex.AmericanPsychologist;55(1):34–43.

Eliades, A. (June 05, 2013).Wellbeing Gardening – Gardening for theBody, Mind & Spirit. Retrieved, July 30, 2020, fromhttps://www.permaculturenews.org/2013/06/05/wellbeing-gardening-gardening-for-the-body-mind-spirit/

EllisonChair in InternationalFloriculture (n.d)Healthandwell-beingbenefits of plants. Retrieved July 30, 2020, fromhttps://ellisonchair.tamu.edu/health-and-well-being-benefits-of-plants/

Engler,B.(2010).Personalitytheories.Anclover;Cengagelearning.Fox, K.M., &McDermott, L. (2020).Where Is LeisureWhenDeath IsPresent?LeisureSciences,1-6.

Frost,S.(n.d).Theadvantagesofhomegardens.RetrievedJuly30,2020,from https://homeguides.sfgate.com/advantages-home-gardens-39103.html

Haslam,C,Steffens,NK,Branscombe,NR,etal(2019).Theimportanceofsocialgroupsforretirementadjustment:evidence,application,andpolicyimplicationsofthesocialidentitymodelofidentitychange.SocIssandPolRev;13:93–124.

Hogrefe.Niemiec,R.M.,&McGrath,R.E.(2019).ThePowerofCharacterStrengths: Appreciate and Ignite Your Positive Personality. VIAInstituteonCharacter.

KesslerM,BeckerD,PeelA,JusticeN,LunnT,CrowleyD,etal(2018).“Changing resource landscapes and spillover of henipaviruses”,AnnalsoftheNewYorkAcademyofSciences,https://doi.org/10.1111/nyas.13910

Kinzler, D. (September 16, 2017). Patience is a virtue especially ingardening. Retrieved July 30, 2020, fromhttps://www.agweek.com/opinion/4326762-patience-virtue-especially-gardening

Kleist,C.(n.d).GlobalEthics:CapabilitiesandApproach.RetrievedJune30,2020,fromhttps://iep.utm.edu/ge-capab/

Kumar,S.(2013).Soil.Soul.Society:ANewTrinityofOurTime,LeapingHarePress.

Lombard,KA.,Forster-Cox,S.,Smeal,D.,O’Neill,MK.(2006).DiabetesontheNajavonation:whatrolecangardeningandagricultureextensionplaytoreduceit.RuralRemoteHealth,6(4):640.

MartinG,Yanez-ArenasC,ChenC,PlowrightRK,WebbRJ,SkerrattLF(2018). “Climate Change Could Increase the Geographic Extent ofHendra Virus Spillover Risk”. EcoHealth, 2018;https://doi.org/10.1007/s10393-018-1322-9.

Niemiec,R.M.(2018).Characterstrengthsinterventions:Afield-guideforpractitioners.Boston:

Nussbaum, Martha (2002) “Capabilities and Disabilities: Justice forMentallyDisabledCitizens,”PhilosophicalTopics,30:2,133-165.

PlowrightRK,EbyP,HudsonPJ,SmithIL,WestcottD,BrydenWL,etal(2015). “Ecological dynamics of emerging bat virus spillover”,Proceedings of the Royal Society B: Biological Sciences, 282 (1798),20142124,https://doi.org/10.1098/rspb.2014.2124

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Sen,A.1992,InequalityRe-examined,Oxford:ClarendonPress.Sen,A.2009a,TheIdeaofJustice,London:AllenLane.Southwick,S.M.,Satodiya,R.,&Pietrzak,R.H.(2016).DisasterMentalHealth andPositive Psychology: AnAfterward to the Special Issue.Journal of Clinical Psychology, 72(12), 1364–1368.https://doi.org/10.1002/jclp.22418

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Walsh,M.G.,Wiethoelter,A,HaseebM.A.(2017).Theimpactofhumanpopulation pressure on flying fox niches and the potentialconsequences for Hendra virus spillover. Scientific Reports, 7(1),8226, https:// doi.org/10.1038/s41598-017-08065-z, https://doi.org/10.1038/s41598-017-08065-zWWF World Wildlife Fundhttps://www.wwf.org.au/get-involved/bushfire-emergency#gs.46obrq

Ethical issues of COVID-19 for persons with disabilities

-ShahanazChowdhury,PhDAssociateProfessor,Dept.ofCommunityMedicine,FacultyofPublicHealth,BangladeshUniversityofHealthSciences(BUHS),Bangladesh;VisitingProfessor,AUSNEmail:[email protected] Introduction Globally,morethan1billionpeople,roughly15percentoftheworldpopulation,livewithsomeformofdisability.People who are older, people with chronic healthconditions,orpeoplewithdisabilities that, forexample,affecttheirrespiratorycapacity,maybeatparticularriskofseriousillnessordeathfromCOVID-19infection.1

In the current situation of a global health crisis duetoCOVID-19, there is thehigher risk faced by personswithdisabilitiesorchronicillnesses,especiallyinlowandmiddle-income countries. In order to successfully meetthischallengeandcomplywith the2030goals,personswithdisabilitiesmustbeincludedinallplanstomanagethecurrentCOVID-19coronavirusoutbreak.Thisimpliesthatthe information providedby governments andinstitutionstopreventinfectionandtoknowhowtoactincaseofillnessmustbeavailableinaccessibleformats,including sign language, video captioning, the use ofalternativetextinimagesandgraphicsdisplayeddigitally,andeasy-to-readversions.2

Even in normal times, people with disabilities andchronic illnesses confront biases in medical care, facewaitingliststogetsupportintheirownhomesinsteadofat nursing homes, and struggle to access governmentbenefits.Butamidaglobalpandemic,thosechallengesareheightened.3

WhiletheCOVID-19pandemicthreatensallmembersof society, persons with disabilities aredisproportionately impacted due to attitudinal,environmental and institutional barriers reproduced inthe COVID-19 response.Many personswith disabilitieshavepre-existinghealthconditionsthatmakethemmoresusceptible to contracting the virus, experiencingmoreseveresymptomsuponinfection,leadingtohigherlevels


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of death. During the COVID-19 crisis, persons withdisabilitieswhoaredependentonsupportfortheirdailylivingmayfindthemselvesisolatedandunabletosurviveduring lockdown measures, while those living ininstitutionsareparticularlyvulnerable,asevidencedbytheoverwhelmingnumbersofdeathsinresidentialcarehomesandpsychiatricfacilities.4ImpactofCOVID19indifferentinstitutions:COVID-19has shown a disproportionate impact in psychiatricinstitutions, social care institutions (orphanages, day-carecenters,andrehabilitationcenters)andinstitutionsforolderpersons,resultinginhighratesofinfectionanddeath.Insomepreliminarystudies,thenumberofdeathsincarehomesrepresentedfrom42%to57%ofallCOVID-19 deaths in those countries. Institutionalized personswith disabilities face a heightened risk of contractingCOVID-19duetounderlyinghealthconditions,difficultyinenforcingsocialdistancingamongstresidentsandstaff,andabandonmentbystaff.Personswithdisabilitieslivingin institutions also face greater risks of human rightsviolations, such as neglect, restraint, isolation andviolence.4COVID-19couldbecatastrophicinsettingssuchas refugee camps or other temporary camps, wherepeople live in close proximity and often lack access tobasicservices.Peoplewithdisabilitiesinsuchplacesfacesevereobstaclestobasicservicessuchasshelter,water,sanitation, and medical care, including in countrieslikeBangladesh,Cameroon,theCentralAfricanRepublic,Greece,Syria,andYemen.1 FacingdiscriminationandbarriersduringCOVID19crisis: Persons with disabilities also continue to facediscriminationandotherbarriersinaccessinglivelihoodand income support, participating in online forms ofeducation, and seeking protection from violence.Particular groups of persons with disabilities, such asprisoners and those who are homeless or withoutadequate housing, face even greater risks.4 It is alsoimportant toremove the barriers in accessing healthservices and hygiene products, as well as to considerreasonable accommodation measures to allow them toworkfromhomeand,ifthatisnotpossible,toensuretheyreceive a paid leave to guarantee their income.2Olderpersons are at an increased risk of multiple rightsviolations in the COVID-19 pandemic,5 such asdiscriminationbasedonage, andmustbe supported toaccess services on an equal basis with others.Whilehavingadisabilityprobablydoesn’tbyitselfputsomeoneat higher risk from coronavirus, many persons withdisabilities do have specific underlying conditions thatmakethediseasemoredangerousforthem.6

Forpeoplewithdisabilities,allthegeneralchallengesthat comewith thepandemic certainly apply, but thereareadditionalbarriers.EquitableaccesstohealthcareisalongstandingbarrierworsenedbyCOVID-19.Thisrangesfrom getting a coronavirus test to being seen in anemergency room. The use of personal protectiveequipment, including masks, can make communicationmore difficult for patients with hearing loss. Medicalresource allocations, including ventilators, may bediscriminatory against patients with disabilities. Thisissue echoes an underlying misconception that people

with disabilities cannot have a high quality of life andtherefore the lives of disabled people may not beprioritized.Therehasbeenashifttowardtelehealthfornon-urgentmedicalvisits.Thathasprovidedchallengesbut also future opportunities for the disabilitycommunity.7

People with disability may be at greater risk ofcontractingCOVID-19becauseof:a) Barriers to implementing basic hygiene measures,suchashand-washing(e.g.handbasinsorsinksmaybe physically inaccessible, or a person may havephysical difficulty rubbing their hands togetherthoroughly);

b) Difficulty in enacting social distancing because ofadditional support needs or because they areinstitutionalized;

c) Theneedtotouchthingstoobtaininformationfromtheenvironmentorforphysicalsupport;

d) Barriers to accessing public health information.Depending on underlying health conditions, peoplewith disabilitymay be at greater risk of developingmoresevereCOVID-19 if theybecome infected.Thismay be because of exacerbating existing healthconditions, particularly those related to respiratoryfunction, immune system function, heart disease ordiabetes;

e) Barriers to accessing healthcare. People withdisabilitymayalsobedisproportionatelyimpactedbythe outbreak because of serious disruptions to theservices they rely on. The barriers experienced bypeople with disability can be reduced if keystakeholderstakeappropriateaction.8

Responses during the COVID19 crisis: Personalassistants and interpreters should be, when possible,proactively tested forCOVID-19 tominimize the riskofspreading the virus to persons with disabilities.9Similarly,confinement measures should be adaptedtothe needs of specific groups to ensure theirwell-being.For example, peoplewho need home assistance shouldkeep receiving it and, in the case of persons withpsychosocialdisabilities,theycannotberequiredtoliveintotalisolation.2

The government and healthcare responses to theCOVID-19 crisis are having a significant impact on thelives of people all over the world. It is vital thatgovernments and health officials ensure that humanrightsarepartofthisresponse.Inparticular,theymustensure that the rights of people from marginalizedcommunities—those who are most likely to see theirlivelihoods evaporate, their healthcare needs gooverlooked,andtheirlivesupendedduringacrisis—aretoppriority.10Allpreparednessandresponseplansmustbe inclusive of and accessible to all persons withdisabilities,includingwomenandgirlswithdisabilities.9Childrenandadultswithdisabilitiesshouldbeenabledtoparticipate in decisionmaking and their treatment andwhenrequiredtheyshouldbesupportedtocommunicatetheirneedswhileundertreatment.11

Governmentsshouldtakeurgentstepstomovepeoplewithdisabilities(whocanbemovedsafely)outofclosedinstitutionsandsimilarsettingsandstopnewadmissions.


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Children with disabilities in residential institutionsshould be reunited with families, wherever possible.Governmentsshouldprovideadultswithdisabilitieswithsocial support and services to live in the community.Inside institutions, authorities should follow stricthygiene and physical distancing and shoulddevelopvisitor policiesthat balance the protection of residentsand staff with needs for family and connection.Withpolicies requiring social isolating to stem the spread ofcoronavirus,peoplewithpsychosocialdisabilities,suchasanxietyordepression,maybeinparticulardistressandmay benefit from additional mental health supportservices. Indeed, self-isolation and quarantine could bedistressingformostpeopleingeneral.

Governmentpoliciesshouldensurecommunity-basedservices continue and crisis counseling programs areaccessibletoall.Disruptionofcommunity-basedservicesshouldnotresultintheinstitutionalizationofpeoplewithdisabilitiesandolderpeople.1Allserviceprovidersmustensure that peoplewith disabilities are not left behindduringtheCOVID-19outbreakandthattheyaretreatedwithrespect,dignityandwithoutdiscrimination.Specificactionsmustbe takenbyvariousgroups toensure thatpeoplewithdisabilityhaveequalaccess to information,healthcare services and the support they need to stayhealthyandsafe.12Wemustensurethattelehealthvisitsareaccessible topatientswithvisionorhearing lossorotherdisabilitiesinordertomaintainequityinhealthcaredelivery. If accessibility is prioritized as we make thischange,atransitiontotelehealthcouldopenthedoortoamoreaccessiblehealthcaresystem.7Ensurepersonswithdisabilitiesreceiveinformationaboutinfectionmitigatingtips,publicrestrictionplans,andtheservicesareofferedinadiversityofaccessibleformats,includingeasytoreadformat, high contrast print and,wherepossible, braille,along with the use of available technologies such assubtitlesinverbalmessaging.9

Conclusion With the spread of COVID-19, it is vital that everyone,includingpeoplewithdisabilityfollowbasicmeasurestoprotectthemselvesandothersfrombecomingillwiththevirus.Equallyas important issocialdistancingandself-isolation that can be difficult for some people withdisability.12Ensureaccessforpersonswithdisabilitiestoessentialservicesandprotectiononanequalbasiswithothers.9 Persons with disabilities, through theirrepresentativeorganizations,aretheoneswhocanbetteradvise the political authorities to include the disabilitydimension intheprevention,mitigationandmonitoringplansrelatedtothisdisease.2Theissuesofpre-pandemiccaredeliveryonlybecomemoreurgentinatimeofcrisisbecause people with disabilities have often beenconsideredinadisasterorpandemicplanning.Weneedto learn from this crisisandensuredisability inpartoffuturepandemicplanning.

