Eubios Journal of Asian and International Bioethics

Contents pageEditorial:Ethics,ValuesandtheTreatytoProhibit 1NuclearWeapons-DarrylMacerEthicalValuesandPrinciplesforHealingSocietyinLightoftheCOVID-19Crisis 2 -StatementoftheWorldEmergencyCOVID19PandemicEthics(WeCope)CommitteeReIlectionsontheimpactofCOVID-19pandemiconlifeandtheworld 8 -RavichandranMoorthy&GabrielTyoyilaAkwenOrganizedreligion,spiritualityandCOVID-19 13 -DarrylMacerBeliefingodvs.worshipofareligion 18 -NaderGhotbiSpiritualhealthcareandmentalhealthissuesduringtheCOVID19pandemic 21 -DhastagirSultanSheriffHealthylifestyleisthekeyforahealthysociety 24-RogelioP.Bayod&DarwinArnosaOvercomingdeath:thestateofmaninthemidstofa 29 pandemic-ChristopherRyanMabolocAcenturywithagonyordeathwithcomfort 32 -SamreenSiraj,ZainishHajani,AfsheenHirani, ShyroseSultan,NasreenRaSiqandSalimaSirajTransgenderRealitiesintheContextofCOVID-19in 35 Bangladesh-NazneenAkhterCOVID-19pandemicanditsimpactonthesocio-economic38 contextofBangladesh-ShamimaAkterRozy&MuhammadAliBankingagainstallodds:concernsofgovernmentbankworkersinthePhilippinesamidtheCOVID-19crisis 43 -GerosonC.Reginio,RandyA.Tudy,RexB.BuacCOVID-19andfoodsecurity:TheEasternVisayasStateUniversityexperienceinthemunicipalityofBurauen 51 -SheldonIvesG.AgatonChangesofhealthcarepracticeintheIieldofophthalmologyduringtheCOVID-19pandemic 55 -SibelInanThisincludesmanypapersfromtheInternationalPublicHealthAmbassadorsConferences(Refer:www.eubios.info)

Editorialaddress,andallcorrespondenceto:Prof.DarrylMacerEmail:darryl@eubios.info

Editorial: Ethics, Values and the Treaty to Prohibit Nuclear Weapons 75yearsafter the Iirstexplosionsofnuclearweaponswehaveseen today the ratiIication of the UN Treaty to prohibit nuclearweapons. There are a few other technologies that humankindhave made that are capable of destroying the whole planet.Eubios Ethics Institute founded Youth Peace Ambassadors in2010inHiroshimawithUNESCO.In2014wehelda Iieldtripofthe14thAsianBioethicsConferencetoNagasaki.It is Iitting on 22 January 2021, this issue launches theStatement “Ethical Values and Principles for Healing Society inLight of the COVID-19 Crisis”, from the World EmergencyCOVID19PandemicEthics (WeCope)Committee,as theresultofdialoguebetween50persons fromall around theworld.Oneoftheprinciplevaluesispeaceandnonviolence. Itmayhavetakenthepandemictobringhometopeoplethefragilityoflifeonthisplanet, which is still actively destroying the lives and hopes ofmanyaroundtheworld.ThankGod, itwasnotanuclearwinter,becausethetollwouldhavebeen2billioninsteadof2million.ThedozenpapersincludestudiesontheimpactofCOVID-19ondifferent communitiesand themeasures thatpeoplehave takentotrytocontrolthispandemic.InthemonthlyIPHAconferencesthatwearehostingweseemanypapersasaresultofnumerousresearch studies that are really opening up the Iield of publichealth ethics in amannerwhichhadnot been explored in suchdetail before. It is not the mighty hydrogen bomb which hasshown us the fragility of human existence. Rather it is a littlevirus, that has now started to mutate and naturally play anevolutionarygamewiththelivesofitshost,us.Surely it is alsowithanoteofhope to see the inaugurationofU.S. President Biden, who immediately rejoined the USA to theParisClimateAccord,andtheWorldHealthOrganization,andhasdeclared he will be part of COVAX, the effort to make theCOVID-19 vaccine accessible to people in every country in theworld. So, I think it’s quite reasonable at least for today thatbioethicists can be proud ofwhatwe’ve been doing to Iight forpreservation of the environment for all living creatures and ofhumanity itself. Let us double our efforts towork so that thosecountrieswhichhavenuclearweaponswillneverhavea reasonto use them, and will eventually give up such as suicidaltechnology.

EJAIB Vol. 31 (1) January 2021www.eubios.info

ISSN 1173-2571 (Print) ISSN 2350-3106 (Online) Official Journal of the Asian Bioethics Association (ABA) Copyright ©2021 Eubios Ethics Institute (All rights reserved, for commercial reproductions).

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)2

Ethical Values and Principles for Healing Society in Light of the COVID-19 Crisis

StatementoftheWorldEmergencyCOVID19PandemicEthics(WeCope)Committee(22January2021)

1.PreambleAs an independent, multidisciplinary, and cross-culturalcommittee, comprised of ethicists from cultures andnations across the world, in the context of our previousstatements, we offer the following statement andrecommendations on Ethical Values and Principles forHealingSocietyinLightoftheCOVID-19Crisis. 1Wehope that this joint statementwillwiden thescope

of reIlections bothwithin and between communities andnations andwill help share amutual vision for a healingsocietybyelucidatingethicalvaluesandprinciplesthatcanassist inmakingbetter societies. Thepossibility of bettersocieties can be achieved through the participation of allpeopletoconsiderwhatwouldbe“better”,andthroughthetransformative potential of what every person on theplanethaslearnedfromCOVID-19.Areas of potential transformation include both

individual and societal development, including but notlimited to public health, education pathways, economicIlows, institutional dynamism, hierarchical systems,authoritative relationships and broader issues of socialconventions. In the context of earlierWeCope Statementson Autonomy and Responsibility, State and Governance,andtheEnvironmentalImplicationsofCOVID-19,weneedtobroadenourconceptionofahealingsocietytakingintoaccount bioethical consideration for all spheres of life.Otherpotentialtransformationpointsrelatetoidentifyingtensionsandthedynamicsofunsustainableorasymmetricinputs and outputs, fragile structures, or contexts thatdemonstrate imperatives that are counter to commonperceptions of morality such as non-beneIicence,maleIicence,unjustness,irresponsibility,ornon-autonomy.Ethical visions related to these themes may aid inincreasing awareness, and hereinwe discuss some of theapplicableprinciplesandhumblyissuerecommendations.

2.HealingSocietyThe term “healing society” suggests that humanity isinjuredwhichmarksthecycleofevolutionofalllifeformswhereininjuriesareperceivedasnewchallengesandoftenleadtoparadigmshifts.Thisispreciselywhyglobalsocietyadopted the Millennium Development Goals (MDGs)followed15yearslaterbySustainableDevelopmentGoals(SDGs). In this statementweaddanothernewdimension

that plays an important role in the healing of an injuredworld which centers on the ethos of interrelationshipsbetweenlivingbeingswhereverandwhoevertheyare.To begin healing society, one may focus on its basic

component, thehumanperson,upholding the individual’sdignity, rights, values, and humanity. Perhaps this wouldmanifest statecraft and social conventions built on trust,rather than coercion backed by a monopoly on legalviolence.Bysocialconventionswemeanmorethansocialagreements or social contracts; the structuring of societyshould be based on effective practices that allow theconstruction of a new ethic inwhich the rules and ideasenablepeopletoarticulatetheirdifferencesasindividualsandsocialbeings.Thecommonhumangoodcanwithstandareasonableasymmetryofownership,ofinformation,butnotprivilegesandrights,especiallypertainingtotherighttouseviolenceasameans.To solve the challenges wrought by the past cycle of

domination and inequality creating dynamics, those withthe most shall no longer be granted unfair privilege andrightstoshapesocietythroughpolicyorbruteforce.Legalsystems shouldbe secondary to other normative systemssuch as those of morality or ethics. The curative societyinvitesustoforgeoursocialrelationshipsbasedonethics,ratherthanmerelylaw.It is not naïve utopianism to recognize that a

foundational agreement of non-violence allows forcoexistenceandcooperation todevelop intouniversal co-evolution. This co-evolution not only allows peaceful co-existence of peoples, cultures and nations, but also ofhumans, non-humans and natural systems.Humanity hassofarsurvivedthetensionandbalanceofmutuallyassureddestruction(MAD),ofaprolongedacceptanceofinequalityenforced by systemic privilege, and the right to useviolence.Byrecognizingtheviolentpathwehavetravelled(e.g., by acknowledging the resources spent on weaponsdevelopment, of proIit from suffering, and the verymechanismsofviolence),wemayintegratetheknowledgewe learned into a broadening universal awareness of thedevastationsuchapathincurs.We may heal, with awareness and loving compassion,

senseless suffering, and achieve the goal of preventingfuture suffering or cycles of systemic violence. Policies ofdomination, forceful coercion, and extraction of commonresourcesshouldbecomedis-incentivizeduntiltheycease.OneshouldrecognizethatanabsolutelybroaddeIinitionofviolence,maybecomeviolentitself.Someattemptstosolveviolence may lead to institutionally mandated structuresthatareaccompaniedbytheblindforceoflawoncitizensand in that sense, the purpose of non-violence can bedistorted by itself. Our common humanity has become

TheauthorshipofthisstatementreadsasAndrewBosworth,DarrylR.J.Macer,NaderGhotbi,NilzaMariaDiniz,ManuelLozanoRodríguez,1

Suma Parahakaran, Ayoub Abu Dayyeh, Abhik Gupta, Kayo Uejima, Sukran Sevimli, Thalia Arawi, Laura Victoria Puentes, and Marlon P.Lofredo,andothermembersof theWeCopeCommittee (listedat theendof thisStatement).ThisStatementdrawson ideasand literaturefrommanysourcesandbeneIitedthroughcommentsfromthefullCommitteemembersandotherpersonsaswell.https://www.eubios.info/world_emergency_covid19_pandemic_ethics_committee

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 3 moreevidentbecauseoflivingthroughaglobalpandemic,wherenonationisimmunetothevirus.

Recommendation1:Adopt theprincipleofnon-violence(ahimsa).Achievethat principle while broadening the deEinition, notweakening it. Attempt to move towards increasinglevels of universality of that broadening deEinition.Thiscouldbe formalized inauniversalagreementonnon-violent means to competition and disputeresolution.

3.EducationPost-COVID educational opportunities should emphasizeinquiry-based learning, which in addition to othercurricula, integrates cross-cultural bioethical themes.Educationshoulddevelop thesyntheticcapabilitiesof thesenses, including observing, understanding and listening.Adopting experiential and outcomes-based educationalmethods and frameworks may build the knowledge,attitudes, skills and ethical habits of learners, with an2

additional focus on reIlection, in order to develop criticalthinkingandethicalcapacityofstudents,andwiththegoalof increased participation and contribution towardsbettermentofthemselvesandtheircommunities.Wherever possible, the components of the Iive human

valuesoflove,truth,peace,rightconductandnon-violenceshould be considered and implemented. To achieve thesevalues, teaching methodologies may adopt mindfulnessand awareness, as an integrated approach to learning.Alongwith inspiration based uponmodelled examples ofconcepts,itcanprovidestudentsthesupporttheyneedfortheintegrationofaffectivedomains(feelings,attitudeandbeliefs), and allows for a true love of life celebrating allindividualsandanintegratedcommunity.Additionally, in terms of the implementation of

education by means of online technology, extra effortshouldbemadetodemonstratetheprincipleof“educationfor humanness” through critical thinking. Critical thoughthastwoaspects:one,theanalyticfunction,whichreferstothe competence of learners to examine the content oflearning and understand the concrete application ofconcepts in real life and context, and two, the integrativefunction,whichaddressestheformativeaspectoflearningwith respect to human values, attitudes, and openness toreality.Increasingthecreative,adaptiveresilienceofstudentsis

paramount. Education opportunities should be abundantandhaveaclearaimtosupport individualandcommunalwellbeing.Educationshouldmultiplyopportunities,whileproviding support for thosewhochoose to target speciIicgoals. Policy and research should also counter negativeeffects of commercial advertising on students, especiallythose lacking the cognitive ability and/or bioethicalmaturity to understand the persuasive content of the

material.EducationshouldbeconsistentwiththeselfandscientiIicevidence.The curriculum should balance subjective force and

objective reality, the contradictions of which can bereplacedby the ideaof intersubjectivity.Therelativismofthe subjective in the face of doubts about objectivity insome philosophical conceptions such as contemporarypragmatism, can be included in the concept ofintersubjectivity. This social concept highlights thearticulationbetweenthe individualrealityofeachsubjectwhichcanbeunderstoodasasocialconstructionbasedonlanguage.What lies at the basis of communication is notnecessarilymutual agreement butmutual understanding.Perhapswhatisconsideredtrueisasharedworldthatthespeakerandtheinterpretershare.