Many people with disabilities are at high risk ofCOVID-19,buttheirperspectiveisnotbeingincludedineffortstoaddressinequitiesintheresponse.Thisincludesunderstanding theuniquechallengesof thiscommunityduring this crisis. COVID-19 has elevated thatconversation,andthelegacyshouldbeacontinuedfocusondisability disparities and constant efforts to addressdisabilityinequities.Asweallmakesubstantialchanges

in our daily lives, such as working from home andadjustinghowweconnecttoothers,looktopeoplewithdisabilities for guidance, as we have always usedalternativestrategies.WemustlookforwardthatCOVID-19will leadustobetterunderstandingof inclusionandbringinganopportunitytothedisabilitycommunity.13References 1. https://www.hrw.org/news/2020/03/26/protect-rights-people-disabilities-during-covid-19

2. https://bridgingthegap-project.eu/the-impact-of-covid-19-on-people-with-disabilities/

3. https://time.com/5826098/coronavirus-people-with-disabilities/4. https://www.ohchr.org/Documents/Issues/Disability/COVID19_and_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.html7. https://hub.jhu.edu/2020/04/23/how-covid-19-affects-people-with-disabilities/

8. http://www.emro.who.int/violence-injuries-disabilities/violence-infocus/considerations-for-people-with-disability-during-covid-19.html

9. Toward a Disability-Inclusive COVID19 Response: 10recommendations from the International Disability Alliance,InternationalDisabilityAlliance(IDA).(2020)

10. https://docs.google.com/forms/d/e/1FAIpQLSdgrf14DRGtDam8hkL6spXTxBkAXl5IijAcF58mMWcbAuImzg/formResponse

11. nws_disability-inclusive_covid-19_response_-_twg_on_inclusion_guidance_note_-april_2020

12. http://www.emro.who.int/violence-injuries-disabilities/violence-infocus/considerations-for-people-with-disability-during-covid-19.html

13. https://hub.jhu.edu/2020/04/23/how-covid-19-affects-people-with-disabilities/

COVID-19 and mental health: government response and appropriate measures

-GenevieveBandares-PaulinoDean,LawSchool,CorJesuCollege,[email protected],ResearchandPublicationOffice,CorJesuCollege,[email protected]

Abstract Asgovernmentsaroundtheworldimposedlockdownsorstay-at-home measures, people began to feel the stress as timedragged on. Therewere already reports on some individualscommitting suicide. How do governments respond to such aphenomenon?OurmainfocusisthePhilippinegovernmentandhowitrespondedtotheCOVID-19pandemic.Inthispaper,wearguethattheproblemwithCOVID-19wentforthjustdealingwith physical health. First, people suffer not just from beinginfectedbutthepsychologicalstressofpossiblygettingthevirusandthetollofthegovernmentlockdownorquarantine.Second,the PhilippineBayanihan ‘WeHeal As One Act’ lacks focus onmentalhealthissueswhilethegovernment'sresponseseemedtofocusonsecurityissues.Third,therearecountriesaroundtheworldthathaveactedeffectivelyinprotectingpeople’smentalhealth.Lastly,weproposeappropriatemeasurestohelpaddressthepeople'smentalhealthwhilestillinthepandemicandforafutureone. Introduction COVID-19 has brought so many problems both forindividualsandgovernments.Theseproblemscouldlead


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into enduring health problems, isolation, and stigma(Torales,O’Higgins,Castaldelli-Maia&Ventriglio,2020).However,itseemsthatmostofthenewsnowadayscenteron one thing: national security. In the Philippines, themilitaryisactivelyinvolvedinthefightagainsttheCOVID-19 pandemic. With the nationwide imposition ofcommunityquarantineindifferentlevelssuchasGeneralCommunity Quarantine (GCQ), Enhanced CommunityQuarantine (ECQ), and Modified General CommunityQuarantine(MGCQ),themilitaryandthepoliceareintheforefrontof implementing it.TherewerealsocriticismsonthecompositionoftheInter-AgencyTaskForce(IATF),a body responsible for the country's response to thepandemic. Some people were critical of the absence ofexpertsinthemedicalfield,exceptthechairmanwhoistheSecretaryoftheDepartmentofHealth(DOH),adoctorby profession; others were retired military personnel.Whilethemilitaryandthepolicemustbeinvolved,somepeoplequestionedifotheraspectsofthispandemiccrisisaretakencareof.Oneoftheseisthementalhealthofthepeople.

Inthispaper,wepresentthescenarioofmentalhealthsituation as reported. We argue how important thisproblemhastobeaddressedjustlikeotherhealth-relatedconcerns. We also point out the lack of governmentresponse about the people's psychological and mentalneeds, particularly during the prolonged lockdown orquarantine,thetermusedbythePhilippines.Moreover,wealsoidentifymeasuresthatcatertomentalhealthintimes of a pandemic. This paper addresses the gap ofhaving a comprehensive plan in fighting against theCOVID-19 pandemic. It also contributes to the body ofknowledgeontheimportanceofmentalhealthandhowgovernmentsmust include it in thewhole spectrum ofhealthcare.COVID-19andmentalhealthThedevastatingeffectofCOVID-19wasnotjustdeathdueto complications. People suffered mental problems.Stayingathomeandthefearofdeathtookatollforsome.For example, preventing people’s mobility causeddistressandlonelinessamongIndiansandledtosuicides(Dsouza,Quadros,Hyderabadwala&Mamun,2020).Inareview of literature of articled published related toCOVID-19 pandemic, Rajkumar (2020) found anxiety,depression,andstressasthemostcommonpsychologicalreactions.InPakistan,reportssuggestedthatthecauseofsuicides in the country was mainly due to lockdownrelatedeconomicrecession(Mamun&Ullahm,2020).InBangladesh,amancommittedsuicidebecauseofpressurefrom villagers who suspected him of having the virusdespitenodiagnosis(Mamun&Griffiths,2020).

Despite being known for their resilience in times ofdisaster or crisis, Filipinos did not escape from thepsychologicalbattle.TherewerereportsofFilipinoswhocommittedsuicidelikethecaseofaFilipinamarinerwhotook her own life inside her cabin while waiting forrepatriation back to the Philippines (Ramos, 2020). InLebanon,aFilipinadomestichelpertookherlifewhileatthe shelter run by the Philippine embassy (AgenceFrance-PresseReuters,2020).A34year-oldinOccidentalMindoro, Philippines, diagnosed with Dengue Fever,

thought himself of having the COVID-19 virus, andcommitted suicide. He alsowrote anote tohiswife toquarantine herself, although thewife did not showanysymptoms (Delos Reyes, 2020). There were otherunconfirmedreportsbothinthePhilippinesandabroadwhosuccumbedtothesamefate.Thesereportswereveryalarming.Peopleandthegovernmentshouldrealizethatmental health is as important as other health-relatedproblems.COVID-19andnationalsecurityWepointedearlierthatnationalsecurityseemedtotakea priority stance in the Philippines in dealing with thepandemic.When one speaks of the Philippine NationalSecurity Laws, they actually refer to the following: (a)Philippine Constitution; (b) Laws enacted by Congresssuch as the Revised Penal Code and the relatively newlaws,theRA10173otherwiseknownastheDataPrivacyActof2012,RA10175ortheCybercrimePreventionActof 2012, theRA11036 or the PhilippineMentalHealthAct.Alsoincludedaretheanti-terrorismlaws,namely:RA9372 or the Human Security Act and RA 10168 or theTerrorism Financing Prevention and Suspension Act of2012;(c)Executiveissuances;(d)Jurisprudence;and(e)Internationaltreaties.

National security is defined as a “state or conditionwherein the people’s welfare, well-being, ways of life,governmentandits institutions,territorial integrityandsovereigntyandcorevaluesareenhancedandprotected”(2011-2016NationalSecurityPolicy,SecuringtheGainsof Democracy). Based on the definition of nationalsecurity, it is correct to say that almost all laws of thePhilippinesarenationalsecuritylaws.Lawsthatenhanceandprotectthepeople'swelfare,well-being,waysoflife,government and institutions, territorial integrity andsovereignty, and corevalues arenational security laws.Butthereisaneedtoamendthepresentnationalsecuritylawstobetrulyresponsivetotheneedsofthepeopleandofthetimes,especiallyduringapandemic.

Experiences may show that the present nationalsecuritylawsareinsufficienttoaddressthesituationsandproblems that threaten national security. The currentnationalsecuritylawsmaybeinadequatetoaddresstheconditionsandissuesthatthreatennationalsecurity.TheMarawiSiege, theYolandaandPablo typhoons,and theMindanao major earthquakes, and now the COVID-19pandemiconlyrevealtheinadequaciesofthePhilippinelaws in response to both man-made and naturalcalamities. For example, RA 10121 or the PhilippineDisaster Risk Reduction and Management Act or lawwhich was enacted to (a) strengthen the PhilippineDisasterRiskReductionandManagementSystem;(b)tosupportnationaldisasterriskreductionandmanagementframework and; and (c) to institutionalize theNationalDisaster Risk Reduction and Management Plan do notevencontainaspecificprovisiononthementalhealthofsurvivorsof thesenaturalorman-madecalamities.Thementalhealthoftheinternallydisplacedpersonsbroughtaboutbythesedisastersisnotprioritized.PhilippineGovernmentandtheBayanihan‘toHealasOne Act’.OnMarch 20, 2020 Republic Act No. 11469,


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otherwise known as the Bayanihan toHeal asOneAct,alsoknownastheBayanihanAct,wasenactedtograntthePresidentof the Philippines additional authority tocombat theCOVID-19 pandemic in the Philippines. Acursoryreadingof the lawshows that the lawprovidesthe President with the power to implement temporaryemergency measures to respond to the crisis broughtabout by COVID-19, such as but not limited to thefollowing: • adoptingandimplementingmeasures,whicharebasedon World Health Organization guidelines and bestpractices,topreventorsuppressfurthertransmissionandspreadofCOVID-19througheducation,detection,protectionandtreatment;

• hasteningtheaccreditationoftestingkits;• providinganemergencysubsidyamounting to five toeightthousandpesostolowincomehouseholdsbasedonprevailingregionalminimumwagerates;

• providing all public health workers with "COVID-19specialriskallowance";

• directing thePhilippineHealth InsuranceCorporationtoshoulderallmedicalexpensesofpublicandprivatehealthworkersrelatedtoexposuretoCOVID-19oranywork-related injury or disease during the pandemicemergency;

• enforcing measures against hoarding, profiteering,injuriousspeculations,manipulationofprices,productdeceptions,cartels,monopoliesorothercombinationstorestrainttradeoraffectthesupply,distribution,andmovement of food, clothing, hygiene and sanitationproducts, medicine and medical supplies, fuel,fertilizers, chemicals, building materials, implements,machineryequipmentandspareparts foragriculture,industryandotheressentialservices;

• ensuringthatdonation,acceptance,anddistributionofhealthproductsforCOVID-19publichealthemergencyarenotunnecessarilydelayed;

• ensuring the availability of credit especially in thecountrysideby lowering theeffective lending ratesofinterest and reserve requirements of lendinginstitutions;

• liberalizingthegrantofincentivesforthemanufactureor importation of critical or needed equipment orsuppliesforcarryingoutthepolicyofthislawprovidedthat importation shall be exempt from import duties,taxesandotherfees;

• ensuringtheavailabilityofessentialgoodsbyadoptingnecessary measures to facilitate and minimizedisruptiontothesupplychain;

• movingstatutorydeadlinesandtimelinesforfilingandsubmissionofanydocument,paymentoftaxes,feesandotherchargesrequiredbylaw;

• directing all private and public banks, quasi-banks,financing companies, lending companies, and otherfinancialinstitutions,includingtheGovernmentServiceInsuranceSystem,SocialSecuritySystemandPag-ibigFundtoimplementagraceperiodof30days,minimum,for the payment of all loans falling due within theenhanced community quarantine without interests,penalties,feesorothercharges;

• Provide a minimum of 30 days grace period onresidential rents falling due within the period of the

enhanced community quarantine without interest,penalties,feesandothercharges;

The word "bayanihan" is a Filipino word which

meanscommunalwork;thespiritofcommunalunityandcooperation. Like other laws that aim to respond tonaturalandman-madedisastersmuch focus isgiven torehabilitationof infrastructure and the reestablishmentof the livelihood of the people, but there is no specificprovisiononhowtohelpsurvivorscopewiththetraumaand to deal with post-traumatic stress disorder.Lawmakers are somuch into rebuilding bridges, roads,andbuildings,andreenergizingtheeconomybutforgettoaddressthe"invisiblewounds"ofthevictims.InresponsetotheCOVID-19pandemic,theBayanihanWeHealasOneAct,a lawenacted inresponsetothepandemic,didnotcontainaprovisiontoaddressthepeople'smentalhealth.Itisfocusedmuchontheeconomicandmedicalaspects,the effects of which are visible to the naked eye. Butmental health is as important as physical health. Theinvisiblewoundsneedaddressingaswell.Thefailuretoprioritizethetreatmentoftheinvisiblewoundshasledtodeath by suicide. Hence, this law,while addressing theconcernsofthepandemic,lacksthespecificinclusionofmentalhealthissues.

NotableresponsesonmentalhealthduringCOVID-19pandemicTheCOVID-19pandemic,aswementionedearlier,isnotonlyaboutphysicalhealth.Itisalsoaboutmentalhealth.Whilemostofthecountriesfocusedontheformer,therewerenotableresponsesthatincludedmentalhealth,oratleastledtomentalhealthcare.InChina,a24-houronlinepsychological counselling was offered using onlineplatforms like WeChat. It was done by mental healthprofessionals coming from medical institutions,universities,andmedicalsocieties(Liuetal.,2020).TheChinese availedof these services,mainly because thesewere very accessible using their personal gadgets andalsobecausetheyneededhelp.

Germanyreapedthebenefitsofitsearlierpromotionofdigitalsolutionsforhealthcareservices.Asthecountryquickly responded to the pandemic, Health Innovationbecameoneofthemostimportantsourcesofinformationas it listed different trusted telemedicine services, forexample, the Corona-Bot, an application that providesonline chatting services. According to the chairman ofHealth InnovationHub, Corona-Bot allowed patients toaccessrelevantinformationandgetadvicefromexperts(Olesch,2020).Theywerealsoprotectedfromfake-news,which could lead to panic and psychological stress asexperiencedbymanypeoplearoundtheworld.

Vietnamwascreditedforitseffectivestrategy.Nolessthan the WHO praised Vietnam’s response to thepandemic. The Vietnamese did not experience panic,generally speaking, because of how the governmenthandledthesituation.Itwasabletogetthecooperationof the people, civil society, and government (La et al.2020).Specifically,thegovernmentwasabletogainthesupport of media in spreading accurate information,which made the people updated, felt secured, andconfident.


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NewZealandisaclassicexampleofhowpeoplewerehelped to feel at ease, at least during the pandemic,because of the swift response of the government likelockdownand the timely information theygot fromthegovernment. For example, theprimeministerwas seenusingdifferentmediaplatforms,includingFacebookLive,explaining the government’s move and how peopleshouldcooperate(Bremmer,2020).AppropriatemeasurestowardsmentalhealthIntimesofpandemic,mentalhealthshouldbepartoftheprogramsandservices.Firstandforemost,thereshouldbe education and training among the respondents, andgovernment health officials on how to deal withpsychologicalissuesbroughtaboutbythepandemicandthe measures by the government on addressing it(Pfefferbaum&North,2020).Thesepeoplearecrucialinthe fightagainst thepandemic,but if theyarenotwell-informedabouttheissuesrelatedtomentalhealth,theiractions are inadequate to serve the overall need of thepeople.ThereisalsoaneedtodebunkthemythofCOVID-19becauseitcanalsoleadtodistress(Kar,Arafat,Kabir,Sharma,&Saxena,2020).Oneoftheseisdownplayingthepandemic's negative effect, especially on thepsychological and mental stress it causes. Thus, theknowledge and wisdom should start from responsiblepersonsandagenciestobecascadedtoordinarycitizens.