Recommendation2:Society should strive to create an educationalexperienceconsistentwithnotonlyasocialorculturalepistemology,butbasedonself-directedandscientiEicevidence, which elicits intellectual leaps, matchingindependentimaginationandastrongcreativepower,withthebestknowledgeofthegivenfacts.

Recommendation3:In order to foster solid ethical values, the curriculumshouldequipstudentsto:a) Appreciate the human and ecological conditionsaround them and personally interpret theirexperiences through critical ethical reElection, andthink of innovative, ethical, and creative solutions toproblemstheyencounter.b) Recognize the intersubjectivity that allows anincrease in the scope of consciousness, individuallyandcollectively.c) Balance subjective force and objective reality asexperienced by students towards an increase of theboundaries of awareness, both individually andcollectively.d) Promote organic educational developmentpathways, which support the mental and physicalwellbeingoflearners.

4.EconomicsIt is possible to transition the economy using thechallenges of COVID-19, towards healthier and resilientdynamics,which support thewellbeingof allmembersofsociety.Theprimarydynamic thatmust change is the coercive

and deceptive extraction ofwealth from public resources(e.g., the “commons”), internally and externally. Currentpowerpoliticsneedstoberestructuredtobetterrepresentthe people, and to provide more methods for consensusbuilding.ItisnotnecessarytotaxallIinancialactivitiesorredistribute private wealth. However, it is necessary toacknowledge and correct the inappropriate loss of land,

WeCopeCommittee(2021),ImplicationsofCOVID-19forEducation.2

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)4water and property as a result of colonization and otherIinancial privileges that have led to severe inequality, aswell as a divergent decoupling of Iinancial markets fromrealeconomic facts. Itdoes requiredrastically supportingthosewiththeleastwealth,andlimitingthemoralhazardperpetrated by those with the most, as well as somecreativeideasthataregroundedinbothfactandnecessity.The response by economic authorities to COVID-19

demonstrated the fragility of the economic structures atthe start of 2020. Itwas not a new or creative response,rather it was only different in the quantity of moneycreated and delivered. This situation is unprecedentedbecause it is clear that a repeat of past strategies (thatcoincidentally beneIit an increasingly smaller andwealthiergroup),cannolongersavethebroadereconomicsystem. If it continues like this, the Iinal break can bedramatic. It is not enough to simply save the smallestpercentage and expect the unproven trickle down toincreasetoaratethatcanrevivetheeconomicgrowth.Because the system failed to reformuntil the very last

minute,adilemmaof‘toolittletoolate’isovercomeusingthe dynamics of weekly or bi-weekly injections of publicfunds, to the public itself. This has saved lives and hasforestalled the nearly inevitable structural collapse. Intheory, gradually increasing the frequency and amplitudeof the handouts can synchronize economic activity andcreateanewrhythmicengineofgrowth,eveninthemidstoftheeconomicchaosatpresent.Thosechangesmustbedonesoonandundertakenwith

unparalleled commitment, and they shouldbedirectedatthose who are most vulnerable and in dire need ofeconomic help. This will subsidize the wellbeing of thepublicasawhole.ItmustnotbeusedasatoolofinIlationonly, but Iirst as a source of protection for those worstaffected by COVID-19, and secondly as a tool of demandcreationforeconomicstimulation.ItisalsoanopportunitytoreIlectonthethesisofinIlationasasourceofextractionand power. It is also a chance to build new economicinfrastructures, and rollback the extractive andunproductiveforcesthathavethriveduntilnow.Novel redistributive dynamics may support both

resilient wellbeing and public health. Since Iinancialmarketshavedecoupledfromrealeconomics,thereislesshazard in adopting certain non-counterparty boundmechanisms, as the fallacious and Iictitious nature ofwealth may allow for the directed altering of Iinancialratios and direct the Ilow towards a common goal. Thesame loopholes and mechanisms of extraction that wereonce realized without zero-sum linear constrictions caneasilybeusedas a sourceof funding for thepublic good.This is a temporary ability, as the Iinancialmarketsmustalso eventually return to reality, but a great opportunity,nonetheless.Suchanactioncombinedwithsimultaneouslyincreasing the distribution of ownership businesses viavarious creative means can ultimately result in the re-couplingof Iinancial and real economics circles; even if itdoesnotcreateequalityintheratesofwealthincreasing,it

willcreateequalityindirection.Someshipswillrisefasterthanothers,butwecansupportallships.Aprecursortosuchatransition,aswellasaninevitable

by-product of attempts to make such change, will likelyinvolve vast debt restructuring and relief, and possibledebt jubilees, as well as eliminating individuals’ incomeand purchase taxes. Economics should no longer bestructurally violent, via coercive or punitive paternalmodelsofauthority.RelaxationofthefortiIiedgatekeepingof economic activity will allow micro-currents oftransactional economic energy to stimulate and reshapeeconomicprocesses.Allowingabundanteconomicactivityto take place and the wealth of proIit to sink throughdistribution helps free capitalism for all and securesocialismforthosewhoneedit.

Recommendation4:Develop an economy that structurally supportsvulnerablemembersof societyandall others.Decreeand adopt for them the samemonetary and Einancialmottossuchas: ‘somethingfromnothing’, ‘whateverittakes’ and, central bank policy backing, which arecurrentlyaffordedonlytotheprivilegedfew.Thismayinclude a basic universal income, which shouldincrease in line with a global price inElation trackerthatfollowsratesofchangeincostofliving,includingfood and energy, as well a basket of commodities tomaintainrelativepurchasingpower.

Recommendation5:Embark on a public awareness program fortransparent formaland informaleconomiceducation,atall levels, thatexplainshowuniversalbasic incomeworks.WhereitisnotpossibleduetoindebtednessorEiscal mismanagement, or lack of transparency orpolitical will, alternative schemes involving acombination of redistributed public land andproductive resources, combined with conditional butuniversal access to needed low interest loans maysufEice.

5.RightsInternational society is, in good measure, founded onmutual respect andadoptionof theUniversalDeclarationofHumanRights. Thegoverning statutesof all countriesenshrinehuman rights in law, although it is true thatnoteveryone can celebrate their full human rights. A healingsociety is one in which there is self-determination andrespect for human rights and responsibilities of allpersons.During the quarantine and lockdowns, most directives

dictatedasaresponsetoCOVID-19havebeencoerciveandforceful, and yet have been impossible to effectivelyenforce.Theyhavecommonlybeendamaging toattemptsto self-organize by individuals, at grassroots, or to locallydecided community responses to the situation. Theabsence of consistent scientiIic facts, and abundantfearmongering,hasmadethesituationmoreperverseand

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 5 ritualistic. Healing from this mindless mentality willrequireconcertedeffortofresearch-policyevaluation.Human security means people must have what they

needandhavefreedomfromfear.Itdependsonresilienceandresiliencedependsonthefreedomforindividualmoralagentstomakedecisionsthatincreasetheirwellbeing.ThereIlexive lockdown response has ensured that thepandemic’s health effects were not limited to the directeffects of the virus butmultiplied the suffering indirectlyandinmorecomplexways.Therewasawiderangeofstylesoflockdownsandother

measuresthatcouldbeasimpleapproachbutwereoftenmismanaged.Analysisoftheimpactsrevealthecomplexityof myriad other public health issues. Estimated deathsrelated to a broad range of issues, from malnutrition inchildren, to missed treatments and diagnosis of non-COVID-19diseases,tolong-termpoverty,tobreakdownsinfood supplies, and rising prices, were some of directconsequencesstillbeingexperienced.Insteadofchoosingmodulatedortempereddemocratic

responses, some policy makers over-reacted withoutconsideringthelong-termeffects.Bydecimatingsocialandeconomic systems, ‘the cure may be worse than thedisease’, collective resilience is lower as a result, shouldtherebeacontinuedcrisis.Therefore,wereferreaders to therecommendationsof

ourAutonomyandResponsibilityStatement:Recommendation 1: The concepts of autonomy and ofresponsibility should be considered in their broad moralmeaning (and not in a narrow legal meaning), and in theculturalcontexttounderstandthedifferentwaystheycanbeexpressedandthespeciSicmeaningtheycanacquire. Inthecurrent pandemic individual autonomy must be balancedwith social responsibility to control the spread of theinfection.Recommendation 2: The exercise of autonomy and ofresponsibility require somebasicpolitical, economic, social,and educational conditions to be truly and effectivelydeveloped. Otherwise, people can neither be recognized asautonomous,norcantheybeheldmorallyresponsible.Inthecurrent pandemic, basic conditions for the exercise ofautonomyandresponsibilityshouldbeassured.Recommendation 5: Moral legitimacy of individualautonomous decisions depends on their universal potentialto be adoptedbyall. Therefore, they ought to be altruistic,cooperative, and helping to strengthen solidarity andequality. These general requirements for moral behaviorbecome even more important in exceptionally vulnerableanddemandingsituationssuchasthecurrentpandemic.And we refer readers to the recommendations of our

StateandGovernanceStatement:Recommendation 5: Human rights and fundamentalfreedoms are not to be unwittingly and unnecessarycompromisedbytheStateinitsCOVID-19management.Recommendation 1: State policies and regulationspromulgated for the prevention and control of COVID-19need to be just, compassionate andhumane, science-based,andtrulyresponsive,non-discriminatoryandequitable.This

timeofglobalhealthemergencyisanopportunity,aswellasa challenge, for governments around the world to provethemselves as resilient, cohesive, trustworthy, credible, andlegitimateinstitutionscapableofcreatingandimplementinglawsandpolicies thatbuildresilient,cohesive,andtrustingcommunities.

6.Well-beingWell-being is being comfortable, healthy and happy. Thelong-termdamagesofourresponsestoCOVID-19arestillunknown and have not fully realized but they have thepotential to cause the worst public health effects by anorderofmagnitude.ThedevastatingresponsetoCOVID-19hasfailedbynotrecognizingthedualityofsecurityagainstinsecurity, and seeking total security against a speciIicthreat,whichcreatedtheopposite inamultipliedfashion.InreIlectionitisworthconsideringKarlPopper’swords,“...onlyfreedomcanmakesecuritysecure.”Currently, therearedifferentdegreesof social chaos in

mostcountries'politics,astheyrespondtooutbreaksandnewmutationsofthevirus.Healingfromchaosisachievedby way of synchronization and dampening of extremeactionsonallsides.Themanyfacetsofhumansecurityinanewworld order can only be addressedwith the willingparticipationofindividualswhohavetheaudacitytohopeforincreasingtheirwellbeing,andtoachievethatabetterbalancebetweenfreedomandsecuritymustbereached.Traditional models of social contracts point out the

difIiculty to fully balance equality and freedom becausestate models choose to privilege one or the other. Socialjustice starts from the deconstruction of the oppositerelationship between freedom and equality and theredeIinition of solidarity as a unifying element. Solidarityallows the compatibility of individualism and privatefreedom,with life insociety, identifyingthesimilaritiesofthepeoplewhoarepartofagroup.Thus,solidarityistherecognition that differences with other people are lessimportant than the desire to avoid pain and suffering.Utilitarianism can also achieve a connection betweenfreedomandequality,whichhasbeen takenadvantageofbytheuseofeconomicanalysisinlaw,throughtheconceptof"prospectiveresponsibility",whichaimsatefIiciency.The most sustainably secure social systems are those

whicharenotpaternalisticallyandcoercivelyenforcedbycentralizeddictatesof lawora top-down ideology, rathersecurity comes from thewilling participation andmutualinterdependencieswhich arise from, and are inherent to,healthyself-organizationofmoralagents.Onehalf shouldnot dominate the other, nor can a select few effectivelydictate to the many. A thorough analysis of differentsystems of government and democracy needs to beconducted to examine the balance between the commongoodandindividualself-determination.

Recommendation6:Wemaypromotewell-beingby:a) Enacting policies which recognize that securityrequires mutual participation, and that pursuing a

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)6policy of an absolute form of security results ininsecurityofotherforms.b) Enacting policies which engage the public arenecessarytonegotiatingcommonsecurity.Thismaybeachieved by providing a range of options, andoutcomes, and recognizing the freedom individualmoralagentshavetodecideoverthebestoutcome,aswellasdevelopingnewoptionsbasedonfeedback.c)Developingchannelstonegotiatewiththepublicona case-by-case basis, to defuse tensions and dampenany chaotic potentials, and to offer reasonableconditionstooptinoroutofdecrees.d) All countries should transparently evaluate theimpacts of policies that include restrictedmovement,maskmandates,andheightenedsurveillance,and thebeneEits and liabilities of individual agency. Theassessment may include analysis of the misery thatresulted from the policies, the lives saved, and theenhancements in the maturity of health-minded andlovingcitizens.

7.LessonsLearntonEthicalPolicyThe essence of cross-cultural bioethics is to increase andserve the well-being of all beings, and to increase theirmaturity to discuss policies and to make informeddecisions.ThepandemichasprovidedmanyopportunitiesforreIlectionontheefIicacyofresponsetowardsbioethicalimperatives. It has not been easy to face the challenges.Fromadynamicperspective,oneoftheconsistentaspectsof policy response has been the application of simpleresponses to complex issues, as well as short-termappearanceversuslong-termeffects.The hard truth is that many of the responses to the

COVID-19 pandemic exacerbated unhealthy conditions.This may have been a result of misunderstanding, mal-intent, fear of the pandemic, and/or an opaque vision ofsociety. Together, it has resulted in dilemmas far beyondthe biological effects of the virus. Attempts to inIluencehealth and well-being are essentially futile, if appliedwithout holistic facts. There may be fractal logicalfractures, repeating at scales and causing more fracturesand fragility, rather than providing solutions. Simplesolutions,whichignorethesefacts,createdislocationsthatdamagethewhole.There are plenty of negative situations arising from

misunderstanding, mal-intent, and/or opaque visions,including foremost the discounting of myriad healthproblems other that COVID-19, discounting of social andpoliticalgrievances,andeconomicrealities.Thesehaveallbeen rolledup into the container labeled Sars-Cov-2, andsummarily made worse, rather than better for the massmajorityofhumans.The cumulative result is that unsustainable extremes

that will repeat ad-inIinitum, ad-nauseum must bereconciled.The failures of policy to this point can still beremedied if the right lessons are learnt and responsesapplied. The big challenges are economic, psychosocial,and structural, and may impact all facets of life.

Structurally,societymustnotsimplybethoughtofasgearsandcogsmoving inadirection,or itsantithesisregardinganyoppositionorresistance.Rather,wemustintegrateanunderstandingofenergeticdynamismandnon-directionalpathways, which balances the beneIits of lowerdimensional chaos with the divergent risks of higherdimensional chaos, with the caveat of quantumabsoluteness. Achieving this awareness in society willrequirethatpastassumptionsandexpectationscontinuallyfacere-evaluationwithevolvingawareness.Psychosocially, dissonance is prevalent as a result of

fractured order, best described as an independentdivergentlocalizedperspectivewhichismadeworseasthecoercivedominantIillthenarrativevacuum;itisaformofchaoticdislocation.Insomecases,dampeningthosevoiceswillbebeneIicialandinothers,elevatingthequietwillbethe best option. Discourse in the public sphere can be ahealing force. Tolerance of divergent views is where thesocietybeginshealing.Thechallengeofholismistoacknowledgetherepeating

fractalaspectsofanideology,forbetterandforworse.Itiseasytopromoteholism,butitisthemostdifIiculttoenactit. This is most true in the economic sphere of life. Oneexample for the need to correct simple responses tocomplexissuesandthefailuretodosocanbefoundintaxreceipts.Governmentsknowinglyorunknowingly createda Faustian dilemma once they arbitrarily judged somebusinesses as essential and others as non-essential, thusplacing themselves as the determiner of values beyondtheircapability,morallyor legally, tocalculate. It isanewtwistontheclassicaldilemmawherebypickingupthetoolforces them into an impossible role to play. It isdetrimentaltothepopulaceastheybecomedependentonsuch subject arbitrations that cannotmeet the necessarydemands. Overall, it ensures entropic reiIication in adynamicwherebythelowerpathbecomestheonlypath,ashigher-awareness and higher-complexity balances aretradedforoverlysimpleenergeticbalances.Ineachsociety,andateachlockdown,thedeIinitionsof

essentialhaveshifted. Inadvertently therule-makersusedtheir position to pick losers andwinners in society. Thiseconomic suppression has and will continue to hurt thegovernments and the citizenswhich trust them. Inclusivecapitalism it is not, it is the very deIinition of exclusiveprivilege,anditrepeatsatscalesandfunction.If we are to enact inclusive capitalism, which is not

corrupted fromthe inception,wemustendtheartiIiciallyimposed scarcity, and its counterpart of manipulateddemand.Thegoalbecomesoneof sustainable abundancythat repeats at all scales, allowing for the beneIicialdistributionof resourcesand themoralagencyneeded tosustain a higher complexity of homeostasis without thesuffering caused by disproportionate inIlationary effects.The creation of a reIlective index that is a non-linearcalculation of connectivity and distribution ratios, andgrowth curves of local resources, will be helpful. Thediversity of homeostasis on a directionally non-binaryindex,onceachieved,willprovideadynamicmapthatwill

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 7 correlate with inIlationary and deIlationary pressuresintegration into classical accounting systems, with thecaveatofincentivizingthenon-exploitationofnature.

Recommendation7:Createanindexthatinessenceisananti-miseryindex,perhaps called the ‘Potential Abundancy Index’. Itshould account for the connectivity, and potential foraccessofindividualstothetotalityofresourcesinthelocalityof themeasurement, thegrowthof resources,andthescoremaderelativetootherlocalities,withouta singular point of reference, but a dynamic Eloatingscore, in a Eloating continuum. It should alsoincorporateother factorsof importance including thehurdles to connection, such as gatekeeping functions,andentropiccostsasascoredetractor.

SelectedReferencesBoardofGovernorsoftheFederalReserveSystem.(June2020).MonetaryPolicyReport–June2020.DepartmentofHealthandSocialCare,OfIiceforNationalStatistics,GovernmentActuary’sDepartmentandHomeOfIice.(April82020).InitialestimatesofExcessDeathsfromCOVID-19.Retrievedfromhttps://assets.publishing.service.gov.uk/government/uploads/system/uploads/attachment_data/Iile/892030/S0120_Initial_estimates_of_Excess_Deaths_from_COVID-19.pdfHeadey,D.et.al.(2020).ImpactsofCOVID-19onchildhoodmalnutritionandnutrition-relatedmortality.TheLancet,396:519-21.Retrievedfromhttps://www.thelancet.com/article/S0140-6736(20)31647-0/fulltextDeutscheBankResearch.(May82020).Honey,weshrankoureconomy!DeutscheBankAG/London.Dieppe,A.(2020).AlistairDieppe.Washington:WorldBankGroup.Joffe,A.(2020).COVID-19:RethinkingtheLockdownGroupthink.Preprints,2020100330(doi:10.20944/preprints202010.0330.v2).Macer,DRJ.(1998).BioethicsistheLoveofLife.EubiosEthicsInstitute.Raworth,K.(2017).DoughnutEconomics.BusinessBooks.Rorty,R.(1989).Contingency,IronyandSolidarity.CambridgeUniversityPress.UNESCO(2005).UniversalDeclarationofBioethicsandHumanRights.WorldBankGroup.(June2020).EconomicProspects.Washington:WorldBankGroup.

Members,WorldEmergencyCOVID19PandemicEthics(WeCope)Committeeh t t p s : / / w w w . e u b i o s . i n f o /world_emergency_covid19_pandemic_ethics_committee

Dr.ThaliaArawi(Lebanon)Dr.MounaBenAzaiz(Tunisia)

Dr.LianBighorse(SanCarlosApacheNation,USA)Dr.AndrewBosworth(Canada)Dr.RhyddhiChakraborty(India,UK)Mr.AnthonyMarkCutter(U.K.)Dr.MireilleD'Astous(Canada)Dr.AyoubAbuDayyeh(Jordan)Dr.NilzaMariaDiniz(Brazil)Dr.HasanErbay(Turkey)Prof.NaderGhotbi(Japan)Prof.AbhikGupta(India)Prof.SorajHongladarom(Thailand)Prof.MiwakoHosoda(Japan)Prof.DenaHsin-ChenHsin(Taiwan)Dr.AnowerHussain(Bangladesh)Prof.Bang-OokJun(RepublicofKorea)Prof.HassanKaya(SouthAfrica)Dr.SumairaKhowaja-Punjwani(Pakistan)Prof.JulianKinderlerer(SouthAfrica)Dr.LanaAl-ShareedaLeBlanc(Iraq)Prof.MarlonLofredo(thePhilippines)Prof.ManuelLozanoRodríguez(Spain)Prof.DarrylMacer(NewZealand)Prof.RaffaeleMantegazza(Italy)Dr.AzizaMenouni(Morocco)Dr.EndreyaMarieMcCabe(DelawareNation,USA)Dr.RavichandranMoorthy(Malaysia)Prof.FiruzaNasyrova(Tajikistan)Dr.SumaParahakaran(Malaysia)Prof.MariadoCéuPatrãoNeves(Portugal)Prof.DeborahKalaPerkins(USA)Dr.LauraVictoriaPuentes(Colombia)Prof.OsamaRajkhan(SaudiArabia)Ms.CarmelaRoybal(TewaNation,USA)Prof.MariodossSelvanayagam(India)Prof.MihaelaSerbulea(Romania)Dr.SukranSevimli(Turkey)Dr.JasdevRaiSingh(England)Dr.RaquelR.Smith(USA)Prof.AnanyaTritipthumrongchok(Thailand)Dr.KayoUejima(Japan)Prof.ErickValdésMeza(Chile)Dr.LakshmiVyas(UK)Prof.YanguangWang(China)Prof.JohnWeckert(Australia)Dr.AnkeWeisheit(Uganda)

Inquiriesto:Prof.DarrylMacer,Chair,WeCopeCommittee;Email:darryl@eubios.infoTel.+1-949-439-9307.ThisstatementispublishedinEubiosJournalofAsianandInternationalBioethics31:2-7.

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)8

Reflections on the impact of COVID-19 pandemic on life and the world

-RavichandranMoorthy,PhDPresident,AsianBioethicsAssociationUniversityKebangsaanMalaysia-GabrielTyoyilaAkwenDepartmentofPoliticalScienceFederalUniversity,GashuaYobeState-Nigeria

AbstractTheCOVID-19pandemichaspresentedtheworldwithanunprecedentedglobal challenge thathas impacted almosteveryone. The pandemic has causedmajor disruptions insystemsofwork,education,Iinanceandindomesticaffairs,affecting nearly every aspect of people’s lives. Besideshealth and safety, thispandemic also causedhavoc in thelives of people, in lockdowns, movement control, schoolclosures, high levels of emotional distress, higher risks ofviolence and increased food insecurity. Drawing fromexperiences of some countries around the world, thispaper reIlects on the said impacts, challenges and futurescenarios of this pandemic to individuals, communities,andnations.