Second, mental health should be part of the wholehealthcare services during a pandemic. For example,mental health experts should be part of the availablepersonnel in hospitals. For instance, in China, mentalhealth professionals were stationed in hospitals andavailable for on-site services (Li et al., 2020). In theBayanihan We Heal as One Act, there was no clearstipulationasregardstomentalhealth.Itappearedtobeneglected or not seen as a priority at all. Fiorillo andGorwood (2020) proposed five important things toaddressmentalproblems:(1) limit thesourceofstress,(2) break the isolation, (3) maintain usual rhythm, (4)focus on the benefits of isolation, and (5) ask forprofessionalhelp.Ofthefive,itisthelastonethatneedsgovernment support. First, the government provideseducation on the needs, accessibility, and benefits ofreceivingsuchhelp.Second,assistancemustbegiventothe people in receiving this kind of help. Third, thegovernment promotes the training and professionaleducationofmentalprofessionalsandexperts.

In the Philippines, the government shall allocate abudgettomakeitsNationalMentalHealthCrisisHotlineworkingandnotmerelyaprogram.Initsadvertisement,theNCMHissupposedtobea24/7mentalhealthcrisisphoneserviceestablishedby theDepartmentofHealth.However, there are various complaints that it is notfunctionalasthereisnoonetoanswercalls.Thishotlinemustbeoperational,anditsexistencemadeknowntothepublic.

Third,thegovernmentshouldactfast.Thereisaneedforearlyinterventiontoavoidtheconsequenceofmentalillness caused by isolation (Galea, Merchant, & Lurie,2020).Learningfromthelessonoftherecentpandemic,thegovernmentmustbeproactiveratherthanreactive.It

should include planning for the inevitable effects tolonelinessanddepression.

Fourth, as effectively done by the mentionedcountries, the government must have an accurate anddependable information dissemination system.Withoutproperinformation,peopletendtopanic.IntheworldoftheInternet,somuchfalseinformationorfakenewsareproliferated,evenduringthepandemic.Thegovernmentmustensurethatpeoplegettherightinformation.Conclusion The COVID-19 pandemic is not just a physical healthproblem.Itisalsoamentalproblemasevidencedbytheeffects to people due to stress brought about by themeasures imposed by the government, particularlylockdowns.Lessonshavebeenlearned,andtheseincludethespecificanddeliberate inclusionofmentalhealth inthe whole healthcare program and systems. Moreimportantly, the government needs to expand itseducationandtrainingoffront-liners,healthofficials,andpolicymakers on how to respond to people'spsychological and mental health needs during apandemic. Mental health should be part of the wholehealthcareprogramandsystems.Thegovernmentmustbe fast in responding,providingearly intervention, andusingmedia platforms to provide accurate and reliableinformationtothepeople.Allthesemeasuresarecrucialto keeping the mental health of the people during apandemic. References AgenceFrance-PresseReuters(May26,2020).Philippine investigatesdomestichelper’ssuicideatshelterinLebanon.SouthChinaMorningPost. https://www.scmp.com/news/asia/southeast-asia/article/3085881/philippines-investigates-domestic-workers-death-shelter

Bremmer, I. (2020, June 12). The best global responses to COVID-19pandemic.Time. https://time.com/5851633/best-global-responses-covid-19/

De los Reyes, N. (2020, March 20). Man who thought he had Covidcommits suicide. The Manila Times.https://www.manilatimes.net/2020/03/30/news/latest-stories/man-who-thought-he-had-covid-commits-suicide/708043/

Dsouza, D.D., Quadros, S., Hyderabadwala, Z. J. & Mamun, M. (2020).AggregatedCOVID-19suicideincidencesinIndia:FearofCOVID-19infection is the prominent causative facto. Psychiatry Research.https://doi.org/10.1016/j.psychres.2020.113145

Fiorillo,A.,&Gorwood,P. (2020).Theconsequencesof theCOVID-19pandemic on mental health and implications for clinical practice.European Psychiatry, 63(1), e32, 1–2https://doi.org/10.1192/j.eurpsy.2020.35

Galea, S., Merchant, R., & Lurie, N. (2020). The Mental HealthConsequences of COVID-19 and Physical Distancing: The need forprevention and early intervention. JAMA Internal Medicine, 180(6),817-818.

Kar,S.K.,Arafat,S.Y.,Kabir,R.,Sharma,P.,&Saxena,S.K.(2020).Copingwith mental health challenges during COVID-19. InCoronavirusDisease2019(COVID-19)(pp.199-213).Springer,Singapore.

La,V.P.,Pham,T.H.,Ho,M.T.,Nguyen,M.H.,PNguyen,K.L.,Vuong,T.T.,...&Vuong,Q.H.(2020).Policyresponse,socialmediaandsciencejournalismforthesustainabilityofthepublichealthsystemamidtheCOVID-19outbreak:Thevietnamlessons.Sustainability,12(7),2931.

Li,W.,Yang,Y.,Liu,Z.H.,Zhao,Y.J.,Zhang,Q.,Zhang,L.,...&Xiang,Y.T.(2020).Progressionofmentalhealth servicesduring theCOVID-19outbreakinChina.Internationaljournalofbiologicalsciences,16(10),1732.

Liu,S.,Yang,L.,Zhang,C.,Xiang,Y.T.,Liu,Z.,Hu,S.,&Zhang,B.(2020).Online mental health services in China during the COVID-19outbreak.TheLancetPsychiatry,7(4),e17-e18.


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Mamun,M.,&Ullah,I.(2020).COVID-19suicidesinPakistan,dyingoffnot COVID-19 fear but poverty? – The forthcoming economicchallenges foradevelopingcountry.Brain,Behavior,and Immunity.https://doi.org/10.1016/j.bbi.2020.05.028.

Mamun, M,. & Griffifths, M. (2020). First COVID-19 suicide case inBangladeshduetofearofCOVID-19andxenophobia:Possiblesuicideprevention strategies. Asian Journal of Psychiatry, 51.https://doi.org/10.1016/j.ajp.2020.102073

Olesch, A. (2020, March 26). Germany benefits from digitalinfrastructure during COVID-19 pandemic. Healthcare IT News.https://www.healthcareitnews.com/news/europe/germany-benefits-digital-health-infrastructure-during-covid-19-pandemic

Pfefferbaum, B., & North, C. (2020). Mental Health and the Covid-19Pandemic. The New England Journal of Medicine.https://doi.org/10.1056/NEJMp2008017.

Rajkumar,R.P.(2020).COVID-19andmentalhealth:Areviewoftheexistingliterature.AsianJournalofPsychiatry.https://doi.org/10.1016/j.ajp.2020.102066

Ramos, C. M. (2020, June 12). Filipina cruise ship worker commitssuicide while awaiting repatriation. Inquirer.net.https://globalnation.inquirer.net/188383/filipina-cruise-ship-worker-commits-suicide-while-awaiting-repatriation

Torales, J.,O’Higgins,M.,Castaldelli-Maia, J.M.&Ventriglio,A.(2020).The outbreak of COVID-19 coronavirus and its impact on globalmental health. International Journal of Social Psychiatry.https://doi.org/10.1177/0020764020915212

Challenges for organ recipients and elderly persons during the COVID-19 Pandemic-Maria-KeikoYasuoka,PhD.Visitingresearcher,GraduateSchoolofHealthSciences,HokkaidoUniversity,JapanEmail:mkya11@let.hokudai.ac.jpAbstractAllpatientsandpersonswithimmunehealthproblemsrequiregreater care, in clinical and public health practices, becauseinfectious diseases such as COVID-19, attack their immunesystem.Therisktobeavictimincreasesmany-foldcomparedtohealthypeople.Becauseof increasedmorbidityandmortality,theyfaceanxietyofuncertaintyeveryday.InthispaperIfocusoninformantswhoareorganrecipientsandcandidateswhoareinthewaitinglist,andelderlypersonswhoareinelderlyhomeswhichareassociatedwithcurrent Japan’srapidlysuper-agingsociety. I argue that during the pandemic period, thegovernment has been struggling how to protect Japanesepeople’s health but not enough for immune-compromisedpatientsandelderlypersons.

Organrecipientshavetotakeimmunosuppressantdrugstoavoidrejectionoftransplantedorganseveryday,sotheirbodiesare always immunologically compromised. Organ recipientshave to avoid all kinds of infectious diseases with protectivevaccinations, avoiding raw food, wearing masks, avoidingpeople,thecoldanddryenvironmentandsoon.Amongorganrecipient candidates, those waiting for a kidney are dialysispatients,andtheirnumbertwokillerisinfectiousdisease.

Anotherhighriskgroupareelderlypersons,especiallythosewho stay in elderly homes. Elderly people whose immunesystemisweakenedareatriskofcarehomeacquiredinfectionsbyresidents,caregivers,officialvisitorsandfamilymembers.Inthepandemic,mostadministratorsprohibittobringfoodsandrefuseallvisitors(includingfamilies),however,elderlypersons’lossofmotorfunctionwithbeingphysicallyseparatedfromtheoutsideworldcanproducebedfastelderlypeople,whoprogresstodementiarelatedtoisolation,poorcommunicationandsocialconnections.IntroductionInJapan,COVID-19pandemicstartedinSapporocity,in

theNorthernpartofJapanandmyhometown,whereIlive

now.SapporoisinternationalbigcitywithapopulationoftwomillionanditisfamousforSnowFestivalandWinterOlympics. Sapporo is a sightseeing town and has atourism-based economy. So not only Japanese but alsomany foreign tourists visit, especially in winter-timemany foreign skiers stay and sightseeing visitors comefromallover theworld.During“SapporoSnowFestivaltimewhich is held the sameperiodof LunarNewYearduring February4 to 11 every year.Manypeople fromWuhan(China)cametoSapporoandthe1stwave(Wuhantype)officialpandemichadstartedinSapporoandtherewasa“Declarationofastateofemergency”fromFebruary28toMarch19.AfterMarch2020thepandemicspreadalloverJapan.Theofficialpandemic“DeclarationofastateofemergencyhasbeenstartedalloverJapanonApril7until May 6, 2020. Sapporo started the 2nd wave ofpandemic and the Sapporo governor declared anotherstateofemergencyfromApril12untilendofMay. ThesecondwaveissaidtohavebeenfromtheEuropeantype.Asaresult,manyJapanesehadto“StayHome”forvariousperiods(Scott2020).Broaderimplicationsofthestayathomepolicy:EmergencyLevel3(20April–31May2020)COVID-19 pandemic spread in Japan and we are

threatened by not only health problems but also aneconomic recession. Sapporo’s economic situationbecome“Business level3” from20April to31May.Wehaveto“stayhome”excepthospitalsandgrocerystores.Alsowestayhometo80%reducetomeetothersinpublicand avoid three “Mitsu” (close), (1) closed spaces, (2)crowded places, (3) close-contact setting, and thegovernmentcallsfor“ZeroMitsu”(close)forallpersonswholiveinJapan.Forexample,HokkaidoUniversity(myuniversity) has been closed except for the hospital andsomelaboratorieswhichkeepanimalsorhavingspecificreasons,andwehavetoworkathomeexceptprofessorswhohaveprivate rooms.At thestartof thenewschoolyearon1stAprilnostudentshadliveclassesandpartiallye-learningwasprovided.Graduallyprofessorspreparedonline classes, but there was cancelation of practicaleducation. For many part-time lecturers and otherworkersacrossJapanthereisnoworksonopayment.Ithasbeenreportedthatoverall20%ofJapanesestudentshave togiveup theiruniversitiesbecause theirparentshavereducedornosalary,andmoststudent’slosttheirpart-timejobs.Asaresult,theycannotpayuniversityfees.The “Stay home” policy is not only losing jobs but alsodepriving students’ education opportunity, hope andfuture.HighriskpersonsandPatientswithimmunologicalhealthproblemsDuring the pandemic time three categories of personswho are at high risk include Immunosuppressant andanticancer drug users; Patients with diabetes, heartfailure, breathing problems and dialysis patients; andElderly people. These three categories of people havesomeimmunologicalsystemproblemsduetodiseasesoraging. Immunosuppressant users include organrecipients(bonemarrow,hearts,kidneysandliversetc.)toavoidbothacuterejectionandchronicrejection.Also,these drugs are used as treatment for autoimmunedisease patients and thosewith autoimmune disorders


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such as articular rheumatism, myasthenia gravis,systemic lupus erythematosus, Crohn's disease andulcerativecolitis.Inaddition,inflammatorydiseasessuchas allergic asthma. These patients are long-termimmunosuppressantusers.Anticancer drug users suppress bone marrow functionanddecreasethenumberofwhitebloodcellsandreducetheabilityofwhitebloodcellstofightinfection.Diabetes,heart failure, breathing problem and dialysis patientshave increased susceptibility to infection. Diabetespatientshavehighbloodsugar,heartfailurepatientshavehigh risk to be susceptible to pneumonia, breathingproblem patients always face a danger from infectiousdiseases and for dialysis patients’ one of three majordiseases which are life-threatening complications isinfection. Elderly people haveweaker immune systemsthanwhentheywereyoungduetoagingnaturally.Organrecipientsasimmunosuppressantusershaveto

take immunosuppressant drugs every day to avoidrejection of the transplanted organs. Many peoplemisunderstandaboutorganrecipientthatrecipientscanget“rose-coloredlife”withadonatedorgan(CaplanandCoelho 1999). Actually, organ recipients can have asecondlifewithdonatedorganbutitalsostartsabattlewith organ rejection, so they have to takeimmunosuppressantdrugsforever(Lock2002).Dialysispatientswhoaremostlykidneyorganrecipient

candidates(HimmelfarbandIkizler2018),arewaitingfororgandonationwithdialysistosurviveforuptoacoupleof decades or more (three decades or four decades(CooperandCooper,2014).Theycommutedialysiswithwaitingfororgandonation,alsodreamingaboutthelifewithout dialysis treatment (Yasuoka 2015). Becausedialysis is an artificial kidney andwash their blood bymedicalmachine, it harms patients’ blood vessels withsufferinglife-threateningdamage(Offer2007).Elderlypersonswho live in elderlyhomeshavebeen

battlingwithvariousstrategiestoprotectelderlypersonsfromclustersofCOVID-19(Matusmoto2011).ImmunosuppressantUsersOrgan recipients’ daily life is tough thanwe imagine,

because organ rejection is the biggest barrier for themaftertransplantoforgans.Justafteroperation,theyhaveto overcome acute organ rejection with strongimmunosuppressantmedical care. After survival, organrecipients have to avoid chronic organ rejection withimmunosuppressant drugs every day until rejection oforganor death of transplantedorgan itself (thismeansthat recipient’s death or re-transplant). Thanks to theimmunosuppressant drug cyclosporin, organ recipientscan survive, and many kinds of immunosuppressantdrugs have been discovered to save recipients’ lives.However, human beings cannot avoid chronic organrejectionasanormalreactionbythehumanbody,ithasbeen occurring five years’ after of organ transplant onaverage(greatindividualvariationamongrecipients).Soimmunosuppressant drug postpones rejection of thetransplanted organ from recipients, however they cansurvive several years in average. In addition,immunosuppressant drugshave severe side effects andorgan receiver’s body is always in an immunological

disorder situation. It means that organ recipients(immunosuppressant drug users) have high risk ofinfection(Yasuoka2019).Organ recipients always protect themselves from