IntroductionThe COVID-19 pandemic has presented us with anunprecedented global challenge, touching everycommunity ineverynationof theworld.Thepandemic iscausingsystemsofwork,education, Iinanceanddomesticlives to grind to a halt, affecting nearly every aspect ofpeople’slives.Besidestheimpactonhealthandsafety,thispandemic alsohas causedhavoc in the lives of people, inlockdowns,movementcontrol,schoolclosures,highlevelsof emotional distress, higher risks of violence andincreasedfoodinsecurity.Theimpactofthepandemichasbeenestimatedtodouble itsadverseeffectonthe livesofpeople. The socio-economic chaos caused by COVID-19 isindeed widespread and devastating – a large number ofpeople are already at risk of sinking into abject poverty,“while the number of undernourished people, currentlyestimatedatnearly690million,couldincreasebyupto132millionbytheendoftheyear”(WHO,2020).

Business entities and enterprises that supportworkforce are facing great challenges to survive thisordeal;manyhadalreadycrashed,leavingtheirworkforcejobless.Globally, it isestimatedthatalmosthalfof the3.3billionworkforces are in danger of losing their jobs. Themost vulnerable are workers in the informal sectors“because the majority lack social protection and access toqualityhealthcareandhavelostaccesstoproductiveassets”(WHO, 2020). Especially for daily wage earners, loss ofincometranslatesintotheinabilitytofeedthemselvesandtheir families.Protractedmovementcontrolor lockdownsin an extreme situation, will pose serious food securityissues,especiallywiththevulnerablesegmentsofsocieties.

Inthispaper,theauthorswishtoreIlectonsomeimpacts,challenges and future scenarios of this pandemic toindividuals,communities,andnations.

Howthepandemicimpactslives?PublichealthThe COVID-19 pandemic is theworst public health crisisthe world has faced in over a century. Initially, mostCOVID-19caseswereconIinedtotheWuhanprovinceandwithin the Chinese borders, but the subsequent monthssaw a steady rise in spread to other nearby regions andeventuallytothewholeworld.AirtravelandmovementofpeopleacrossbordersandregionshavegreatlyintensiIiedthe spread of this virus. As of 16 December 2020, therehave been 72,196,732 conIirmed cases of COVID-19,including 1,630,521 deaths, reported to WHO (WHO,2020).

The World Health Organisation (WHO) declared theoutbreak as a Public Health Emergency of InternationalConcern on March 11, 2020 (Sharma and Bhatta, 2020).Despite the advice byWHO and actions taken by nationsworldwide, the spread of virus appeared unstoppable.Manycountrieshaveexperiencedcyclesofaspikeofcases.Malaysia, for example, hadmanaged to bring down dailycasestosingledigitinmid-2020,onlytoseeasubsequenthighspike.Thispandemichasplacedenormousstressonthe public health capacities of countries. Many countrieshad todivert their resources fromother sectors topublichealth.Asthenumberofcasesrises,healthfacilitiesneedto cope with the increase in patients demandingspecialized care, placing enormous stress to the publichealthsystem.Manypoorercountrieswithlargeanddensepopulationstruggletomanagethecrisisadequately.Manycountriesstruggletoprovideadequatetestingkits,medicalsupplies,personalprotectiveequipment(PPE)toitsfront-liners andpatients, and its timely distribution to affectedcenters. Front-liners such as doctors, nurses, paramedicsand Iirst responders and theoverall public health systemmaybeill-preparedtodealwiththepandemic.Tomobilizeresources and direct them to targeted areas of responserequires a robust crisis management system in place;without it, there will be ineffective use of resources,resulting in the frustration of the general public. Forexample, “the hospitals in Nepal lack Intensive Care Unitfacilities, isolationwards andmedicines to treat COVID-19.Additionally,theimplementationofinfectionpreventionandcontrolmechanismsarenot strictly followed” (SharmaandBhatta,2020).

Themeasures taken to contain the pandemic, such aslockdowns,stay-homecurfewsandmovementcontrolhaveincreased the incidents of domestic violence and mentalhealth problems. This situation requires adequate healthinterventions in affected communities, as without suchinterventions, family and community institutions can beimpacted. Further, extended lockdowns can result in foodshortages, andmay contribute to childhoodmalnutrition.The longtermimpactcouldwellbearise inthe incidenceof chronic conditions attributable to the ack of physical

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 9 exercise and loss of income and livelihood. The resourcecommitted to deal with COVID-19 pandemic hasoverstretchedthecapacityofmanycountries.Inturn,thisscenariowillreducethecapacityofmanyhealthsystemstocope with existing disease burdens; cessation of routinesurgeries,healthchecks,andimmunizationprogramsmaycause outbreaks of preventable communicable diseases,rising cancer rates, and increasing numbers of late-stagecomplex medical conditions (Haw et al., 2015). It is alsofeared that the ensuing economic recession and job lossmay result in extreme stress to people, especially thosewhoaredirectly impactedwith thescenario–whichmayincreasesuicideratesinsocieties.

FoodinsecurityBeforetheadventofCOVID-19pandemic,manyregionsofthe world had already faced major food insecurity,resulting from political conIlicts, rise in internallydisplaced peoples (IDP) and refugees, degrading socio-economic conditions, disruption of food supply chains,impacts of natural disasters, climate change and fooddestroyingpests.Theincreaseinglobalfoodinsecurityhasnegatively impacted vulnerable communities in manyregionsoftheworld.Althoughthereisanadequatesupplyof global primary food (grains) with relatively stableprices,many countries have experienced “high food priceinSlationattheretaillevel,reSlectingsupplydisruptionsdueto COVID-19, currency devaluations and other factors”(WorldBank 2020).Many countries have tried to controlthepricesoftheirprimarycommodities,whichenablelessIluctuation of major food prices. However, the restrictivenature of lockdowns inevitably pushes prices up. In suchsituations, countries with low and middle-incomecommunities will face more severe impacts, as a largerportionoftheirincomeisspentonfoodcomparedtohigh-income communities. With reduced incomes, manyvulnerable communitiesmay have to reduce the quantityand quality of the food they consume. It has beenforecastedthat“anadditional137millionpeoplecouldfaceacute food insecurity by the end of 2020, an 82 percentincreasecomparedtothepre-COVIDestimateofacutelyfoodinsecurepeople in theworld” (WorldBank,2020;Anthem,2020).

Theimpactsoffoodinsecurityduringthepandemicarelikelytobediversewithinandacrosscountries.Asalludedearlier, people in the informal economic sectors andvulnerable groups, such as the unemployed, women andchildren are likely to be impacted severely. Poorercommunitiesaremore likely to feel thepinch fromahikeinfoodinsecurity,becauseoftheirliquidityandcash-Ilowconstraints and lower adaptive capabilities (Smith andWesselbaum, 2020). In addition to the pandemic,agriculturalandnaturaldisasterssuchasextremeweatherevents and pest problems can hurt food production andcreate further stress on the local, national, and regionalfoodsystems(Hawetal.,2015).AccordingtoaUNreport,food insecurityanddisplacementare linkedclosely. “Nineout of ten of theworld’sworst food crises are in countries

with the largest number of internally displaced persons,while the majority of displaced people are located incountriesaffectedbyacutefoodinsecurityandmalnutrition”(UN News, 2020). To add to this dilemma, COVID-19mitigation efforts like border closures, trade restrictionsandmovementcontrolmeasureshavemadeitdifIicultforfoodproducerstoaccessmarkets,subsequentlydisruptingfood supply chains. The sluggish economic environmenthasalsoresultedinjoblossanddisruptedthelivelihoodofmillions of people around the globe (UN News, 2020;Ejembietal.,2020).

EducationEducation is another sector that is badly hit by theCOVID-19 pandemic. In an attempt to stall the spread ofCOVID-19, many governments around the globe havemomentarily shut schools and institutions of higherlearning. This was done to effectively enforce physicaldistancing.AccordingtotheUNEducational,ScientiIicandCulturalOrganisation(UNESCO)about60%ofstudentsareaffectedbytheCOVID-19pandemicworldwide,andabout1.19billionstudentsareoutofschool in150countriesoftheworld(UNESCOEducation2020).COVID-19ledtotheannulment of the 2020 examinations conducted byCambridge InternationalExaminations (CIE).Theaffectedexaminations include Cambridge IGCSE, Cambridge OLevel, Cambridge AICE Diploma, Cambridge InternationalA Level and AS, and Cambridge Pre-U examinationsscheduled for May/June 2020 throughout the world(Upoalkpajor&Upoalkpajor,2020).Theclosureofschoolshas not only reduced the enrolment percentage andlearning for now, it has the potential of increasing thenumbers of school dropouts in the long run. This cannegativelyaffectsocioeconomicopportunitiesinthefuture.

TheeffectsofCOVID-19as itrelatestoschoolclosuresareprojectedtohaveanextremelynegativeimpactonthevulnerable and risk intensifying the prevailing universalinequalities. With the prolonged spread of COVID-19pandemic, susceptible children will have insufIicientprospects to learn at home. Most of the children in thiscategorymaynothaveaccesstointernetfacilities.Eventothe privileged students, the migration from the schoolenvironmenttohome-basedteachingmaynotproducethedesired result. This is because home-based teaching ismeanttoaugmenttheschool-basedteaching.Forinstance,parents are supposed to complement childrenmathematics lessons by practicingmathematics at home.Thereisnodoubtthatmanyparentsaroundtheworldwillbe able to effectively school their children at home. Thiscannot be said of the general population. Certainly, thereare some signiIicant disparities among families in theextent to which they can assist their children’s learning(Oreopoulosetal.,2006).Manyparentsmaynothavetheluxuryoftimetocommittoteachingtheirchildren.Again,the non-cognitive abilities of the resources and thequantity of knowledge is an issue. Consequently, theseincidentswould lead to an increase in thediscrepancy inhumancapitalgrowthfortheaffectedpartners.

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)10Theseriousshort-terminterruptionofschoolsisfeltby

many families around the world. Home-schooling is notonlyamajorshocktotheproductivityofparentsbutalsothe learning and social life of children. Without testing,teaching has quickly moved online, alongside studentassessments. This spontaneous movement comes withuncertainty for all parties to the education sector, aseveryone is involved inone formof trial anderroror theother. Numerous continuous assessments have beenhaphazardlygradedorcancelled(BurgessandSievertsen,2020). According to Marinoni et al. (2020), the Africancontinenthas77%ofhighereducationinstitutions(HEIs)closure, while Asia PaciIic and Europe have 55% apieceandthatofAmericasstoodat54%,eventhoughatthetimeof their survey Africa was not the worst hit by theCOVID-19pandemic. This shows that theAfrican leaders’precautionarymeasures led to a high percentage of HEIsclosure.

ThepercentageofHEIshasaffectedboththeadmissionof local and international students in al l theaforementioned regions. This shortfall may snowball to2021because families and studentsarebadlyhit andareyet to recover from the consequences of COVID-19pandemic and may not have the wherewithal to pursuehighereducationatthemomentorthenearfuture.

The suspensionof in-person classes’ or school closureand the implementation of distance education canunhelpfullyaffectstudents’educationviafourmajorways:less timedevoted in learning, stresssymptoms, change inthe manner of student’s interaction, and the dearth oflearningenthusiasm(DiPietroetal.,2020).

Another impact of the COVID-19 pandemic oneducation can be seen in the shrinking of the Iinancialspace to fund education, as a result of the shock ongovernment income and economic slump. In developingstatesnumerousitemsinthe2020educationsectorbudgetmay not be executed due to the swinging Iinancialshortage.Nevertheless,morefundingisneededtopreservethe learning process as part of the state's palliativeprocedures. The most pressing needs for governmentsaround the world at the moment is how to improveteachers'incentive,learners'readinessandstimulatelocaldigital and media enterprises (Upoalkpajor andUpoalkpajor,2020).

ImpactoncitiesandurbancentersIn highly urbanized cities, the typical pathogen exchangemechanismsofCOVID-19transmissionareexacerbated,soitisnowonderthat95%ofallCOVID-19casesworldwidehave occurred in cities and urban areas (UN-Habitat,2020).Therefore,diseasepreventionisacrucialconcerninurbanplanning.Approximatelyonebillionpeoplegloballylive and work in informal, under-serviced and insecureurbanenvironments, andbillionsmoredependonpatchyand inadequate piped water, power, and affordablehealthcare in cities with declining infrastructures.Restraintsoftheprecariousplacesinwhichindividualsliveand work signify that it is practically impossible to

segregatethepeoplewithsymptoms.Apartfromthis,mostessentialworkerssuchascleanersandwastecollectorsincities and urban places are prone to high-risk. Thiscategoryofworkersisthelowestpaidinmosturbanareasof the world. Therefore, lockdowns in cities and urbanareas have resulted in extensive economic difIiculty andjoblosses,mostlyformigrantemployeesandtheirfamilies.The above situation can also affect low-income states,especially those in Africa that depend on inwardremittance.Up to 16%of theGDPofAfrican state comesfrom remittances from Europe, America, and Asiancountries that experienced lockdown inmost of the year2020(TheEconomist,2020).

TheCOVID-19pandemic showed that cities andurbanareasareextremelyfragile;therefore,theirinhabitantsareunsafe.As of 1 June2020, the global spreadof COVID-19stoodat above sixmillion identiIied cases andmore than371,000 deaths, predominantly amongst city/urbanresidents (WHO, 2020). At the metropolitan level, thesocial distancing procedures, movement restrictions, andclosureofpublicrestaurantsput inplacebygovernmentshave obstructed food consumption behavior. This canimpact on diets. Also, some cities experienced panicbuying, leading to hoarding of goods by supermarketowners(PuligheandLupia,2020).Thelockdownstrategyalso extensively impacted on economic and societal costsin urban areas. In many urban centers, mostly indevelopingcountries, lockdownsinreactiontothespreadofCOVID-19havecast lightonmanyeconomicandsocialconcerns,someofwhichincludehomelessness,healthcare,debt, and food insecurity (BjörklundandSalvanes,2011).The situation ismadeworse by the fact thatmost of thecity dwellers in this context are dailywage earners. ThiscorroboratedthepositionofBraimah(2020),whichshowsthatthelockdownmeasuresinmostAfricancitieshaveledto utter poverty, Job losses, family pressure, hunger, andincompetencetopaybills.

On a positive note, the outstanding lockdownprocedures to render our city streets emptywith limitedvehicleshaveimprovedthequalityofairinourcitiesatthetime of lockdown. This means that if we eradicate allcombustion automobiles from cities by permitting a fewpublic means of transport and the transport of essentialsupplies, the quality of our air improves greatly. ThisIinding wouldn’t have been possible without COVID-19.Lockdown measures have resulted in the availability ofcleanairinurban/cityareas.Duringthelockdownperiod,thenewsthriveswithdescriptionsofextraordinarilyblueskies and improved visibility. Observers disclose a severedeclineingasandparticlesmogovercitiesinsituationsofconIinement (IQAir, 2020). Cities of Delhi, London, LosAngeles,Milan,Mumbai,NewYork,Rome,SãoPaulo,Seouland Wuhan have registered reductions ranging between−9%and−60%comparedto2019data,andbetween+2%and −55% compared with the prior four-year average(Baldasano, 2020:2). Limited economic activities duringthe lockdown in most cities have also promoted cleanerenvironments. There is a signiIicant drop in air pollution

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 11 because COVID-19 has reduced all travel. “COVID-19pandemic is shutting down countries across the world,causinga signiSicantdecline inairpollution inmajorcitiesas countries implement stricter quarantines and travelrestrictions”(Maceretal.,2020:406)

Con9lictzones,refugeesanddisplacementBeforetheadventofCOVID-19pandemic,conIlictswereacriticalsocialdeterminantofhealth,yieldingbroadhealthconcerns ranging from limitations on health systems tohitches in accessing and delivering health services.COVID-19increasedgovernments’capacitytouselimitlessexecutiveauthoritiesthatcouldexacerbatecrisesandhavean overwhelming impact on conIlict-affected populaces.Even though the UN Security Council has called for aninternationaltruceinconIlictareastoallowsafepassagetodefenselesspopulationsforteachingthemhowtopreventandrespondtoCOVID-19, thiscallhasnotbeenfollowed.Global treaties and peace agreements have also beenunheeded as the world concentrated on the COVID-19pandemic.Also,asobservedbytheUNHighCommissionerfor Human Rights, COVID-19 brought about an alarmingincrease in security agents brutality and violation ofhumanrightsunder thepretextof emergencyprocedurestocurbthepandemic(Hawetal.,2015).

The difIiculties faced by the masses as a result ofCOVID-19 preventionmeasures have triggered protest inpartsof theworld. InAfrica, for instance, somecountrieslike Malawi, Nigeria, Rwanda, Kenya, Ivory Coast SouthAfricaandZimbabweexperiencedprotests.Theseprotestsmet with police brutalities attempting to prevent themasses fromviolating the lockdownorders. In states likeUganda, South Africa, Kenya, and Nigeria, there arereported cases of police confrontation and subsequentdeathofpoorcitizens.InSouthAfrica,securityagentshavebeenindictedforemployingextremeforcewhileexecutingCOVID-19 lockdown measures (Miller, 2020). They havearrested over 230,000 people and are accused of beingresponsible for the death of 11 South Africans (Haffajee,2020). InNigeria,policebrutalitywaswitnessed instateslike Ogun, Lagos, and the Federal Capital Territory. Theruthlessnessbythepolicenegatessomeoftheproceduresthat allow people to go out for essential reasons like thepurchase of foodstuff and medication. While there were400establishedcasesand12deaths inNigeria, thedeathtoll arising from extrajudicial execution by lawenforcementagentsstoodat18people(Aljazeera,2020).

The lockdown strategy has also affected refugee andinternally displaced persons (IDPs). As for humanitariansituations, most governments have postponed receivingnewrefugeesandasylumseekers.Forinstance,inUgandafrom 25 March 2020, refugee response centers at theboundary points and the Department of Refugees (DOR)ofIices in Kampala were closed (Bukuluki et al., 2020).Whilethesemeasureswereaimedatcurtailingthespreadof COVID-19, they also had negative implications on therefugees and other vulnerable groups (Mbiyozo, 2020).This also negates the United Nations High Commissioner

forRefugees(UNHCR)policyonrefugees,whichstatesthatrefugees in all settings should be given access to safe,cheap, enough and nonstopwater to cover domestic andpersonal uses (UNHCR, 2019). This is goal number 6 ofSustainable Development Goals (SDG), which is toguarantee availability and effectivemanagement ofwaterand hygiene for all people by the year 2030 (Bukuluki etal.,2020).Insituationsoflackofaccesstowater,refugeesin cities will face challenges to stick to public healthprocedures, such as self-isolation, improved hygiene, andsocialdistancing(Klugeetal.,2020).

Refugees are prone to the risk of poor healthconsequenceswhen contracting COVID-19, aggravated bypoorlivingstandardsandhurdlesinaccessinghealthcare.Thismakes them themostvulnerableamongall categoryof thepopulation.Thesituation inSwedencanbeusedtobuttress this point. It was discovered that during 2020periodoftheCOVID-19pandemic,refugeesinSwedenwhowere previously confronted by challenges such asunemployment, crowded living conditions and strains inobtaining health carewere theworse hit (Mangrio et al.,2018). In Sweden, more migrants have died due toCOVID-19 compared to the rest of the population(Elisabeth et al., 2020).A goodnumber of these refugeeswho died in Sweden as a result of COVID-19 pandemicwere from Eritrea and Somalia. As usual, the refugeesdwelling places are overcrowded and socially destituteareasofSweden(Valerianietal.,2020).Moreso,Trueloveetal.(2020)substantiatetheongoingargument,whentheyposit that the COVID-19 pandemic has more dreadfulconsequences in refugees’ camps than the overallpopulationinBangladesh.MostoftheconIirmedCOVID-19cases are Rohingya refugees from Myanmar, with about600,000foundintheKutupalong-BalukhaliExpansionSite(Trueloveetal.,2020)

ConclusionThe COVID-19 pandemic can be viewed from socialperspective, mainly from vulnerability and resiliencediscourses (Moorthy, Benny & Gill, 2018). While thispandemic has impacted people across the globe, asdiscussedearlier,thegroupsinthelowersocietalstrataaremore severely impacted. Therefore, it is criticallyimportanttoputinplacerobustsystemsandmechanismsthatcanincreasetheresilienceofthesegroupstofacethispandemic. It is time for the international communities topull support and resources to assist themost vulnerablesegments in our societies. There should be concertedglobal initiatives to soften the impacts of COVID-19,especiallyinthehealth,economicandsocialsectors.

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Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 13

Organized religion, spirituality and COVID-19

-DarrylMacer,Ph.D.President,AmericanUniversityofSovereignNations,NewZealand/USAEmail:darryl@eubios.info

AbstractThere appears to be a signiIicant difference betweenorganized religion and spirituality. In this paper I willcompare both and explore some impacts of thesedifferences in terms of theway that people of faith haveresponded to the COVID-19 pandemic, how people havebeen exposed to the virus through religious sites andfestivals,andhowreligiousinstitutionshaverespondedtotheCOVID-19pandemic.

ThefunctionofreligionThereareanumberof functionsoforganized religion forhuman lives. In terms of theworship of the Creator God,many people have addressed a need for some form oforganization to provide order or a direction of ourspirituality throughtheestablishmentofvariousreligiouspractices. Spirituality is generally associated withimproved emotional health (Kowalczyk et al., 2020), aswellaswithbetteroutcomesfrommedicaltreatment(Bestetal.,2015).There are a number of references in different faith

systems to the advantages of more than one personpraying together, or praying in large groups at the sametime,whetherthatbeinthedailyprayerservicesfoundintemples, churches andmosquesor sharingprayers at thesameIivetimesinthedayamongthefollowersofIslam.ItmayalsobeinprayerstotherisingsuninShintoorApachereligion.Wealsoseeritualizedprayersatcertaintimes inour lives such as birth, death, circumcision, or teenageconIirmationoffaithorcomingofageceremonies.Wealsosee even some details in the placement of our hands inprayerthatrangeacrossculture.Ihaveobservedveryreligiouslyobservantelderlyladies

in both Catholic countries and Buddhist countries, whoIind the religious rituals and organization in theirrespectiveplacesofworshipagreatcomforttothem.Theymay lightcandlesor light incense,withtheenergyof Iire,andthesmell,aswellasthesymbolismoftheburningofaIlamethatwillbetemporary,asislife.ThesesymbolsthatremindusofourmortalitymaywellbeusefulremindersofseekingGodandourneedtopray.TheyalsoshouldremindusthatthefaithfulintheirheartswillIindorganizationofreligious services in their ownvillage and circle towhichtheyarebornand live in,aroutetospirituality.Thatmaybe because of their genes, their parents, and the spiritlivingintheirculture.Religion has had mixed impacts on the environment.

Some particular animal species are seen messengers ofspiritsandofGod,sothatparticularbirdsmaybeseenas

messengers of God or evil, the presence of a black catmaybe an omen in some culture, and a wandering deerfrom the forest may be seen as a messenger of spirits.Many taboos on the hunting of animals or the picking ofplants, serve as important preservers of biodiversity(Bosworthetal.,2012).Beforeyoueverbelittlea customorataboo,learnmoreaboutthewisdomitmayrepresent.