infection through protective vaccinations, prohibit orrecommendnottoeatrawfood(itdependsonkindsoftransplantedorgans),wearingmasks,avoidingcrowdedplaces,thecoldanddryenvironmentandsoon.MostoforganrecipientsfeelwhatelsedoweneedtodomoreinCOVID-19pandemic?Inspiteoforganrecipients’dailylifeinthefightagainst

infectious disease, most organ recipients feel anxietyabouttheirsafelifeandtheydon’tknowwhattheyshoulddo and how to protect their body during COVID-19pandemic as amatter of life or death.According to therecipients’ association (Japan Transplant RecipientsOrganizationwebsite2020), theirsafeguardagainst theCOVID-19 are to strengthened daily protection againstinfection,warmthemselves(bodies),and“Inthecase,ifdoubt 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. Mostorganrecipientsknowaboutthemandtheyarepracticingintheirdailylifealready.Theyexpectmoreinformationand feel that they need more revolutionary ideas orstrategiesforCOVID-19pandemic(Loupy,Aubert,Reese,Bastien,Bayer,Jacquelinet2020).“Please watch my heart transplanted friend’s video…I

wouldliketotalkaboutCOVID-19whichcreatesdisorderin society now. There are not only weakened immunesystem elderly people but also internal disability personssuchasorganrecipientswhompeoplecan’tberecognizedbyappearance.I’malsousedtobeakidneyrecipientandnowdialysispatient.Ourimmunesystemareweakenandother physical functions are poor due to dialysis causedkidneyfailure.Pleaseforyourcooperationsuchaswearingmaskorstayhome.”(narratedbyakidneyrecipientandhesharedusaheartrecipients’videobyfacebook).<https://www.facebook.com/profile.php?id=100009595178034&fref=hovercard&hc_location=chat>OrganRecipients’StressMany organ recipients feel stress during the COVID-19pandemic strongly because they usually have a risk ofinfection, so they pay attention avoiding infectiousdiseasescarefullyintheirdailylife.Whatisworse,thereis no particular strategies to avoid COVID-19 for organrecipients. However, it is obvious that organ recipientsarehighriskpeople,sotheirstressandanxietyhavebeenincreasingdaybyday.Asurvey foundorganrecipients’stress levels were high: no stress (6%); a little stress(10%); stress (27%); very stressed (39%); very strongstress (18%) (Resource: Japan Transplant RecipientsOrganizationwebsite2020).Intotal94%oforganrecipients feelstress,especially

57% of organ recipients feel strong stress/very strongstress.DuringCOVID-19pandemic,organrecipientsareforcedtoliveaverystressfuldailylife.Ironically,stressdecreases organ recipients’ immunological capacity, sothis situation leads to a vicious cycle for them. DuringCOVID-19pandemictime,it issostressfulforeveryone,however, pandemic stress brings about death to organ


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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 muchmorespecificmeasures.DialysisPatientsDialysispatients arealso forced intovery toughdays

too.Before1980,mostkidneyfailurepatientsdependedon dialysis to survive, in otherwords, dialysiswas thelast-ditcheffortatsurvival.Butnow,dialysisbecomesabridge medical treatment to wait for organ donation.Kidney organ recipient candidates are actually kidneyfailure patients and they cannot live without dialysiseveryanotherday(3days/week).Dialysispatientshaveweakened immune system due to long term dialysistherapy,becausethereareafeworgandonationsinJapan.Dialysis have various complications and patients arebattling with dialysis disequilibrium syndrome, blood-pressurevariation,bleedingtendency,shunttroublesandcomplications caused by long-term dialysis.Re(re)transplantcandidatesareusedtobeingadialysispatientsandtheywereluckyenoughtobeabletoreceiveadonatedorganandbecameanorganrecipientsonce(ortwice).Several years after the first transplant, unfortunately

(or naturally), they faced transplanted organ’s chronicrejectionandremovetherejectedorganoutoftheirbodyand these patients also have a compromised immunesystemduetotakingimmunosuppressantdrugsoveranextended period of time. After chronic organ rejection,theyhavetobebacktodialysisagainandwaitforanotherorgan donation, that is, “retransplant”. Most of kidneyorganrecipientshavetorepeatthiscoursewithfightingside effects and complications to their last breath. Inaddition, thanks to recent medical advance, re-re-transplant is available now. Kidney organ recipientcandidates have to repeat dialysis patients andimmunosuppressant drug user patients forever. As aresult, their immune system gets weakened (Kliger,Cozzolino,Jha,Harbert,Ikizler,2020).Anotherhighriskfordialysispatientsistheirdialysis

facilities problem and it is possible to spark COVID-19clusters inside dialysis hospitals/facilities. Becausedialysistreatmentisprovidedforthepatientsinalargeroomwheremanypatientshavetoliestillintheirbedforfourhoursperdayandthreedaysperweek.Suchalongtime,theyhavetospendtogethersharingoneroom.ItishighriskforaCOVID-19clusterforthedialysispatientsduring receiving dialysis treatment. In addition,considering commuting dialysis hospital/facility everyotherdayisalsohighriskforpatients.Itisimpossibleforthemto“StayHome”andthereareuncountablechancesandriskstocatchtheCOVID-19morethanhealthypeopletosurvivewithdialysistherapy.Becausedialysisismasstreatmentgenerally, so JapaneseAssociationofDialysisPhysicians (Japanese Association of Dialysis Physicians2020) demands special attention for all dialysishospitals/facilities. Fortunately, there are no COVID-19clusters in dialysis hospitals/facilities yet (updated2020/04/14). Another reason that dialysis patients arehigh riskpersons induringCOVID-19pandemic ishighrisk people need dialysis therapy. About 50% dialysispatientshavediabetes,whoarepotentiallysevereagainst

COVID-19.Alsodialysisusersare70yearsoldinaverageandtwothirdpatientsareover65yearsold,sotheyarealsohighriskelderlypeopletoo.DialysisTreatmentThere are two kinds of dialysis (blood dialysis andperitonealdialysis),howevermostofpatientsdependonblood dialysis now. The three major cause of death ofdialysis patients are ①heart failure, ②infection,③cancer. Themajor infectious diseases which dialysispatients are susceptible to pneumonia, shunt infectionandurinarytractinfectiousdisease(Refertoanexamplepicture:https://www.jinlab.jp/basic/img/thumbnail/other_3disaster_2ontime.jpg).Theparticularfactorspredisposingtoinfectionofdialysispatients are low nutrient conditions due to dietaryrestrictionandnutritionleakagewithdialysis,stagnatingurine(decreasedurineoutputandanuria),andinfectionofinternalshunt.Thereare334,505dialysispatientsinJapan,andthey

haveincreasedabout5,000since2019(JapaneseSocietyforDialysisTherapywebsite2020)andtheircrudedeathrate is 10.1%. In spiteof their carefuldaily activities, ablooddialysispatientdevelopedCOVID-19 inTokyoon25March,2020. Then the Japanese Society for DialysisTherapyreleasedanannouncementformedicalstaffstoprotect COVID-19 cluster in dialysis hospitals/facilities.They called for: “Make a thorough distinction dropletinfection and contact infection precaution additionally,with standard precaution. Directmeasurement of bodytemperatureofdialysispatientseverydayandgraspthehealthconditionofthem.Guidancetodialysispatients,inthe casepatientshave a feverover37.5℃ orbreathingproblems, they have to make a phone communicationbefore visiting dialysis facilities etc.” All dialysishospitals/facilities have been trying to do the best toavoidCOVID-19clusterseveryday.ElderlyPeopleandElderlyHomesElderlypeoplealsohaveahighrisktobeassociatedwithsevereinfectiousdisease,andtheelderlycaresystemisn’tequippedtocopewithCOVID-19pandemicinJapan,asarapid super-aging society (Backhaus 2017). Especially,elderly homes face COVID-19 clusters and actually theoutbreakof theCOVID-19clusters inelderlyhomeshasbeenannouncedeveryweek.AsofApril2020about550elderlypersonswholiveinelderlyhomescaughtCOVID-19,and60persondied.Itmeansthatabout10%elderlypersonspassedawaydue toCOVID-19clusteruntil theendofApril.Specialistspointedout“thereisadangerthattherewillbemoreandmoreinfectedelderlypersonsandthedeathinelderlyhomesinJapantoo”.Personally,I’macaregiverdaughterformymotherwho

staysinelderlyhomenow.Mymother’selderlyhomehasbeenstrugglingthroughvariousstrategiessinceFebruary2020 andgradually safety guardshavebeen strict.Mymother’selderlyhome’sstrategiesare:closedtovisitors,elderlypersonscannotgooutexcepttohospitals;elderlypersonshavenorecreation.However,thesestrategiesaresaferforelderlypersons,thegovernmental“StayHome”Policy risks decline in elderly person’s motor functionwhilebeingphysicallyseparatedfromtheoutsideworld


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and producing bedfast elderly people seriously (Lock2013).According to NHK (Japan Broadcasting Corporation

website2020),26COVID-19clustersbrokeoutinJapanby31March2020,andtheyhavebeenincreasingdaybyday (See: (https://www.minnanokaigo.com/news/yamamoto/lesson38/)).Thecausemaybefamiliesbringsome change of clothes, and full-time caregivers assistchangingofclothesforthem.Notonlyelderlypersonsbutalsocaregiverstaffcatchinfectionstoo.Therearemanychances to touch a potential route of infection forcaregiver staffs to assist elderlypersons such asmeals,recreations, baths and toileting (and disposal). Theelderly homes who got infection clusters have a highmortalityrate,8.0%ofthoseaged70-79years,and14.8%for those aged 80 years and above (Data fromhttps://www.mhlw.go.jp/english/index.html,MinistryofHealth, Labour andWelfarewebsite 2020). In addition,elderlypersonshavetendencytoquicklybecomesevereafterinfectionofcoronavirusandprogresstodeath.It is also easy for elderly persons to spread infection

from one elderly person to other elderly persons rightaway.OnceCOVID-19clusterhappensatanelderlyhome,ithas to temporarycloseassoonaspossible toprotectotherresidentsinsidetheelderlyhome.Personally,I’macaregiverformymother,andshelivesinanelderlyhomenow and I always visit my mother with her favouritesweets every Saturday regularly. However, when IvisitedherjustbeforeleavingfortheUSinFebruary,herelderlyhomeprohibitedallfoodsfromoutsiders.On28February,theSapporo(Hokkaido)governorhadstartedthefirst“Declarationofstateofemergency”,Ilearneditduring theconference in theUSA.When Icameback toSapporoandIwantedtoseemymother,herelderlyhomeprohibited all outsiders visit even family members,especiallyoverseas travellers likeme.So Icouldn’tgiveher favouriteGhirardelli chocolates yet and shemissedmesomuch.Exceptionally, I canmeetmymother,onlywhen I take her to hospital, so I made a strategy as acaregiverdaughterformymothertoreduceherisolation,keepphysicalabilityandprotectherdementiastabletoadjustherelderlyhomes’strategiesforCOVID-19cluster.

Figure1:Peppertherobot(http://eijyukai-akiyamaen.jp/post/wp-content/uploads/H28.8pepper①.jpg)

MystrategiesasacaregivertoavoidCOVID-19clusteraretocallmymotherinelderlyhomeeverySaturday,totake her to hospital every time, to bring her favouritesweets/drinksonhospitaldayandhavetogether. Ialsotakemylaptopandshowherpicture. The“StayHome”policyforelderlypeoplemayprogressdementia,whichisrelated to isolation, poor communication and socialconnections.NoInfectionRiskCaregiver;AiRobot(Pepper)TherearemanyhighriskpeopleintheworldduringtheCOVID-19pandemic.Wehavetopreparenotonlythefirstwave of COVID-19pandemic but also the secondwave,andthethirdwave,andeverfurtheruntilwewillbeabletopreventCOVID-19infectionwithavaccine.However,nobody knows when. We also think about other wayswhich protect us from COVID-19 in parallel to vaccinedevelopment. Taking advantage of the COVID-19pandemic,useofAIrobotshavebeenaccelerating(Figure1)AI robots attract attention from all over the world,

because they can perform various works such asdisinfection and cleaning, delivery service andconversation.Itisbenefitforustopreventthespreadofinfection and decrease person-to-person contacts.Actually, there are already some robots which areworkinginhospitalsforpatientsandinelderlyhomesinJapan.ConclusionsTheCOVID-19pandemichas revealedvarioushigh riskpeople and things in our daily life, and they are muchmorediversethanIimagined.Inthispaper,Ifocusedonthree categories of people: organ recipients, dialysispatients and elderly persons who are at high risk forinfection, however, there are so many other high riskpersonsandthingsaroundthemintheirrealityworlds.Organ recipients (immunosuppressant users) who arealways ina fightagainst infectiousdiseases, facestrongthreat and stress during pandemic. Dialysis Patients(mostlykidneyrecipientcandidatesandinwaitinglists)areconstantlythreatenedwithinfection,andcommutetodialysishospitalsthreedaysperweektosurvive.Elderlypersons (residents in elderly homes) have high risk ofbedfastanddementiadueto lessphysicalactivitiesandlackofcommunication.These people are all battling with stress, fear and

isolation. Also we have to pay attention to variouscaregiverswhoprovideround-the-clockcareforpatientsand elderly people in hospitals and elderly homes allaroundtheworld.AlthoughCOVID-19hasbeenmakingourdailylifechaoticandmanypeoplehavebeenforcedintohavingahardlife,wecanfeelhumanlovebyvariouskindsofcaregiverswhoworkforothers,thatis,“Loveoflife”.ItisnecessarytoconductmorebioethicalresearchconcerningissuesfacingpeopleathighriskforinfectionofcoronavirusduringCOVID-19pandemictime.


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ReferencesBackhaus,P.(2017),CareCommunication:MakingahomeinaJapanese

eldercarefacility(London:Routledge)Caplan,A.,andCoelho,D.(1999),TheEthicsofOrganTransplants:The

Current Debate (Contemporary Issues) (Buffalo, N.Y.: PrometheusBooks).

Cooper, A., and Cooper, J., (2014), Staying Alive: Dialysis & KidneyTransplantSurvivalStories(London:RossendaleBooks)

Himmelfarb,J.,andIkizler,T.A.(2018),ChronicKidneyDisease,Dialysis,andTransplantationE-Book:ACompaniontoBrennerandRector’sTheKidney(Philadelphia:Elsevier)

Kliger, S.A., Cozzolino, M., Jha, V., Harbert, G., Ikizler, T.A., (2020),‘Managing the COVID-19 pandemic: international comparisons indialysis patients’ in on behalf of the International Society ofNephrology,ElsevierInc.,1-5.

Lock,M.(2002),TwiceDead:OrganTransplantsandtheReinventionofDeath(Berkeley:UniversityofCaliforniaPress).

Lock,M.(2013),Alzheimerconundrum:entanglementsofdementiaandaging(Princeton:PrincetonUniversityPress).

Loupy,A.,Aubert,O.,Reese,P.P.,Bastien,O.,Bayer,F., Jacquelinet,C.,(2020)‘OrganprocurementandtransplantationduringtheCOVID-19pandemic’,inTHELANCETVol395,e95-e96.