ThefalsedichotomyandspiritualsnobsSome critics of organized religion, strict adherence todenominations of faith, and religious rituals, may attackwhat they see as a superIiciality of organized chanting,usingwordsof distant languages such asLatinmasses inservices, priestly clothes and hats, and other symbols offaith,claimthatthesearesomehowdistinctfromtruefaithof direct connection to God through spirituality. It’sactually snobbery to believe that one’s own faith andspiritualityisbetterthananotherperson,justbecauseofarejectionoforganizedreligion.In the same spirit, however, there are thosewho had a

distinctly negative impression of organized religion thatmaywell havegood reason to reject it.Over timearoundthe world, we can clearly see religious authorities maybecomeinstrumentsofearthlyoppressionandrepressionofthefreespiritofhumanbeings.Therearemanymodernincarnations of the Spanish inquisition and the “HolyCrusades”,andinter-religiousconIlictsareoftenstilltiedtonationalismandpoliticalregimes.AsaChristian,Iseethisindependence of thought enshrined in the UniversalDeclarationofHumanRightsasfreedomofbelief, implicitintheconceptof“ImagoDei”(TheimageofGod).RathertoreIlect thewonderful human diversity,we can argue thatwhatevergetsyouthroughthenight,aslongasyoudonotharmothers,canbeembracedasitbuildsourrelationshipwiththeSpirit.Actually“smellsandbells”(theexpressionthat incense,

gongs and chanting with music) are forms of sensorystimulation that can make many of us closer to thespiritual. It’s probably no coincidence that we can seeincense has independently evolved as a facilitator ofspiritual experiences in a number of religious spaces,whetherwebeRussianOrthodoxorBuddhists.Thesecanbe vehicles of spirituality, but as Ghotbi (2021) writes,“Worshippingyourreligionisjustcreatinganotherformofidolatry”.Inside the English traditions we may also Iind this

distinction between the “High Church and Low Church”,and the high Church tends to be associated to moreorganized religion including incense and a Iixed religiousliturgy (Order of Service), whereas a low church maybefreerintermsofthewaythatitteaches.However,traditionstillsetsupapatternineachspaceofworship,whetheritbeafamiliardrumbeat,anelectricguitar,drumsandfolkmusic, or a pipe organ. All can fulIil certain urges forhuman reIlection and worshiping of God and spirit(s). Iappreciate that in some places we can seamlessly movebetweenboth in the sameday,dependingonmeeting theneedforsomemodernorclassicalmusic,somehour-long

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)14academic exegesis of scripture, ablution of our body towashourhands,feetandmouth,andasimplehugorsmile.Weneedall.Godblessall.

SeparationofusandthemThe monotheism and polytheism debate is anotherexample of a snobbish argument that was often used incolonization, basically to say that my gun is bigger thanyours (i.e. My god is bigger than yours). We can seeelements of polytheism in Judaism (meant to be thefounder monotheistic religion pathing the way toChristianity and Islam), and elements of monotheism inHinduism (meant tobepolytheistic).There are traditionsin all faith systems of a balance between knowing ourCreatorGodandknowingmanyspirits,andalsoprayerstoourancestors.Theexclusive clausesof salvationhave sadlybeenused

to separate the “enlightened” from the “pagan”, and areevenstillusedtokillsomepeople,andtosuppressculture.Itcertainlyseemsaparadoxthatsomeonewholooksatthegrainsofsandinabeachoradesertcouldthinkthattheyhave an exclusive revelation of the Creator. For theChristians,thewordsthatonlythroughfaithinChristJesuscanyouentertheKingdomofheaven,needtobebalancedwith the teaching that God is all loving and there willalwaysbereligiousandfaithfulpeoplethathavenotseenaBible.The evangelist zeal to convert the “pagans” to one’s

religionhasanumberofmisadventures,aswellasalotofgenocidalblood.Anthropologists changed this evangelicalfocus towritingbooks andpapers about “lost”people, aselements of encyclopedias to celebrate the conquests ofknowledge. Ironically the same rituals that weresuppressed as songs of the devil by evangelists ofChristianity and Islam, and some other forms of humancreativity, were applauded by some anthropologists –sometimes even shipping a few token indigenous peoplewhowerenotmassacredtobecircussideshows.At the same time religion has brought out the best in

some people’s creativity. Church music is a common artform that is appreciated in the wider community wellbeyond Christians, and we actually see some broadercelebrationofChristmascarolsandEastermasses.Wealsosee participatory songs and dances in many religiousfestivals. Likewise,we can Iind themelodious chantingofBuddhist monks something which also brings about afeeling of spirituality. The drumbeats of Native Americanmusicsongsandparticulardancingrituals,andthecalltoprayerfromtheminaretsofmosques,arealsoexpressionsoforganizedmusicthatpleasetheearsandheartsofmanysouls.Wecanalsoseemeditationandyogaas techniquesthat can be seen in all religions, yet their rediscovery assecularhealth techniqueswas ledbyreference toEasternspirituality.

ReligionandthePandemicReligiousleadershaveimportantresponsibilitiesinpublicpolicyandhealth(BarmaniaandReiss,2021).Itisbeyondthe scope of this article to make any judgment on howeffectively those roles are performed, but some religiousleadershaveledbyexamplepromotinghandwashingandphysical distancing, wearing masks, and promotingequitable distribution of medical resources and vaccines.Barmania and Reiss (2021) present how religion isimportant for COVID-19 health promotion by examininghow religionplays an important role in determininghowlikely it is that someonewill get infectedwith COVID-19,they draw on both complexity theory and approaches todealingwith religion in scienceeducation to suggesthowreligiousleaderscanhelpintheeffortsagainstCOVID-19.I refer readers to some ongoing projects to map the

responses of religious authorities to COVID-19. Various3

a c a d em i c a s s o c i a t i o n s a l s o h a v e p r o v i d e drecommendations, such as the American PsychologicalAssociation. Religious faith can increase resilience to4

quarantineandotherstressfulsituationsthathavebeenafeatureof2020inmostcountries.In some theological discussions the explanation of the

timing of rains, sunshine, plagues, pandemics, disastrousweather,volcanoes,earthquakesandwindscanbeseenasdirectlyattributabletoGodspeakingtoourcommunity.Wehavetheexpressionthatthisattributionoftheunexplainedisthe“GodoftheGaps”,andwithmoderntechnologyandunderstanding ofweather patterns or tectonic plates, wedon’tneedtorefertoGodasareasonfornaturaldisasters,orforthepatternsofrain.However,ifGodisthecreatorofall the universe, it doesn’t really matter if God is usingtectonic plates or weather patterns or chaos theory orzoonotictransferofdiseases,tobringabouttheoccurrenceofnaturalevents.Thenecessityofchancecanexplain thewaythattheCreatorGodcanallowrandomnessandchaostoleadthewayoftheworld(Polkinghorne,1989).Ratherthereal issueisthemoreinterestingandadeep

philosophical question of predestination versus free will,whichwereallywillnotknowtheanswer to,because it’snotascientiIicquestion.Youcannotprovethatyoubelievein God because God came to speak to you through God’sintervention,or through theprayersof the faithful friend,or God came to answer to your prayers directly. Andconversely you cannot disprove that events didn’t occurbecauseofhumansinortheabsenceorpowerofprayer.It’sratherapersonaljourneythatwetakeastohowwe

attributedifferenteventswithdifferent causes.Perhapsacommon response of both organized religion andspirituality is to say that we should be thankful foreverything that we are given whether it came about bychance or by divine intervention or by someone’s blood,sweat and tears (i.e. hard work). As scientists we can

https://berkleycenter.georgetown.edu/subprojects/religious-responses-to-covid-193

https://www.apa.org/topics/covid-19/faith-crisis4

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 15 explore how much the inIluence of genes, nurture,television, capitalism, communism, culture and so on is,but we actually have to respond to a more importantquestion.

ReligionandCOVID-19Thisbringsustothequestionofwhatarethedemandsofyour faith that shape your response to the COVID-19pandemic. The response of religion should be to feed thehungry and take care of the sick, and we can see somesigniIicantprogressintheexpressionofpracticalreligiousfaithsystemsthroughthesolidarityseenbygovernments,businessesandreligiousorganizationsin2020.The central ethical principle underlying science is

beneIicence, the pursuit of understanding of themechanismsoftheworldisfoundedinunderstandingthescientiIicmechanisms.ThisisnotonlyseeninmajorfaithsystemsthathavebeencriticalfortheadvancementofthescientiIicmethod,ChristianityandIslam,butalsoinsomeindigenous epistemologies of knowledge (Macer, 2015).The former Head of State and former Prime Minister ofSamoa, Tui Atua Tupua Tamasese Ta’isi EIi (2009)describedthe importanceof theSamoanconceptsof tapu(the sacred) and tofa sa’ili (the search for wisdom) inidentifyingethicalpracticesforapplicationinresearch.Hearguesthatit ispossibletoIindamiddlegroundbetweenideasandpracticesgroundedinreligion,thespiritual, thesacred and science. Against the background of anexploration of different facets of the Samoan concept oftapu,whichencompassesthesacred-nessoftheoriginsofall things as well as the afIinity between people, thecosmos,andanimateandinanimateearthlyphenomena,heenvisagesaPaciIicbioethicsthatreachingoutforwisdom.As many people lost their employment, soup kitchens

andfooddeliveryfromreligiousorganizations,hasbeenapositiveopportunity toshow love.Someexistingsystems,such asmission soup kitchens and SikhGurdwaras,wereideallysetuptorapidlyexpand,andtheyhaverisentothechallenge.Religious festivalshavealsobeenopportunitiesfor practical solidarity, from Diwali (Vyas, 2021) toChristmas.2021willbeanothertestoffaithasweseethescrambleforthevaccines.Thereisacommonreligiousfocusonmobilizingurgent

directassistancetomeetthesocialandeconomicneedsofvulnerable communities, and advocacy that gives voice tothevoicelessbypressingforactiononandsupporttothesecommunities at all levels (G20, 2020). Many local faithcommunitiesaremobilizing support for food, shelter, andlivelihoods,but“Despitenotablemobilizationofvolunteersand Iinancial resources, religious community efforts toprotect and support vulnerable communities suffer fromweak coordinationwith, and limited support from,publichealth and other efforts, so that efforts over- all are farmore fragmented and less effective than could readily bepossible.”(p.46).Oneofthequestionsthathasemergedinthe pandemic is how does each society deIine, “essentialreligious services”? Although we can Iind commonalitieswhere faith systems come together, there have also been

reports around the globe of religious discriminationhinderingtheresponsestothepandemic,especiallywhenthisoccurredamongreligiouspilgrims(Sarkar,2020).Hopefully,epidemiologyandmortalityhaveproventhat

the pandemic is notwhat some extremists said – namelythat it is a message from God to kill off sinful people,because despite early claims of some faithful people thattheywouldbesafeintheirhouseofworship,somehousesofworshiphaveactuallybeenseatsofsevereinfection.Forexample,someoftheearlyoutbreaksinKoreawerelinkedto religious places of worship. Including the ShincheonjiChurchofJesus.AnumberofcasesinIranandTurkeywerereportedamongthosewhovisitedIran’sShiaMuslimholysites of Qom and Mashhad in February 2020 (Al-RousanandAl-Najjar,2020).AlargedelegationofIslamicTablighi-JamaatinKualaLumpurwasthecauseofthesecondwaveofthepandemicinMalaysia,withattendeesfromtheeventtravelling toBrunei,Cambodiaand Indonesia (CheMatetal.,2020).With regards to the Iirst question, it doesn’t seem that