Matusmoto,Y.(2011),Facesofaging:thelivedexperiencesoftheelderlyinJapan(Stanford:StanfordUniversityPress).

Offer,D.(2007),Dialysiswithoutfear:aguidetolivingwellondialysisforpatientandtheirfamilies(NewYork:OxfordUniversityPress).

Scott,K.,(2020)COVID-19FEAR,SAFESTRISK?:Youranxiety,fearandInformationiskillingyoubeforethevirus(Tokyo:AmazonServicesInternational,Inc.).

Yasuoka,K.(2015),OrganDonationinJapan:MedicalAnthropologicalStudy(LanhamLexington:Books).

Scott, K., (2019), Noushi Zokiishoku to mukiau tameni: IryoushaRecipientsDonor familieshenokikitori tyousakara (To faceBrainDeathandOrganDonation:InterviewResearchfromMedicalstaffs,recipientsdonorfamily)(Kyoto,Japan:KoyoShobo).

References(WebPages)1) Caregiver AI robot, <http://eijyukai-akiyamaen.jp/post/wp-

content/uploads/H28.8 ｐｅｐｐｅｒ ①.jpg>, accessed29/04/2020.

2) COVID19coronavirusspreadinjapanbeginfromHokkaidovectorillustration <https://www.shutterstock.com/ja/image-vector/covid-19-corona-virus-spread-japan-1658883610>,accessed04/29/2020.

3) Japanese Association of Dialysis Physicians, Home page,<http://www.touseki-ikai.or.jp>,accessed05/25/2020.

4) JapaneseSocietyforDialysisTherapy,Homepage,<https://www.jsdt.or.jp/index_e.html>,accessed05/25/2020

5)JapanTransplantRecipientsOrganizationHomepage,<http://www.jtr.ne.jp/index.html>,accessed05/04/2020.

6) Jin Lab, <https://www.jinlab.jp/basic/other_3disaster_2ontime.html>,accessed04/29/2020.

7) Ministry of Health, Labour and Welfare, Home page,<https://www.mhlw.go.jp/english/index.html>, accessed14/04/2020

8) Narratives by A heart recipients and a dialysis patients(reretransplant candidate) by facebook,<https://www.facebook.com/profile.php?id=100009595178034&fref=hovercard&hc_location=chat>,accessed03/26/2020).

9) NHK (Japan Broadcasting Corporation),<https://www.minnanokaigo.com/news/yamamoto/lesson38/>,accessed04/29/2020.

10) The Japan Society for Transplantation, Home page, <http://www.asas.or.jp/jst/>,accessed05/04/2020.

1TheGlobalBurdenofDiseases,InjuriesandRiskFactors(GBD)

figureof6.7millionairpollutionrelateddeathsisquotedintheeditorialofTheLancet,LancetNeural(2018) 17: 1032ThisisreportedfromvariousstudiesintheUKandUSAandarereviewedinConticinietal(2020) whorecognizethatthereis

Gasping for breath: Is air pollution or moral blindness the unseen killer? A review -AlexanderR.Waller,PhDAUSNVisitingProfessorofEnvironmentalEthicsandEducation,ThailandEmail:[email protected] Abstract Airpollutioncausesmillionsofdeathsgloballyeveryyear.Thecauseislargely,butnotsolely,fromfossilfuelcombustionintheelectricitygenerationandtransportsectorsaswellasvariousagriculturalandwastemanagementpractices.Thispollutioninthe formof ground level ozone, particulatematter and acidicgases such as nitrogen oxides and sulfur dioxide causesrespiratory, cardiovascular and neurological problems inhumans.Thesehealthconcernstendtohaveagreaterimpactonmorevulnerablesectorsofsocieties, includingstreetvendors,agricultural workers and school children. There is a growingbody of evidence that the pollution has equally devastatingimpactsonotherorganismsincludingplants,whichmayharmwhole ecosystems. As humans are integral to rather thanindependent of nature, then this will have further reciprocaleffects on us. A survey of people in rural central Thailandindicatesthatpeoplearelargelyunawareofthemaincausesofand,tosomeextentambivalentof,therisksassociatedwithairpollution. An absence of policy to address this throughmechanismssuchastaxationakintotobacco,alcoholortheUK2017 sugar tax and compulsory environmental educationprogrammescouldbeviewedasevidenceofmoralblindness.InlightofsomeeventsoftheCovid-19pandemic,theimportanceof developing united policies to cope with worldwide airpollutionisneverbeenmoreapparent.Thereisgoodnewsinthatdataonlocalairqualityisbecomingincreasingavailableinuser friendly apps, which creates an opportunity to developparticipatory education programmes that could emphasisepersonalresponsibility,toaddressboththetwinpandemicsofairpollutionandenvironmentalmoralblindness.Keywords: Air pollution, Global Burden of Disease, MoralBlindness,SDGs,ParticipatoryEducationIntroductionAir pollution-related diseases claim approaching sevenmillion lives each year1 . Furthermore, in 2018, studieslinked air pollution to a wide range of diseases anddisabilities frommillions of cases of diabetes to lowerintelligencelevels. TheWorldHealthOrganization(WHO)

Director-GeneralTedrosAdhanomGhebreyesusreferredtoairpollutionas “thenewtobacco”. TheWHOhaslongcalledairpollutionapublichealthemergency,attributing7 million deaths (including 600,000 child deaths) toexposure to unhealthy air, which 90 per cent of theworld’spopulationbreathes,UNEP(2019).Ithasalsobeenlinked to increaseddeath rates fromCOVID-19 in somecountries2.Thecombustionofcoalcausingsmoginmajorcitieslike

Londonandvehicleemissionsbeingtheprimarycauseofphotochemical smog in cities likeLosAngeleshasbeenwelldocumentedsincethemiddleofthelastcentury. By

acorrelationbetweenairqualityandhigherdeathrates. TheyconcludethatthisislikelyduetoairpollutantssuchasPM2.5,SO2and NOx impairing defence of upper airways. They call forfurtherresearch.


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the end of the 20th century legislation such as the USAmbientAirQualityStandardshadidentifiedsixcriteriapollutants: PM10,ozone,nitrogendioxide,sulfurdioxide,carbonmonoxideandleadaswellasnearlyafurther200HazardousAirPollutants(HAPs) thatneedcontrol,Turns(2006). Thegrowingawarenessoftheeconomicimpactofair pollution hasmeant that combatting it has risen insustainable development agendas. For example, it wasemphasizedasthematic sustainabledevelopmentprioritybyUNESCOmemberstates,Wals(2009). Afocusedreviewfor the Forum of International Respiratory SocietiesEnvironmental Committee by Schraufnagel et al (2019)

concludesthat:“Airpollutionislargelyanavoidablehealth

risk thataffectseveryone,although themost vulnerable—the ill, the elderly, children, and the poor—facedisproportionate risks. Urban growth, expandingindustrialization, globalwarming, andnewknowledgeofthe harmofairpollutionareamongthefactorsthat raisethedegreeofurgency forpollutioncontrol andstress theconsequences of inaction. Fortunately, reducing airpollution can result in prompt and substantial healthgains”.”The agenda of the Sustainable Development Goals

(SDGs) is an action plan to ensure a healthy andsustainableplanetforpeopleandotherlivingorganisms.

TheEuropeanEnvironmentAgency (2017) reportonairpollution illustrates how twelve of the SDGs areconnectedwithairpollution. TacklingsomegoalssuchasSDG3healthandwellbeing,SDG7cleanandaffordableenergy, SDG 11 sustainable cities and SDG 13 climateactionwilldirectlymeanaddressingairpollution. Othergoals will be more easily achieved if there less airpollution: aspollutionreducescropyieldsthiswillimpactonSDG2,zerohunger;SDGs14and15relatetonaturalecosystems that are affected, which will be discussedlater. EvenSDG4toensureinclusiveandequitablequalityeducationopportunitiesforallrelatestoairpollution,asinsomecitiesschoolsareclosedwhenairquality, duetoPM2.5 andotherpollutants,isexcessivelylow. Worsestillsomeschoolsarelocatedincloseproximitytoroadsthatcarry heavy traffic. High levels of pollution affect thehealth of students and hinders their capacity to learn,King(2019).

Scaleoftheproblem Ambient air pollution causes millions of prematuredeaths every year. Exact estimates vary yet worldwidestudies by Lelieveld et al (2020) and The LancetCommission on Pollution and Health (2017) both agreethat, forall typesofpollution, this isover8millionperyear. AheadlinefromtheWHO (2018) reportAirpollution

3 https://www.who.int/airpollution/infographics/Air-pollution-

INFOGRAPHICS-English-1.1200px.jpg?ua=1Accessed2-3-204 UNNews2014Morethanhalfofworld'spopulationnowlivinginurbanareas,UNsurveyfinds[Accessedonline2-4-20availablefrom https://news.un.org/en/story/2014/07/472752-more-half-worlds-population-now-living-urban-areas-un-survey-finds]

andchildhealth: Prescribingcleanairwas: “Morethan90%

oftheworld’schildrenbreathetoxicaireveryday.” Thispaper reviews the extent that air pollution has majorhumanhealthandsomeenvironmentalimpacts,outlinessome of the causes of outdoor air pollution and thendiscusses the barriers and suggests ways forward toimproveairquality. Thefocusisonoutdoorairpollutionand the application of ethical principles to clarify therights and responsibilities of various agents. It isessentiallyareviewpaperandusefulprimerforfurtherresearch into the need and potential benefits ofenvironmentalethicseducationtotackleoneofthemostpressing global health concerns. It aims assist in somesmallparttoreducethemoralblindnessthatsurroundstheproblemsofairpollutionandsimilarenvironmentalissues.

AirpollutionthesilentkillerfromWHO3

CitiesOver twenty years ago Rogers (1995) wrote that citiesproduced around 75% of global pollution. Since the lastdecade of this century more than half of the globalpopulation lives in cities4, so theproblemsofurbanairpollution are even greater. As urban traffic is a majorsourceofairpollutionandtheconcentrationisclosertothe source and has greater impact on the health andwellbeing of the inhabitants it must be a priority toaddressthisavoidablehealthburden. Manyofthesecitiesare in thenorthernhemispherenotablyeasternEuropeacrossAsia,andparticularlySouthAsia: Wangetal (2017)

report serious winter particulate pollution inUlaanbaatar, Cichowicz and Wielgosinski (2018) relatechanges levels of air pollution in selected German andPolish cities to changes in global industry, services andtradeandtheAIRQUALIQAirwebsiteregularlyidentifiesmanycitiesinIndia5asbeingtheintheworst20citiesforair quality globally. The IQAir 2019World Air Quality

5 BBC world service podcast The Real Story: India’s PollutionProblem puts this figureasbeing15of theworst20pollutedcitiesasIndian. Theyattributeonly15% ofthisurbanpollutiontoagriculturalsources.


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Report lists nineteen Asian capital cities having thepoorestairquality. Indoor/ outdoor pollutionThis paper deals primarily with the issues related tooutdoor air pollution. However, many of the principlesthatWHO(2000) referencetodeterminearighttohealthyindoorairareequally relevant tooutdoorairpollution.

Legislationandpublicawarenessoftherighttocleanairindoors has been significantly improved in manydevelopedcountriessincethattime. Someofthepollutantchemicals are the same in both indoor and outdoorpollution,althoughindoorairpollutionlargelyrelatestoproducts from tobacco smoke, radon build-up fromradioactiveunderlying rocksand/ orbuildingmaterialsaswellascarbonmonoxidefromincompletecombustionoforganic fuels. In less developed and rural communitiesindoorairpollutioncanbecausedfromsolidfuelburningandevenmosquitocoilsthatreleasesubstantiallevelsofformaldehydeandPM2.5,TharaphyandChapman(2010).

With regards to outdoor air pollution, the scale, causesand effects are much broader compared to indoor airpollution. Lelieveldetal(2015) calculatedthatatleast3.3million premature deaths per yearworldwide could beattributedtohighlevelsofoutdoorPM2.5. Theyfoundthatthiswascomplicatedbyvaryingparticulatetoxicity,butpremature deaths were more prevalent in Asia. Jerrett(2015) comments on further findings from Lelieveldsaying that the high levels of pollution in parts of Asiarequiresignificantlymoreattentionthanrelativelylowerlevelsinotherpartsoftheworld.PM2.5isjustonefractionof outdoor, but its visibility as well as it causing somerelatively immediate health effects and noticeablereductions during the COVID-19 pandemic has given itgreater media profile recently in comparison to otherpollutantssuchas ozoneandnitrogenoxides.CausesofairpollutionTheWHOwebsiteemphasizesthatoutdoorairpollutionhascauses,frombothnaturalandanthropogenicsources.

Maduna and Tomasic (2017) further classify emissionsdependingonwhethertheyarefrompoint, line,surfaceor diffuse volume sources. Some of the anthropogeniccauses are outlined below. Point sources includesfactories and power plants, whereas roads are linesources. Theusefulness inclassifying in thisway is thatthe impacts of pollution to wind patterns and climateconditionscanbemorereliablybeassessedorpredicted.

Thefractionsofeachsectoroftheglobaleconomythatisultimately responsible for causing air pollution indifferentregionsdependsonthetypeofpollutionaseachfuel and the combustion conditions produce uniqueblends of waste gas products. For this paper thesubstancesofmainconcernarecarbonmonoxide,sulfur

6 EuropeanEnvironmentAgency: Contributionofthetransportsector to total emissions of themain air pollutants [Accessedonline 25-7-20. Available from: https://www.eea.europa.eu/data-

dioxide, nitrogen oxides, ozone and particulate matter.

Carbon dioxide andmethane are also gases that causeenvironmental concern due to their being greenhousegases, but the focusof this paper is onmore thedirecteffectsonthehealthhumansandotherorganisms.

Figure1: Airpollutionwithin the transport sector fromEuropeanEnvironmentAgency(2019)6 Figures1and2illustratethecontributionsfromvarioussectors. Aviationtransport,althoughhavingahighcarbonfootprintperpassengermile, actuallyonlyaccounts for3% of the global air pollution, whereas road transportaccountsfor20% ofPM2.5pollution.

Figure2: Whatarethesourcesofairpollution?FromWHOwebsite7TrafficandtransportAccordingtoLelieveld(2020) toxicologyreportsindicatethat particles from diesel engines are more toxic thanthosefrompetrolenginesandthatbotharemoreharmfulthan biomass burning. Air transport requires very highlevels of fuel consumption and releases waste gasesdirectlyintothehighatmospherewheremanymolecularand radical species are involved in secondary reactionpathwaysthatproduceafurtherspectrumpollutantandnon-pollutantchemicals,howeverasshown inFigure1,apartfromNOxitaccountsforlittleofthetotal.HouseholdenergyandelectricitygenerationTheglobal“consumption” anduseofdomesticelectricityisstillrisingexponentiallyasmoreandmoreeconomiesbecomemoreaffluent. Yetthemajorityofthiselectricityis not generated from clean or renewable technologies.