“sinful”peoplearebeingtargetedbyCOVID-19;ratherweseeahighermortalityrateinolderpeopleandpeoplewithpre-existingconditions.Themortalityisalsohigherinmenthanwomen.DespitetheageismthatelderlypeopleIindinthe normal ethical dilemmas of rationing of healthcare,futility,andorganallocation,itisabreathoffreshairthatthe elderly are receiving their vaccines Iirst in manycountries.This false argument that sinful peoplewill be killed off

because theyareespecially targetedbyavirusordiseasewas seen a few decades ago with the humanimmunodeIiciency virus (HIV) and AIDS,wheremy 1993research on attitudes to disease found that many peopledifferentiated between so-called sinful people who got itthrough their behavior, and so-called innocent people—the people who caught it through blood transfusions, ormedical malpractice (Macer, 1994). After decades ofresearch,mostpeoplecanbeeffectivelytreatedwithdrugstomanageHIV, andmany people in developing countrieshaveaccesstothesedrugs.Another group of people that has severe effects after

infectionbythesars-cov2-virusarethosewithpre-existinghealthconditions.Weshouldn’targuethatpeoplewhoareobese,becameobesebecauseofover-eatingorgluttonyorthat they are dying at higher rate because of their sin.Similarly,while somediabeticsareathigh risk, andsomediabetics are diabetic because they have consumed toomuch soda drinks and sugar, it is the food culture thatinIluencespeopletobecomeaddictstosugar.Inonesense,the disease is not very different to a number of wide-ranging infectious diseases that kill many babies andinfantsintheworldtoday,andpeoplelivinginpovertyareathigherrisk.Theresponseofprovidingvaccinestotheseat-riskpersonsearlier, isonebasedon loveofothers, theGoldenRule,acommonreligiouscommand.Religious prohibitions that are linked to health

promotioninsomereligions,includeavoidanceofdrinkingalcohol,drugtaking,gluttony,sexualactivitywithmultiple

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)16partners, and suicide. Conversely the Islamic and Sikhrecommendations towash before a religious service, andexpressions such as “cleanliness is next toGodliness”, areimportant to reduce the spread of disease. This was aphrasepopularizedbytheMethodistleaderJohnWesleyinthelateeighteenthcentury(Callahanetal.,2010).One of the central sacraments to the Christian faith is

that of holy communion, where people share bread andwine.IntheIirst lockdowninmanycountriesallreligiousservices were prohibited including receiving holycommunion (Norman and Reiss, 2020). In a number ofcountries this communion serviceuses grape juice ratherthan wine, and also uses individual cups rather thandrinkingfromthesamecontainerthatismerelywipedbyaclothbetweenmouths.OnecouldexpecttheglobalnatureofCOVID-19andpublichealtheducationwillfurtherpushcommunities towards the use of individual cups as amatter of hygiene. In some cultures where the climatepermits,religiousserviceshaveshiftedtooutdoorsettingsonly.Religious leaders have also taken important roles in

reducingthespreadofdiseasethroughboththegatheringof largenumbersof people at funerals, and also touchingthe dead body. Jaja et al. (2020) described how funeralgatherings inSouthAfricawere linked to somespreadingof COVID-19. There are reports that in some countries,including Indonesia, families took their dead relativesbodiesfrommorguestoensurethattheyreceivedaproperburial (Karmini and Milko, 2020). Although COVID-19 isnotsosevereasEbola,itisstillapublichealthrisk.Thecentralityofintensiveinteractiveritualsthataretied

to the communal beneIits of religion (e.g., social support,emotional catharsis, perceived healing) will result in acontinual tension between many religious groups’ desirefor in-person gatherings and the social distancingrequirements necessary to limit the spread of COVID-19andotherinfectiousdiseases(Bakeretal.,2020).Forthosewho research the sociology of religion, the impact of theshift to Internet based gatherings of worshippers is aninteresting research question, with overlaps to theconcepts of virtualmeetings in all spheres of our humanco-existence.ReligiousexceptionalismissomethingIhaveseeninthe

United States, reinforced by interpretations by theSupremeCourtthatfreedomofreligionismoreimportantthan following public health policies to avoid havingcrowds of people gather together. This decision was5

counter to public opinionwhere 4 in 5 persons opposedseparate standards for places of worship. Even we Iind6

that some religious followers still rejectmasks, believingthatGodwillprotectthem.Perry et al. (2020) found that “Analyzing panel data

collectedinthethickoftheCOVID-19crisis,weSindChristian

nationalism was the leading predictor that Americansengaged in incautious behavior like eating in restaurants,visiting family/friends, or gathering with 10+ persons(thoughnotattendingchurch),andwasthesecondstrongestpredictor that Americans took fewer precautions likewearing a mask or sanitizing/washing one's hands.Religiosity, in contrast, was the leading predictor thatAmericans engaged in more frequent precautionarybehaviors.”The issue of religious freedom is a sensitive one

everywhere, and a political issue in the United States,whichhasthelargesttollinhumanliveslosttoCOVID-19.Bettercommunicationmayhaveavoidedtheemergenceofa confrontationbetweena right togather toworshipandthenecessityofpublichealthrestrictionsongatheringsofmultiple people. One could predict that it is more likelythat the general public will criticize religious places thatpromote an exceptionalism for religious services,especially asmore infections are spread.Evolutionwouldpredictthatthetypesofmutationstomakethevirusmoretransmissibledetectedattheendof2020willbecomeevenmorecommon.Thereareavarietyofapproachestodecidingwhethera

practice is ethical or not. In theWestern Abrahamic andpost-Enlightenment worldviews, there is a strong beliefthat universal values can be realized through objectivecriteria.Contrastingly,theIndicsystemsbelievethatwhileuniversal values exist, they are not achievable, becausehumanbeingsapplytheirownsubjectiveexperiencesandemotions to their knowledge of values (Singh Rai et al.,2010).Therefore,whereastheformerascribesadegreeofobjectivity as a prerequisite for legitimacy, the latterconsiderssubjectivityasamajorinIluencingfactorspeciIictoindividuals,groups,cultures,andsoon.Thisworldviewwilltoleratemanyindividualchoicesaslongastheydonotdo harm and will also tolerate belief in attempting toimproveourselves.

EndoflifeCareTherehasbeensigniIicantcriticismofthedecisionstakenby many medical authorities and hospitals, especially intheearlymonthsofthepandemic,torefusepermissionforthe loved ones of dying patients to be at the bedside ofpersons dying from COVID-19. Although video telephonecalls were often provided, these are not a substitute forholding the hand of a spouse, parent or child, when thepersonindying.Therearealsoconcernsthat the lovedonesmaynotbe

able to personally see the dead body of their loved one.Religiousandculturalvaluesareviolatedbysuchpractices,andaccommodations to thepublicheathrulesneedtobeconsidered.

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

3813310001/

https://www.pewforum.org/2020/08/07/americans-oppose-religious-exemptions-from-coronavirus-related-restrictions/6

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 17 Many of the ethical issues raised by COVID-19 are not

unique to the disease. Decisions over the extent that lifesustainingtreatmentshouldbeapplied,andwhenitshouldberemovedhavebeenexploredinmedicalethics.HsinandMacer (2006) found that the Taoist idea to Ilow withnatureintherefusalofexcessivelifesustainingtreatmentwas shared among elderly Christians, Buddhists andfollowers of other religions in Japan, New Zealand andTaiwan.

UnityandsolidarityThe year 2021 offers a chance for our world to showsolidarity.Thereissomerejectionofthosewhodon’twearmasks, and I sometimes see the comments that someonedidn’t wear a mask and therefore they deserve to havecoronavirus.Sadly,somepeoplearetakeninbyconspiracytheories that deny the virus, even as they utter their lastwordsbeforebeingintubated.God will protect us through wearing a mask and

followingthescienceofpublichealth.ItisablessingifGodgave you an immune system that will protect you, butasymptomatic people can still spread the virus to otherswhoarenotsoblessed.Ifsomeonewasnottaughtproperhygiene,thenteachit

to them; do not blame them. Particular groups of peoplelivingincrowdedrooms,slums,refugeecamps,usuallydidnot enter these spaces because of their free will.Fortunately, intheworldtoday,mostpeopleseeadiseaseasmoreactivelyattackingthosebornwithanunfortunategenetic lottery, those living with poor nutrition and inpoverty as victims of the economic system, rather thanbecauseofanymoralfaultoftheirown.Thereneedstobehealth evangelism rather than a culture of the saved andtheunsaved–bethechangeintheworldthatyoudesire.Religionandspiritualityremindusofourmembershipof

the community of living beings and souls (Macer, 1998).PaulTillich(1963)wroteinTheEternalNow,“Onecannotbestrongwithoutlove.Forloveisnotanirrelevantemotion;itisthebloodoflife,thepowerofreunionoftheseparated.”In the words of Erich Fromm (1963), “If I truly love oneperson,Iloveallpersons,Ilovetheworld,Ilovelife.IfIcansaytosomebodyelse,‘Iloveyou’,Imustbeabletosay:‘Iloveinyoueverybody,Ilovethroughyoutheworld,Iloveinyoualsomyself ’.

AcknowledgmentsanddedicationThis is a work in progress, and I will add academic andscriptural references. Your comments are very welcome!Thisdescribesalivingwork,andIwishtothankjustafewofthespecialpeoplewhohavehelpedmeonmyjourney(Idonotlisttheirtitles).IthankmyfatherJohnMacerforhispassionand loveofnaturetogetupearly towalkaroundlakesides and rivers watching Iish, enjoying birds, andlisteningtothewind. I thankmymotherEileenMacerfortheeyesofanartisttoseethebeautyofboththerealandthesymbolizedinart,andinthesetheloveoflife.IthankHeatherHammonds for her focused prayerwhich helpedbring me to faith. I thank John Bowker, Humitake Seki,

Jayapaul Azariah, Helena Martin, Yeruham Frank Leavitt,Farhat Said-Pervaiz, Joanna Hammonds, AnanyaTritipthumrongchok, LianBighorse, PaulHammonds, TimForester, SahinAksoy,MinakshiBhardwaj,TimothyBoyle,Jasdev Rai Singh, Sang-yong Song, Nader Ghotbi, MihaelaSerbulea andWendsler Nosie, for the discussions on thispaper,prayers,supportandjoyoflife.

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Belief in god vs. worship of a religion

-NaderGhotbi,M.D.,Ph.D.RitsumeikanAsiaPaciIicUniversity(APU)Beppucity,Oita,JapanEmail:nader@apu.ac.jpEmail:nader@apu.ac.jp

Abstract Religionsarehumaninterpretationsofthemeaningoflifeandthepositionofthemanintheworld,andhowhumanactions and relations shouldbe regulated toprotect theirharmony; they are not directwords of a god(s). There issome wisdom in them as well as ideas that may need areconsideration,whichisveryhuman,andtheonlywaytoIind the truth is tocriticallyexamineeach teachingbasedon the current knowledge and understanding andattending to the needs of a rapidly changing society andenvironment. Unfortunately, most organized religionsrequire a blind acceptance of certain pillars promoted asfundamental ‘beliefs’, implying that critical evaluation isnotwelcome.ThiscannotcontinueasthenewgenerationmoreandmoreIindssomeofthesebeliefsirrelevanttotheissues of the time. Respecting equal rights for men andwomen, and autonomy over sexual and reproductivechoicesareexamples.SpiritualitycanbeawayoutofthisstateofconIlict,anditcanhavebeneIitsforallpeoplefromanyreligioustradition.

Introduction A study over religion versus spirituality may start byreviewing the literature left byAlbert Schweitzer (1875 -1965),therecipientofthe1952NobelPeacePrizeafterhiswork on the concept of “Reverence for Life” (Schweitzer,1936). Schweitzer was a theologian, a medical doctor, ahumanitarian, and a pioneer bioethicist. Especially hiswork translated as “The Quest of the Historical Jesus”(1910)isworthmentioninginwhichheexaminedhowtheimageof Jesushadchangedwith the times.Heconcludedthat the life and thinking of Jesus must be interpretedthrough convictions of "late Jewish eschatology" and later attempts at understanding him by making parallels to adifferentwayofthinkinghadbeenmisleading.BydaredtocriticallyexaminehisownbeliefsasaChristian,Schweitzerproved hewas aman searching for the truth. One of hissigniIicant convictions was that: “We are brothers andsisters to all living things and owe to all of them the samecare and respect that we wish for ourselves.” (Brabazon,2000).