Thegenerationofelectricity isstillheavilyreliantupon

and-maps/indicators/transport-emissions-of-air-pollutants-

8/transport-emissions-of-air-pollutants-8]7 https://www.who.int/airpollution/infographics/Air-pollution-

INFOGRAPHICS-English-4-1200px.jpg?ua=1]


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fossilfuelincludingcoalcombustion. Thesulfurinthecoalproduces sulfur dioxide, which in addition to nitrogenoxidesisamajorcontributortowardsacidrain. Thecause,effectsandabatementmeasuresrelatingtoacidrainhavebeen known for many years and in more developedcountriesagreatdealoftechnologyandlegislationhavebeensuccessfullyimplementedtoaddressthis.AgricultureandcropresidueburningAlthough some agricultural practices, notably forestclearances by “slash and burn” and waste residue orstubble clearances receive attention in the press,Lelieveldetal (2015) foundthatagriculturalsourcesarethe second-largest contributor to global mortality fromPM2.5. This is due to releases of ammonia from livestockand fertilizers that lead to atmospheric formation ofammoniumnitrateandsulfateparticles. Healsocalledforgreater research on the contributions by agriculturalpractices. Jerrett (2015) commentsonthepotentialimportofLelieveld’sfindingssayingthat; “muchmoreattentionneedstobepaidtoagriculturalsources,bybothscientistsand policymakers”. More recentwork by Lelieveld etal (2020) reportsthatover5% ofmortalityisduetobiomassburning. The burning of crop residues, slash and burnagriculture and forest clearance frequently makesheadlinenewsinSouthAsianandSouth-EastAsianmedia,especiallywhenthisisseentoworsenairqualityinlargecities 8 . The area influenced by agricultural processesdependsonmanyfactorsaccordingtoPratoandHuertas(2019), but they found that when comparing carbonmonoxide, nitrogen dioxide, PM10 and PM2.5 fromsugarcaneburningintheUSA,itwasthePM2.5thathadthegreatest area of influence due to its low mass andlongevity in the atmosphere. PM2.5 is of great causeconcerntoimpactsonhealth. Dioxinsarealsoaconcernfrom agricultural waste burning, Canadian Commissionfor Environmental Cooperation (2014), more researchneedstobedonetoaccesstheirimpactglobally.ForestfiresandTransboundaryissuesNotman(2019) observesthatitwas40yearsagothatPaulCrutzenhad identified biomass burning as a significantsourceof tracegases in theglobal atmosphere. Notmanreports that the 2017 Californian fires released tenmillionkgoffineparticlesintotheatmosphere. ThefiresinAustraliain2019– 2020werecoveredwidelyandtheglobal media and brought images of devastation alongwithstoriesofeconomicandenvironmentaltragedy. Yetlessattentionwaspaidtothelongtermhealthimpactsoffiressuchashowfarreachingorlongtermtheseeffectsmightbe. Peatfiresproducesignificant levelsofcarbonmonoxide and other species that have been linked to

8 Biswas,S. (2018) reportedfortheBBCthatDelhi’ssmogwastheresultofIndia’sfarmingrevolution. Ellis-Petersen(2019)wrotein The Guardian that vulnerable Indian farmers claim to bescapegoats for urban smog. Confounding factors includedemand for cheap food, poor enforcement of environmental

healthissues,Neitzeletal (2009),Weinhold (2011),PageandHooijer(2016) andCassou(2018). Johnston etal(2016)point out that the diversity of the constituent mix inlandscape fires depends not only on the substrate, butalsoonthewatercontentandthetemperatureintensity.

Recent studies using satellite evidence have clearlyshowntheextentofwhichaerialparticulatematterhasno respect for national or geographical boundaries. ForexampleChakrabartietal(2019) usedsatelliteandhealthsurveydatatoestimatetheburdenofdiseasefromcropfiresinIndiaandwithinafewmonthsBBCNewsreportswerequestioningwhetherthiswasthecauseofpoorairqualityinPakistan.9 Extance(2020) relatesthat nowthereis the potential to track sources of pollution throughremoteisotoperatiomassspectrometry,whichprovidesevidence rather than mere hearsay. He illustrates howthis technology has been used to distinguish betweenlocal and transboundary PM2.5 pollution in Korea thatoriginatedinChina. TypesofairpollutionA large number of texts provide thorough accounts ofdifferent compounds in the air pollution mix. A usefulsummary isavailable inMadunaandTomasic (2017). InthispaperhoweverIfocusmoreoftwomainconstituentsthat both have significant impacts on health, namelyozone and particulate matter (PM), which is present insmokeinvarioussizes. Thesizeisofrelevanceinasmuchas it affects the time the particles remain airborne andhow deep they can penetrate into the lungs, alveoli orpass into the blood stream. PM has serious effects onhuman health and also on global climate change, withincreasingevidenceof itscontributiontoarcticmelting,Baronetal(2010). PM2.5smallsize,largesurfaceareaandlong residence time in the air,whichmakes it likely toadsorb contaminants such asmetals that could lead tobraindamage;King(2019). Thesecannotonlycomefromdiesel exhausts, but also brake, tyre and road surfaceabrasionandwearmakingPM2.5considerablymoretoxicthanwouldotherwisebeso. In addition, various chemical species including

levoglucosan, methoxyphenols (MPs) and polycyclicaromatichydrocarbons(PAHs) addtothecomplexityandprovide signatures to the carbonsootmix;Neitzeletal (2009) and Weinhold (2011). Agricultural burning hasbeen estimated to be responsible for 20% of particulatematter and 50% of PAHs released into thewider globalenvironment,KambisandLevine(1996).Ozone is formed from various atmospheric reactions

involvingthephotolysisofnitrogendioxide,carbonylandhydroxyl radicals. Agricultural burning can also be asignificantsourceofdioxins,CEC(2014). Therateofozone

protection laws, and contributory pollution form traffic andfactories. 9IsIndia’scropburningpollutingPakistan’sair?RealityCheck:

BBCNews8November2019[Accessedonline20-2-20. Availablefrom: 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 hasmeantthatassomelegalframeworks,suchastheUS1970Clean Air Act, were based upon limited understandingandfocusedonhydrocarbonemissionsthentheyhadlessimpactonairqualitythanwasanticipated;Jacob (1999).Gaddeetal(2009) saythatopenburningofcropstubble

results in the emissions of harmful chemicals likepolychlorinated dibenzo-p-dioxins, other dioxins andPAHs. These air pollutants have both carcinogenic andtoxicological properties. Many are stored in fatty bodytissueandaccumulateovertime. Otherharmfulortoxicgasesincludecarbonmonoxide,

sulphurdioxideSO2 andvariousnitrogenoxidesNOx. Theacidicoxidesaremajorcontributorstoacidprecipitationcausing harm to a number of terrestrial and aquaticecosystems. Problemscaused– humanhealthWhileairpollutionisoftenignoredasahealthriskfactor,the 2018 Lancet Commission on pollution and healthestimatedthatapproximatelyninemillionexcessdeathsworldwidecanbeattributedtodegradedenvironmentalconditions,andthatapproximatelyhalfofthesearedueto significant ambient (outdoor) air pollution. Themaincausesofdeathare lungandheartdisease, lungcancer,and stroke as shown in figure 3. Lelieveld et al (2019)

estimates8.79millionin2015. Thisagreeswellwiththeglobalestimateof8.9millionbyBurnettetal (2018).Toput this into perspective, the WHO estimates that theexcessdeathratefromtobaccosmokingis 7.2millionperyear;henceairpollution isnowratedas the larger riskfactor. Lung cancer and other lung diseases such as

emphysema,asthmaandbronchitisareallstronglylinkedtoairquality. Thereisgrowingevidencethathigherlevelsof air pollution also inhibits the growth of children’slungs, which leads to poorer health in later life and areduction in life expectancy. The lungs are the mostvulnerableorganinthebodytodamagefromalltypesofairpollution,buttheyarenottheonlyorgantosuffer.

Figure3: Thefractionsoffatalitiescausedbyairpollution10TheWHO infographic in figure 3 states that 24 % of

strokes are related to long term exposure to poor airquality. However,thebrainisalsosubjecttomoredirect

10 https://www.who.int/airpollution/infographics/invisiblekiller2_all4_2018.jpg?ua=111Acaution is raised that todatealthough there isagrowingbodyofepidemiologicalevidence,thereislittledirectevidence

harm fromseveralpollutants. BBCScience editorDavidShukman (2019) reportsthatthereisthepossibilitythatPM2.5 is small enough to be transported to and enternervesinthebrainandtherebycauseplaquestodevelop,whichareassociatedwithdementia.King(2019) providesanillustrationthatbeingclosetoacongestedroadcouldexpose children to 100millionmagnetite nanoparticlespercubicmetre. Thesecangodirectlytothebrainthroughthe olfactory nerve. King also draws attention tosuggested links between exposure air pollution duringpregnancyandthedevelopmentofautisminchildren.Lelieveld et al (2019) found that within Europe the

figuresfordeathbyischaemicheartdiseasefarexceededother specific fatalities related to air pollution. In fact,thesetogetherwithcerebrovasculardiseaseaccountforapproaching 40% of the 650 000 plus deaths theyattributedtoairpollutioninEurope.Thedetailedstudyaccountedforothercontributoryfactors. Inadditiontophysiologicaldiseasearepeople’sgeneral

wellbeing. Few studies have been undertaken todetermine links between mental health and airpollution11,butrecentlyVienne (2020) publishedresultsfrom a 17-source database that combined individualsurvey data, air pollution data at the city and countrylevel,climateinformationandmacroeconomicindicators,inLatinAmerica.Oneofherstatisticalanalysesshowedthatonaverage,anincreasein1μg/m3inthemeanannualconcentrationofPM10thereisanassociatedreductionofself-reported happiness level. Rocha et al (2020) foundassociations between air pollution and Alzheimer’sdisease, dementia and migraines amongst otherneurologicalconditions,from52PubMedarticles. Khanetal (2019) demonstrate that inboth theUSandDenmarkthere is a clear association between pollution andpsychiatric disorders including bipolar, schizophrenia,depressionandepilepsy.MoralpollutionLuetal (2018) reviewevidencethatindicatetheabilitytopredictunlawfulandunethicalactivity inenvironmentswithhigherlevelsofairpollution. Theydemonstratethataspoorairqualityraisesanxietylevels,thenthisinturncan lead to behaviours which are intended alleviateanxiety. They note that various alternativemechanismsfor this link need further research, such as the broken-

windowstheorybyKeizeretal(2008),whicharguesthatmoral concerns are diminished in degradedenvironments. A further alternative theory that lowerlight levels in smog induces a sense of anonymity thatlowers inhibitions against engaging in unlawful orunethicalbehaviourasshownbyZhong,BohnsandGino(2010).

ofcausallinksbetweenneurologicaldisordersandairpollution,in theeditorialofTheLancet,LancetNeural (2018) 17: 103. Apossiblepathwayfortoxinstoreachthebrainisvianervesfromthenasalcavity.


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PressureonhealthcaresystemsThe global Covid-19 pandemic has seen unprecedentedpressureonmanynationalhealthcareprovidersaroundtheworld. Theannualimpactofairpollutionalreadyhada tremendous cost and consumed an enormousproportion of national budgets. An initial study in fourEuropean countries demonstrates that there is acorrelation between nitrogen dioxide exposure anddeathsfromCovid-19,Carrington(2020). AnotherstudyinAmericashowedanassociationbetweenPM2.5anddeathsfrom thevirus,Wuetal (2020). Neitherof thesestudiesclaimedthattherewasadirectcausallink,butthereisapossibleindicationthatlong-termexposuretohighlevelsof various pollutants weakens people resilience tosubsequent infections. Furthermore, as the populationdemographics in many countries shows agingpopulationstherewillbeagrowingburdenonhealthcareto treat and care for patients suffering from long-termexposure with progressive illnesses such as mentalhealth, lung and cardiovascular diseases. As furtherpandemics are also likely in the future, it would beprudenttotakeactionnowtominimalisetheeffectsofairpollution and plan and prepare so that health caresystemshavesufficientcapacity.ProblemsfornaturebeyondhumansKing(2019) discussesreportsthatautopsiesondogsfromheavily polluted streetsMexicoCity revealed thatwerefoundtohavebraininflammationsandproteinclumpingthat are indicative of Alzheimer’s disease in humans.

Canariesweretraditionallyusedtotestfortoxicgasesincoal mines. Many ornithologists are encouraged byreports such as Drewitt (2015) who describes theresurgentgrowthofperegrinenumbersincitycentresintheUKastheyfeastonabundantpigeonpopulations. Inthistimeofhearingmoreandmorereportsofdecliningnumbersofpredatorsdueanthropogenicactivitiesthisissurelygoodnews. Yetiftheseawesomebirdsareexposedtodamaginghighlevelsofpollutiondirectlyandthroughthe consumption of polluted prey, then sadly thisresurgencemaybeshort-lived. SanderfootandHolloway(2017) provideareviewofliteratureregardingtheeffectofairpollutiononavianspecies. Theynote that severalstudiescomparingthepopulationsofthesamespeciesinpollutedandlesspollutedenvironmentsdoesindicateapattern, however they acknowledge that severalconfoundingfactorssuchashabitatdegradationandfoodavailability make it impossible, at this stage, toconclusivelyprovethatairpollutionisthemaindrivingfactor in population declines. Their review doesnonethelessreportinvivophysiologicalstudiesonbirds’lung tissue that do strongly indicate pollutant damage.Ejazetal (2014) recordedincreasesintoxinlevelsofvitalorgans in some birds. This could potentially lead tobioaccumulation in predators or scavengers. It is oftenassumed that amphibiansaremodernday indicatorsofpollutionastheypossesshighlypermeableskin. However,Kaplan (2009) reports in Nature that amphibians,

surprisingly,oftenappearmoreresilienttoairpollutionthatwouldbeexpected.Theeffectsofozoneonplantshasbeenknownformany

years and lichens are well known pollution indicators.

Rich (1964) referstostudiesongerminatingseedsasfarbackasthelatemid-19thcentury. Richlistswelloverfiftyspecies that had already been identified to suffer fromozone. Over the last half of the 20th century to date thegrowinglistofand extentofthisdamagetoagriculturallyimportantcropshasbeenidentified. VanDingenen etal(2009) providetwomodelstomakepredictionsofglobalstaple crop losses by 2030 due to surface ozone. Bothmodels show significant impacts that would makeachievingSDG2moreofachallenge. Lesswork has been done to identify the effect of air

pollution onwhole ecosystems but Lovett et al (2009)

studied the impact of fur pollutants, sulfur, nitrogen,ozone,andmercuryineightNorthAmericanecosystemsand concluded that: “Effects of air pollution wereidentified, with varying levels of certainty, in all theecosystem types examined. None of these ecosystemtypesisfreeoftheimpactsofairpollution,andmostareaffected bymultiple pollutants.” The US EnvironmentalProtection Agency (2017) says that the impact on thephotosyntheticabilityofplantsslowstheirgrowth,makesthemmorepronetoinsectdamageandultimatelyleadsto decreases in biodiversity, contributing to changes inhabitatqualityandecosystemcycles.Howdoesethicshelp?Inextrememoralblindness individualscannotperceiveanethicalissue. Inthecaseofairpollution,itseemsthatwholesocietiesifnotmorallyblindaretakingablindeyeorareexperiencinga formofanalgesia to thesituation.

BaumanandDonskis (2013) refer to this as adiaphora – implyinganattitudeof indifferenceormoralnumbness.

Cliffe (2017) compares attitudes towards tax on sugarwithacceptanceoftaxonalcohol,whichisamuchlowerhealthriskintheUK.Taxationisanacceptedapproachtotackle theglobalsmokingepidemic.Doesanabsenceofspecific tax allocation on fossil fuels suggest moralblindnessorvisualimpairmentbygovernments?Orisitmerely that taxes are politically unpopular and thatenergy providers are a powerful lobby? The range ofsourcesandcausesofairpollutionindicatesthatnoonesector or industry is solely responsible. Governmentsalone cannot realistically enforce changes that areessential to improve air quality. It is therefore largelydowntoindividualchoicesandactions. AsdePaulaandCavalcanti (2000) argue: “Therefore, it is important thatindividualsareawareofthemselvesandothers. Thatistosay,theyevaluatetheeffectsoftheiractionsinrelationtothosewhomtheylivewith,tosocietyasawholeandtothenaturalenvironment.” Thisraisesakeytomoralagencyandethicaldecision

making – it cannot be made in isolation from, orindependent of, other people and organismswho havemoral interests even if they do not have agency. An


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assumption is that all people are able to make therequired evaluations –requiring not only fully availableinformation, but a prerequisite is having higher orderthinking skills. This makes it vital that educationalprogrammesandprogrammesprovideopportunitiesforstudents and participants “to open their eyes” toenvironmental ethical issues through exercises todevelop their ability to critique, appraise and makejustified recommendations through participatoryactivitiessuchasgroupdiscussionsordatagatheringandanalysis. Theuseofguidingethicalprinciplesisausefulapproachtoaiddiscussionandasystematicapproachtounpack complex and controversial issues. It is also arequirementtomakeinformedethicalchoicesthatpeoplehave access to and an understanding of the widerscientific information, as well as socioeconomic andpolitical factors that are relevant. This means thatcomprehensive educational programmes must bedeveloped. Principles TwentyyearsagoaWHO(2000) workinggroupproduceda report, based on nine principles of human rights,ecological sustainability and biomedical ethics, arguingthecaseforarighttohealthyindoorair. Theseprinciplesincluded:

• Righttohumanhealth• Respectforautonomy• Non-maleficence• Beneficence• Socialjustice• Accountability• Precaution• Polluterpays• Sustainability

In the COMEST (2004) report on ethical use of waterreframedsomeoftheseprinciplesintermsofsolidaritybetweenupstreamanddownstreamcommunities,waterasbeingacommongood,stewardship,participationandempowerment. Liuetal (2011) applyprinciplesfromtheUDBHR (2005) todeveloprefinedprinciples suchas thedutyofcarebestoweduponpeoplewhoarefortunatetolive in thevicinityof abundantwater sources. Arguablythiscouldbeappliedtopeoplewholiveinruralareaswithlittle traffic or industrial air pollution; a duty to notpolluteastheyarelivingina“privileged” position. Polluterpays – thismaybepossibletoenforceforpoint

source pollution emitters such as factories or throughtaxation on vehicle emissions or fuels, but it would benearlyimpossibleinthecaseofwildandforestfires. Theissues of corruption and poor law enforcementadditionallyconfoundthisapproach. Inasimilarwaytoplasticbaglittering: istheresponsibilityoftheproduceror the consumer? Several countries do enforce caremissionscontrols,butthereisstillscopeforthesetogomuch further if global airquality is to reachacceptablelevels,ashasbeenshowntobepossibleduringtheCOVID-


INFOGRAPHICS-English-3-1200px.jpg?ua=1Accessed2-3-20

19 lockdowns around the world that have beenaccompaniedbyimprovementsinairquality.Preemptiveaction– Notman (2019) recallshowthe2009

wildfiresinAustraliapromotedachangeinpolicytostartmore deliberate fires to reduce the fuel load. Thishowever,hadanegativeeffectonairquality. Withclimatechangeinmind,thisbecomesaviscouscircleasdroughtperiods renders large areas tinder dry increasing thelikelihood of extensive wildfires. Further preemptiveactionwouldbe to ensure infrastructure is inplace forelectric vehicles, mass transport systems and cleanrenewable electricity generation systems to reducerelianceonfossilfuels. WHO (2017) reports that tobacco kills in excess of 8

million people per year – comparable to Lelieveld et al (2020) figureforambientairpollution. WHOarguesthatbans on advertising andpictorial healthwarnings haveproventobesignificantdeterrents. Thereispotentialforextendingthistocombatairpollutionsuchasdisplayingprominentimagesatfuelstations,onelectricitybillsoronfertilizer packaging for example. Bennett (2020)

encourages students to explore, through computermodeling, how trees can be used to reduce urbanpollution. Thishasaddedenvironmentalethicalbenefitsas students develop a greater understanding of ourrelationshipswiththebiotaaroundus.ThepotentialfortreestocombatairpollutionisdiscussedbyBarwiseandKumar (2020), Yangetal (2015) andUKDepartment forEnvironment,FoodandRuralAffairs(2018). Astreestakedecades to grow this is a form of preemptive action intermsofplanning. UNEP (2019) producedareporton25science based solutions to improve air quality in Asia.

Many of these are preemptive such as legislationregarding fertilizer use, land clearance and energyefficiencystandards.

Figure4: Whoismostimpactedbyairpollution?FromWHOwebsite12Remedialaction– inthissituationgovernmentsmustbe

preparedtohavehealthsystemswiththecapacitytocopewithwhat isagrowingburdenofdiseasefrompoorairquality. Thelongtermnatureandprogressionofmanyof


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the associated diseases, does allow a timeframe forcountries to beprepared. Maybe thiswill be oneof thelessons from the COVID-19 pandemic, that although apandemicwasforewarnedforseverallittlepreparationshadactuallybeendone. The2019UNEPreport forAsiaidentifiesindustrialprocess,vehicleandpostcombustionemission controls as being of the greatest and mostachievableimmediatebenefit. Environmental justice issues – outdoor air pollution

oftenhasgreaterimpactsofpoorerandmorevulnerablepeople,asshownintheWHOinfographicinFigure4,insocietysuchas farmworkers,streetvendors,andthosewhodohaveaccesstocleanenergy. ThereisavastandgrowingbodyofevidencetosupportthissuchasSeryaetal(2019) whoidentifypoorerrespiratoryhealthinfemalestreet vendors in Egypt and Kongtip et al (2010) whoreportedonapilotsurveyofsimilarworkersinBangkok.This is closely related to the principle of not puttingpeople at risk from harm or health and safety atworkprotection. Firefighters are on the frontline whencombattingwildfires thatmay be started accidently, aspart of controlled burning or either deliberate acts ofarson. For example, in April 2020 the Bangkok Post 13reported that there had been seven deaths of peoplefightingforestfiresintheNorthofThailandalreadythisyear.However,thisdoesnotreflectthelongertermhealthrisks to theseworkers. Neitzeletal (2009) foundhigherlevelsof lowmolecularweightmethoxyphenols (MPs) inurinarysamplesfromfirefighters. TheycorrelatedthesefindingswithCO,PM2.5andMPexposuretowoodsmokein controlled burns. They noted that the MP mix wasdifferent in angiosperm and gymnosperm combustion,consequently the toxicity depended upon the fuel. Asoutlined above many individuals, and generally morevulnerable groups, are exposed to high risks from airpollution during travel to or at work yet they do notreadily have the health monitoring and protectionafforded to employed workers. This highlights how inpractice it isoften thepollutedrather than thepolluterwhopays.Non-maleficence - King(2019) highlightsthefindingsof

a study of approximately 3000 school children inBarcelona published by Sunyer et al (2015), whichreportedthatthoseinproximitytogreaterlevelsoftrafficpollution had slower cognitive development. King listsevidence of a link to Alzheimer-like amyloid plaques,attention deficit-hyperactivity disorder, autism inaddition to respiratory illnesses such as asthma. Worsestill is that there isgrowingbodyofevidence that linkslaterdevelopmentalisdetrimentallyimpactedbyinuteroexposuretoincreasedlevelsofairpollution.Surely,itisofparamount importance to protect innocent unborn andyoung school children from the harms propagated andsustainedbytheactionsofadults.

13 “Youthdies inbid todousewildfire” BangkokPost, 23April2020 accessed online 23-4-20 available from

Sustainability - The cost of air pollution in economictermsamountsfromincreasedhealthcare,thereductionincrops,theaddedcostsof“cleaner” technology. However,sustainabilityasaprincipleencompassesmorethanjusteconomics – it demands that current practice does notimpinge on the potential needs of future generations.

Therefore,careforthenaturalenvironmentisessentialasweareinextricablylinkedwithnatureandnaturalcycles.

Airpollutionthatharmsotherorganismswillimpactonfoodchainsandwebs,thisinturnmayaltersomecyclingprocesses and ultimately lead to whole ecosystemdeclines. Theconsequencesofsomegasescausingacidicprecipitationarealreadywelldocumentedand inmanywaystechnologicalandlegalmeasureshavebeentakentoaddressthis. However,prolongedexposuretoPM2.5isfarless clear. The impact onhumanhealth is only recentlybecomingknown,butfurtherstudiesmustbeperformedtoseehowthisharmsawiderrangeofotherorganismsand what happens as these particles are transferredthrough food webs and ecological energy pathways.

Bioaccumulation could well lead to unforeseencomplicationsinthesamewayaspesticidesarenowwellknown to do. If these particles can reach the heart andbrain,aretheyalsoabletoentergametecells?SolutionsandbarriersSince the 1950s many governments introducedlegislationtocombatphotochemicalsmogslargelycausedby burning coal for domestic purposes. This legislationgainedpublicsupportasthepublicwerewellinformedofthe acute health risks and benefits of legal protection.

Thereisgrowingbodyofreportsthatthegeneralpublicarelosingtrustinpoliticiansandwaryofscientistsbeingunbiasedorimpartialwhenpresentingdataoremployingmodels. InasurveyinruralThailandWaller(2020) foundthat only 1% and 2% of respondentswere in support ofraising fossil fuel taxes or using electric vehiclesrespectively. Yet 25% were in favour of planting moretreesincitiesand20% communityeducationprogrammesregarding air pollution. Therefore, key to successfulstrategies,advocatedbyWHOinFigure5,iseducationtogainraiseawarenessofhealthriskswithcomprehensiveanddetailedinformationsharing.Otherstrategiesinvolvetechnical developments in transport, power generationandwastemanagement sectors aswell as taxation andreform of agricultural practices and domestic fuelefficiencyimprovements. William Logan (2012) observes that during the 1996

OlympicsinAtlantatrafficflowintoandoutofthecitywasrestricted,resultedinareductionofemergencyhospitaladmissions. Followingthecompetitionevents thetrafficwasallowedbackinandthelevelofhospitaladmissionrose accordingly. Schraufnagel et al (2019) also reportsthatasignificantnumberofstudieshaveshownthat, once

various environmental policies were put in place, air

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


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pollutionfell. Whenairpollutionwasreducedatnational,localorevendomestic levels therewerehealthbenefitsthat were “almost immediate and substantial”, andcontinuedlongterm.Thekeyforgainingpublicsupportfor such initiatives is through raising awareness andeducationofthehealthandpollutionlinks.Airqualityisauniversalandfundamentalentityfora

healthy environment. Marks (2012) reviewed theeffectiveness of three different approaches to addressclimatechangeandfindsthemallwanting. Hearguedthatthehegemonyofcapitalismrenderedhumanrightsanddevelopment approaches important, yet saw potentialcapacityinadoptingarevisedviewofhumansecurityasgreenhousegasemissions,as likeparticulateemissions,are trans-boundary issues. The human security

perspective highlights environmental threats to fromenvironmental degradation. Marks refers to severalreasonsforadoptingthisperspective,amongstwhich isthat this approach could be more likely to engagecooperation between states and policy makers thandemanding rights ormeasuring up different degrees ofdevelopment.

Figure5: Strategiesfortacklingoutdoorairpollution14However, there is scope and value to investigate the

extenttowhichhumanrightsarerestrictedbytheimpactofairpollution. Therightoftheunbornchildtoahealthylife. The rights of women subjected to poor indoor airqualityfromsolidfuelcooking,whichlimitstheirabilitytomaintaingoodhealth. Theeconomic impactonstreetvendorsandtheirrighttowork. Therightsofchildrentomeaningfuleducationandprotectionfromharm. Rightofaccess, by less advantaged communities, to affordablemedical care. As previously stated, WHO proposed the


INFOGRAPHICS-English-6-1200px.jpg?ua=1Accessed2-3-2015 WHO (2018) Exposure to household air pollution for 2016

[Accessed online 27-2-20. Available from:

https://www.who.int/airpollution/data/HAP_exposure_results_final.pdf?ua=1]16TheBBC(2017) reportedthatrisingairpollutionatBuddha'sbirthplaceinNepaliscausingalarmformonksandpilgrimsasitis 10 times the safe level. Accessed online 30-4-20. Available

application of nine principles to inform policy andpromotehealthyindoorair. However,the2018versionofthe WHO Exposure to household air pollution for 2016

webpagestatesthat:“Globally,41% oftheworldpopulationisexposedtohouseholdairpollutionresultingfromcooking

withpollutingfuelsandtechnologiesin2016.”15Thissuggeststhatthetimeisrighttorevisitwhatare

thebarriers to achievinggreaterprogress in improvingairquality,suggesthowthesebarrierscanbeovercomeandtoexplorethepotentialofalternativesolutions. Themediahave thepotential toplayamajor role in raisingawareness and in education. However, stories maysensationalise, mislead, misinform, or cherry pickprominenteventsorlocations16andnotrelatethewiderglobalscaleoftheproblem. Mediareportsmayfocusonpopulistopinions,suchashilltribeagriculturecausingairpollution.Accesstodata2020sawthelaunchoftheworld’slargestairqualitydataplatform by UNEP, UN-Habitat and the Swiss companyIQAir17. Access todata, particularlypositive trends, is asource of great encouragement. For example, initialdespondency following the Chernobyl tragedy of 1986hasbeenturnedtooneofhopeasithasbeenshownthediversityoflifethatisnowthrivingwithintheexclusionzone. InthewordsofWoodandBeresford(2016),“Whenhumans were removed from an area, nature has aremarkable ability to reclaim that space.” The timelylaunch of the IQAir system has enabled regulardiscussions in themedia of reductions and subsequentrises in air pollution during and post lockdownrestrictions,WattsandKommenda(2020) andNewburger(2020). This was accompanied by some reports inincreased wildlife activities during lockdown, althoughwhether thiscanbeattributed toshort termairqualityimprovements rather than the reduction in humanactivity has not been confirmed. Nonetheless, access todetailed, accurate and real time data is vital forresearchers,qualityeducationandpolicymakersalike.Political considerationsWolinsky (2006) arguesthattherecouldbeacasetosaythat if UNESCO and WHO had worked morecollaborativelyontheUDBHRitmayhavecarriedgreaterstanding. Hisdiagnosismaybegivensomecredenceinthelight of predictions of countries disregarding Article 3

whentakingmeasurestocurbdiseaseepidemic,suchastheCovid-19pandemic. WolinskywindsuphisanalysisbyidentifyingtheoverallbenefitsoftheUDBHR,butgreater

from: https://www.bbc.com/news/av/science-environment-39865269/air-pollution-at-buddha-s-birthplace-is-10-times-the-

safe-level17 This was announced on 10 February 2020 on the UNEPwebsite. [Accessed online 3-3-20. Available from:

https://www.unenvironment.org/news-and-stories/story/whats-

air-world-urban-forum-2020-launches-worlds-largest-real-time-

air]


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synergy between UN divisions (UNESCO, UNDP, UNEP,WHOandFAO) issurelyneededtopromotemorerapidimprovementinairquality. ThisisafteralltheaimofSDGGoal17: PartnershipsfortheGoals.TheroleofWHOintheCOVID-19 epidemic has been questioned by manypolitical leaders. However, many of these leaders, whogenerallyhaveshorttermpoliticalinterests,havetriedtoshift blame away from themselves. This illustrates thevital need for unified action on pervasive global andpersistent issuessuchasairpollution.Blameshifting isalsoseeninthemediaasfarmers,insomecountrieslikeIndia,CambodiaorThailandareoftenreportedasbeingthemainoffendersasairpolluters18. Apportioningblamelargely 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 integratedapproach. Italsoillustratesalimitationoftheshorttermrule ofelected leadersasoftentheyareconcernedwithimmediateresultstoimpressvotersratherthanlongtermaction and less popular strategies such as increasedtaxation.Congestion charges and alternative transportsystemsPandita (2004) exploredhowacivicsocietyorganisationwas instrumental in producing reports, conveningmeetings between various experts and raising publicawareness of the severity and impact of urban airpollutioninIndiaduringthelatetwentiethcentury,whichleadtocourt judgmentsthatinturninducedchangesinlegislation of transportation systems as well ascompulsoryenvironmentaleducationprogrammes,Wals(2009). Inmanycountriesvehicleusechangeshavebeenintroduced under other initiatives such as congestioncharges, subsidieson cleanbiofuelsor greater taxesondieselaspartofstrategiestopromoterenewableenergy,infrastructural support for electrical vehicles andexpansion of mass transit systems that have all beenrolledoutaspartofdevelopmentprogrammesratherasexplicithealthagendas to tackleairpollution. Yetmanyurbanplanningprojectsdoaimdeliberately to improve

healthandgeneralwellbeing,suchtheexpansionofgreenspaces,Baines (2014) and cycle lanes orbuildingschoolsaway from busy roads, King (2019). If revenues fromcongestion charges or additional fuel surcharges wereused to fund mass transport initiatives or communityeducationprogrammesthismaygainadegreeofpublicsupportoratleastacceptance. Noreeetal(2015) proposea similar approach to support national healthcare inThailandbytaxingmedicaltourism.EducationcurriculaDodds (2007) observes that over the last centurymanygovernmentsdevelopednationalisticcurriculaforschool

18Inasurveyof466respondentsinrurallowernorthandnortheasternThailand57% statedthattheybelievedagriculturalandforestburningwerethemaincauseofPM2.5airpollution,and

education. Thisdoesnotmeanthatuniversalvalueswerenot taught, but it does illustrate that ultimately thatultimatelycitizensareprogrammedtoconsidernationalratherthanglobalissuesfirst. Butevenwithincountrieseducationalqualityandexperiencesvarywithinregions.

Forexample,Umavijani (2019) claimstherearelargegapsbetween urban and rural healthcare in Thailand, andmakes recommendations that education and trainingthrough government initiated traditional broadcastingand contemporary social media should be used forinformation sharing to help people take preventativemeasures. A possible benefit of the Covid-19 schoolclosures is thatdue toonline learning therehasbeenapossible leveling of the access to quality education forstudentsattendingdifferentschools, ifanassumptionismadethatallhadequalaccesstotheinternet. EducationofdisadvantagedcommunitiesDorevitchetal (2008) identifiedlimitedinternetaccessbyless advantaged people as a barrier to long termparticipation in a community air quality educationprogramme. UNESCO(2019) stillstatesthatruralpovertyasaparticularbarrier toparticipation inadult learningand education. Buchanan and Russo (2015) provideevidence that if collective action takes place then someparticipants will to some extent compensate for non-

compliance of others regarding energy conservation.

However, if people can identify clear and achievablepositiveimpactsontheirlivesthisdoeshelptoincreaseparticipation. In Thailand, for example, a high level ofcompliance to government lockdown restrictions, couldbeattributedinnosmallpart,toinformationsharingatvillage and community levels by locally elected counciland administration officers. The benefits of communityeducation programmes must be made clear from theoutset to promote and sustain involvement through tocompletion. Furthermore, the show casing of modelcommunitiesthathavehadsubstantialimprovementsinhealth,natureconservationandeveneconomicbenefitsshouldbeendorsedtoencourageuptakeof “courses” byprovidersinotherlocations.Neitzleletal (2009) reportedproblemsincollectingrealtimeurinarydatatomonitorairpollution. Nowhowever,withmorereadilyavailableapps and greater mobile coverage in the 2020s theconditions are more conducive for public engagement,whichmayencouragemoredisadvantagedcommunitiestoparticipateindatagatheringandengageineducationevents.Economic energypoliciesWHO(2017) concludesthattaxesareeffectiveinreducingtobaccouse. Oneof theMPOWERmeasures,adoptedbymanycountriestoaddresstheglobaltobaccoepidemic,istoincreasetaxationontobacco. Whenitcomestotaxingthereisanethicalissueofwhetheritisaregressivetax

19% saidthatenforcinglegislationagainstthisshouldbeoneofthetopthreeprioritiestoimproveairquality,Waller(2020)


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that has disproportionate impact on the wellbeing ofeconomicallyvulnerablepeople. Chitigaetal (2012) foundthatinSouthAfrica overallfueltaxationwasprogressive.

However, some fuels for specific purposes such astransport and paraffin use in homes was regressive.Mkenda et al (2012) had similar findings in Tanzania,wheretaxationonbasicfuelslikefirewoodandkerosenewasregressivebutprogressiveonmoreluxuryfuelssuchaselectricity,ordieselandpetrol. Kosonen (2012) foundsimilar results in Europe. Regressive taxation ontransport does not induce public endorsement ofcongestionchargesmentionedearlierunlesstherevenuefrom them is used transparently to good effect inimprovingmasstransportsystems. WHO(2017) recognisesthattobaccousersneedhelpto

breaktheirdependency. Similarly,forfarmerstoembracealternativeagriculturalpracticesinpoorruralareas,theyneed assistance in the form of education, developmentandconservationfunding: notbeingimposedwithfurthertaxation. However, there may be a case that if tied toeconomicsubsidiestotrailandadoptnewpracticesthenataxaddedtoinorganicfertilizerscouldbeusedtofundtheaforementionedprogrammes.TechnologicalThewideracceptanceoftheuseoffacemaskshasbeenapositiveoutcomefromCovid-19,buttheefficacyofsomemasksneedstobeimprovedandthelimitedbenefitsneedto be fully understood. They are, at best, only able toaddresstheeffectsratherthanthecausesofpollution. Thedevelopmentanduseofelectricvehicles,especiallyiftheelectricityisgeneratedviarenewabletechnologysuchaswind turbines and solar cells would ensure a massivereductioninairpollutionfromfossilfuels. Meanwhileitisessentialthatflugasscrubbersordesulfurization,vehicleexhaustcatalyticconvertersandreducingcoalanddieselconsumptionwill all bring immediate benefits. Farmingpractices can also be improved such as limiting theapplication of fertilizer and applying at the optimumtimes as well as increasing the use of composting oralternative processing rather than burning residues.

Barwise andKumar (2020) review theuseofwhat theytermGreenInfrastructure- trees- asairpollutionbarriersand Yang et al (2015) rank various species, finding thesilvermaple, London plane and honey locust as havingaboveaverage ability atPM2.5removal. Thesewere alsofound to be in the top ten of most commonly plantedurbantreesin60citiesacrosstheworld. Thereisscopeformoreresearchintothecapacityforothertreespeciestoimproveurbanairquality,andtodeterminewhichwillsurviveandthrivebestinlocalclimaticconditions.LegislationMany nations have laws that address air quality, forexampletheUKbannedstubbleburningin1993. Thisandlegislation regarding coal combustion and flu gas

19 “Toxichazealertfor4provinces” BangkokPost,17April2020accessed online 23-4-20 available from

emissionsweredrawnupasUKwascriticizedasbeingthe “dirty man” of Europe and a major contributortowards the acidification of Scandinavian lakes andforests. Importantasnationallegislationis,thisillustratesthe need for regional and international legislation tocombatthisinvisiblekiller. Withsatellitetechnologyandimprovements in chemical sampling and analysistechnologythismakesholdingoffenderstoaccountmorepossible. The next step is to enforce the laws. Notman

(2019) notes two significant issues relating to forestclearance in South East Asia for palm oil plantations.

Firstly, thatbanning lawsarevariably (atbest) enforcedandthatastheforestsareonpeatsoilsthattheseproducegreater quantities of smoke compared to non-tropicalforest fires. The smoke from such forest fires crossesboundariesbetweenThailandandCambodia,Singapore,Malaysia and Indonesia or India and Pakistan. This isclearlyaregionalissueandtacklingitneedsacooperativeapproach.Cheongetal(2019) concludethat:Epidemiological studies on the disease burden and

socioeconomiccostofhazeexposurewould also beusefultoguidepolicy-makingandinternationalstrategyinminimizingthe impact of seasonal haze in SoutheastAsia.Whatcanbedonenowandatreasonablecost?Alternative uses of crop residues include: mushroomfarming, feedstock for biogas generation and oils fromgasification or pyrolysis, cattle beddingmaterial, papermaking, construction material production, or re-

incorporation into soils, which improves soil qualitythrough raising soil carbon content,Kumaret al (2015).

Some of thesemeasureswill produce a supplementaryincomeforfarmersifthereisalocalmarket,othersmayimprovethelongtermviabilityofagriculturalland.Thereissomegoodnewsforexample;thedeputygovernorofChiangMai,KomsanSuwan-ampahassaid19thatthereareplans in place for the education of local communitiesregardingagricultural,wasteandforestfirescausingairpollution inNorthernThailand,afterCovid-19restrictionsare lifted. Education must not be restricted to ruralcommunities – it needs to address all causes of airpollution and meet the needs of the whole of society.

Urban programmes could be include participatoryactivitiessuchasplantingsuitabletreesthatwouldallowstudentstofeelempoweredtotakepositiveactions,havepsychological benefits, improve wellbeing and promotecooperativesustainablebehaviourwithincommunitiesaswellasimproveurbanairquality,asexploredinZelenskietal (2015) andBennet(2020). ConclusionSeveral pressing environmental concerns receive wideattention– globalwarmingorclimatechange,biodiversityloss,deforestation,plasticpollution,ozonedepletionandacidrainaretypicalexamplesofissuesthatareregularlydiscussedinthemediaandaddressedtosomedegreeby

https://www.bangkokpost.com/thailand/general/1901515/toxic-

haze-alert-for-4-provinces


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manygovernmentsandexploredinnumerouseducationcurricula. AlthoughvariousreportssuchastheGBDandThe Lancet Commission on Pollution and Health (2017)have been widely available, a survey of rural generalpublicinThailandshowssignificantgapsinknowledgeofand some ambivalence towards air pollution. RecenteventsoftheglobalCOVID-19pandemichaveraisedtheprofile of air pollution as reductions were observed inlockdownsandcorrelationswithdeathratestopollutionlevelswerereported. Yetthedeathsfromthatpandemicand even the prolongedHIV/AIDS pandemic, are so far,dwarfedbytheyearonyearaccumulateddeathsduetoongoingairpollution. Sonowthetimeisripetosustainmomentum into further monitoring, research,participatory education, and policy development withaccompanying economic and legal enforcements toaddressbothpandemics: airpollutionandenvironmentalmoral blindness. In themedium term these actionswillhelptowardsreachinganumberoftheSDGsandinthelongertermwillcontributetowardsmakingsustainablepracticesbecomeroutine.AcknowledgementsPhayung Morgan for her time and insights shared regardingvillagelevelinformationsharingmeetingsrunbylocalcouncilsin Wichianburi district, Phetchabun Province, Thailand. AlsothankyoutoSutharatSuksangthongandPhayungMorgan forcollecting survey responses in Pak Chong and Wichianburirespectively.ReferencesBaines,C. (2014) “TheRootoftheProblem.” Biologist61(1): 16-19Baron,R.E.,Montgomery,W.D. andTuladhar,S.D. (2010) “BlackCarbonMitigation.” Ch. 4 In Lomborg, B. (2010) Smart Solutions to ClimateChange: Comparing Costs and Benefits. Cambridge University Press:

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https://projects.iq.harvard.edu/files/covid-

pm/files/pm_and_covid_mortality.pdf ]Yang,J.,Chang,Y. andYan,P. (2015) “Rankingthesuitabilityofcommonurban tree species for controlling PM2.5 pollution.” AtmosphericPollutionResearch6(2015): 267-277

Zelenski,J.M.,Dopko,R.I. andCapaldi,C.A. (2015) “Cooperationisinournature: Nature exposure may promote cooperative andenvironmentally sustainable behavior.” Journal of EnvironmentalPsychology. 42(2015): 24-31

Zhong, C.B., Bohns, V.K. and Gino, F. (2010) “Good lamps are the bestpolice: Darkness increasesdishonesty and self-interestedbehavior.”

PsychologicalScience. 21(3): 311-314Waller,A.R. (2020) “ Can’tSeetheWoodfortheTrees–IsSmokefromAgriculturalPracticesCloudingTheIssue?ASurveyofPublicOpinion,Knowledge and Understanding of Air Pollution in Rural Thailand",Eubios Journal of Asian and International Bioethics 30(8) (October2020)421-426.

FurtheronlineresourcesBBCWorld ServiceRadio. (2018) TheReal Story: Air Pollution InvisibleKiller. [Accessed online 18-2-20. Available from:

https://www.bbc.co.uk/programmes/w3cswkdq]BBCWorldNews(2019) Mongolia: Atoxicwarningtotheworld. [Accessedonline 18-2-20. Available from: https://www.bbc.com/news/av/science-

environment-47673327/mongolia-a-toxic-warning-to-the-world]BBCWorld Service Radio. (2020) The Evidence Air pollution: The silentkiller [Accessed online 2-3-20. Available from:

https://www.bbc.co.uk/programmes/w3ct0hqy]WHOinfographicshttps://www.who.int/airpollution/infographics/en/ EJAIB adopts and complies with the Committee onPublication Ethics (COPE) Publication ethics andmalpracticepolicy.OurpolicyisontheEJAIBwebsite.All potential authors should have read these guidelinesand by submission of an article for publication youacknowledge that you have complied with this policy.Violationswillbehandledinproportiontotheintentionandseriousnessoftheviolation.RegisteredaddressofEJAIB:P.O.Box16329,Hornby, Christchurch8441,NewZealand


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