Iwasborn toreligiousparents.Theyareused to theirreligiousbeliefsandarenotinterestedinexaminingthem.However, I hadmany questions about those beliefs sincemychildhoodandIwaslookingfor‘betterbeliefs’andkeptsearchingforotherreligiousinterpretationsoftheworld.Iwas essentially searching for a ‘substitute’ religion, afterdisappointmentover theofIicial religion inmyhomeland,thinking that everyone needs to be afIiliated with somereligion. Inotherwords, Iwas searching fora compatiblereligious ‘identity’. However, nowadays, I see the youngergenerationmostlyintotaldisbeliefoverreligioningeneral.Iseemyselfasbelongingtoagenerationbetweentwoverydifferent generations, one before and one after. Thegeneration before is mostly resistant to change and thegenerations after are much less interested in followingreligioustraditionsofthepast.Ihavebeentryingtoreducethis generational gap by seeking the truth; if I can Iindpieces of it in the past and relate it to the present,connectingthemwithreasonandfacts,andgetthecourageto express the Iindings truthfully. A recent survey in Iranhas surprised religious commentators by revealing thatover50%ofthepopulationhaslostitsreligion(Malekietal.,2020).Theoverwhelmingmajorityof collegestudentswhere I teach are non-religious, especially those fromJapan,China,VietnamandotherAsiancountries,themainexception being some students from Indonesia,Bangladesh, Pakistan and the Philippines. One may evenobserve a revolt among some of the latter group againsttheradicalbeliefstheyleftbehindaftermovingtoJapan.

Animplicationoforganizedreligionsisthattheyhaveaseries of Iixed fundamental beliefs. Most organizedreligions require their followers to abide by thesefundamental beliefs, to not question or critically debatethem,andstaycommittedtoconIirmingthemwhenasked.Asanexample,theTwelverShiaIslamwhichistheofIicialreligion in the Islamic Republic of Iran, requires allfollowers to believe that the Twelfth Imam is still alive,albeit1100yearshavepassedsincehisdisappearance,and

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 19 he is coming to Iight evil andwin awar thatwill set theworldonits Iinalcoursebeforetheendoftimes!Myowncriticalexaminationofthefactsandthehistoryaroundthisbelief has convinced me that it is an untruthful myth.However, as an Iranian, my life would be in danger if Iexpressed doubts about this story. In 2014, the IslamicRepublicof Iranexecuteda37-year-oldmanafter Iindinghim guilty of heresy for insulting prophet Jonah;MohsenAmir-AslaniwhohaddoubtedthestoryinQuranofJonahbeing swallowedby a large Iish only to be returned alivedays later, was hanged for making “innovations in thereligion” and “spreading corruption on earth” (KamaliDehghan,2014).Thatissounfortunatewhenwelearnthatthe story of Jonah in Judaism represents the teaching ofrepentanceandbeing forgivenbygod,and inChristianityJonah’sstoryisamodel forresurrectionandcomingbacktolife.ThestoryofJonahdemonstrateshowasinglestorymaybeinterpreteddifferentlybythreerelatedreligions.

There are other radical differences in the teachings ofthe Abrahamic religions, Judaism, Christianity and Islam.Forexample, thehistorical fact that JesuswascruciIied isprobably the most signiIicant event in Christianity;however, Quran says (verses 4:157-4:158) and Muslimsbelieve that Jesuswasnot cruciIiedbutwasbodily raisedup to heaven by God (Lanier, 2016). Another majordifference is over the status of Jesus in Islam and themeaning of trinity. A fundamental belief in Christianity isthatJesuswas(sonof)god.However,QuransaysthatJesusis aman, not godorhis son, and trinity is understood torefer to the father, son and themother (Mary) instead oftheholyspirit(Quran5:116):“And when Allah said: O Jesus, son of Mary! Did you sayuntomankind:TakemeandmymotherfortwogodsbesideAllah?hesaid:BegloriSied!ItwasnotminetoutterthattowhichIhadnoright.IfIsaidit,thenyou’dknow.”

How is it possible that Abrahamic religions differ somuch on such fundamental beliefs? Can we suggest thatthese differences exist because the teachings donot havethe same (divine) origin but are interpretations of thefoundersofthesereligions?ButwhereisthesourceoftheChristian beliefs? Aslan (2013) explains: “In 325 C.E.,EmperorConstantinebroughttogetherbishopsinthecityof Nicaea to permanently Iix the Christian faith,commandingthemtoreachaconsensusonthedoctrineofthe religion. After months of negotiations, the councilhandedtoConstantinetheNiceneCreed,outlining for theIirst time the ofIicially sanctioned beliefs of the Christianchurch, that Jesus is the literal sonofGod, trueGod fromtrue God. This was a popular belief resulting from thepopularity of the letters of Paul as opposed to those ofJames, the brother and successor of Jesus who wasexecutedin62C.E.AfterthedestructionofJerusalemin70C.E.,Christianityhadbecomeagentilereligionandneededagentiletheology;thatispreciselywhatPaulprovided.”

Discussion Therearealreadyvariousarguments todemonstrate thatreligionsarehuman interpretationsofwhatgod(s)would

wanthumanstobelieveandtodo,includingarcheological,historical,andlogicalexaminationsofthevariousreligioustexts;thereisasmallbibliographyattheendofthisshortarticleforthosewhomaybeinterestedinreadingfurtheronthesubject.However, Ipresent inhereamathematicalargument to supportmy claim! Let’s assume there are Nreligions (R) in theworld (N=the number of all religioussectsthatexist).ForanyRi(i=1,2,3,4,…)thatmaybeatruereIlectionofthegod,thereareN-1religionsthatholdadifferentviewofwhatgodwantshumanstobelieveortodo.Assuming that godmusthavemadeuphismindoverwhat is right and what is not, and there is one truthfulreligion out there, there should be N-1 religions withbeliefsandpractices thataredifferent from the righteousword of god. In a situation like that, nobody can be surewhichreligioussectisbasedonthetruthfulwordsofgod.Thatisbasicallyhowvarioussectsformed!Inotherwords,ifareligion isdivided intosectswithdifferent ‘beliefs’,asinChristianityandIslam,onemayacceptthatthedifferingbeliefs and practices follow the differences in humaninterpretations, not the divine. If the divinity was clear,they would not disagree so much to need to form aseparate sect! Whenever various sects branch out of areligion each having string claims of self-righteousnessover the other sects, that is itself a proof to their non-divinity.ThismaybethereasonwhyEmperorConstantineneededthebishopstoagreeonChristianbeliefsandthenbanallothersin325C.E.(Aslan,2013).

Ifhumansarepronetomistakesandsins,andreligionis supposed to stop them from that, how would that bepossible when the religion itself is based on humaninterpretationsmadeatapointintimelonginthepastand‘Iixed’foreternity?Isn’titthetaskofareligiouspersontoseekthetruth?Howcantheydosoiftheystopthemselvesfrom examining the beliefs that they have committedthemselves to, only because of being born to it, or beingassigned to it because that was the dominant religionwheretheylived.ThenewCoronaviruspandemicprovidedanopportunitytoexaminethereligiousclaimsallovertheworld. In Iran, closing down the sacred tombs of Imamsandtheirsacredfamilymembers,andthenusingalcoholtodisinfectthefacilities,whilealcoholisconsidered‘unclean’,haditsimpact.Thesearejustexamples.Ihavestudiedandfollowed many religions and I have found similar issueswitheachandeveryone.Thebasic issue is that religionsare human interpretations about creation, existence, andlife and what they really mean. These interpretationscannotbecompleteandfreefromerror,especiallyastheysufferfrombeingrelativelyoldandrelevanttoatimewhenhuman knowledge and information was much morelimited. Closing the door to a critical reexamination ofone’sbeliefs,onlyservestowidenthegapwithanevolvingknowledgeandunderstandingoftheworld.AsaChristianchoosing this tradition to express my spiritual beliefs, Ihave a clear stance regarding certain claims: No, god didnot fatherahumanchild tohavehimcruciIiedso thathecouldforgiveoursinsifonlyweattestedtothat!

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)20To be ethical requires one to express what may be

truthful,andtoseekthecouragetodothat.Tosimplysaythesearefaithsystemsandallaretrue,maybeapoliticallyeasy tactic but is confusing, untruthful and thereforeunethical.Oneshouldnotblindlyallowanybelief system,whether ideological suchas communism,or religiousandfatalistic such as the Twelver Shia Islam, especiallywhentherehasbeenevidenceofharmtothelivesofmillionsofpeople. I often toldmyMuslim friends: “Remember yourduty tonot stray from thepathofgod.Worshippingyourreligion is just creating another form of idolatry.” This isespeciallyimportantinIslam,becausethemostimportantpillarofIslamwastobelieveinonegodandtopursueonlythegod,notanythingelseincludingthereligionorasectinitorapersonassociatedwithit.

Searching for God has been a human endeavor forthousands of years (Aslan, 2017). The search is not over;nobody has the Iinal answers; nobody knows the god infull; maybe humans will never will, but it doesn’t meanthey can claim the search to be over and dig their oldreligiousrecordstoIinddirectionsfornowandthefuture.Thenextgenerationswilllookbackatuswithpity,likewewere the fans of a mythical story of fantasy and magicsimilartoHarryPotter,butonlytooboringandfrequentlyirrelevant. A good example is when the public healthsystem wanted to promote the use of condoms to slowdown the spread of HIV and there was opposition fromcertain religious groups that god would not allow that!HowdidtheyknowgodwouldopposetheuseofcondomstopreventHIV?Wasitagenuinedivinecommand,orjustahuman interpretation based on digging in old humaninterpretations?

TheCenter forAmericanProgressreleasedareport in2019 to warn the U.S. public of exploitation of religiouslibertytodenyaccesstohealthcare,todiscriminateagainstfosterandadoptiveparents,toformdarkmoneychannels,and to deny this liberty from some religious traditionswhileprovidingittoaselectfew(London&Siddiqi,2019).Theyalsorecommendedpoliciesandpracticestoreinstatea balanced and inclusive vision of religious liberty, toensurethatreligiousexemptionsdonotunderminepatienthealth, to prohibit for-proIit businesses from claimingexemptions from anti-discrimination laws, and to extendnondiscrimination laws at the federal level. Some say theproblems that existed in medieval times, such as thecondemnation of Galileo for reporting his scientiIicobservations,donotexistanymore.However,thelastfouryears in the U.S. provide a strong counterargument. AsRoose(2020)hasdocumented:“APewResearchCentre report from2016 showed81%ofwhite evangelical Christians voted for Trump compared to16% for his Democratic challenger, Hillary Clinton. WhiteProtestants(58%)andwhiteCatholics(60%)alsovotedforTrumpoverClintoninacampaigndeSinedbyTrump’sracistandinsensitivecommentstowardMexicansandMuslims,aswellashispoortreatmentofwomen.DespitefouryearsofapresidencydeSinedbyTrump’sunprincipledbehavior,nottomention over 228,000 deaths from the COVID pandemic,

white religious support forTrumphas slippedonly slightly.The latest Pew Research Centre report shows Trump isfavored over his current Democratic opponent, Joe Biden,among white evangelicals (78%), non-evangelical whiteProtestants(53%)andwhiteCatholics(52%).”

An anonymous commentator in social media wrote:“America!Itistimetotakeresponsibilityforyourtheology.”Ontheotherhand,aspiritualpersonwhoIindssometruthin every religion, as well as some falsehood, can sharebeliefs with any of all those religious sects. This isimportant because it helps avoid religious discriminationandopensthewaytoanexaminationofone’sbeliefsinthecontext of an advancing body of knowledge and a betterunderstanding of the world. The time to spread magicalstoriesofreligiousmiraclesisover.

For me and an increasing number of people in mygeneration, spirituality is the answer tomost issueswithorganizedreligion.Anexampleistheincreasinginterestinthework of liberal theologians like John Shelby Spong, aretiredAmericanbishopoftheEpiscopalChurch,whohascalledforafundamentalrethinkingofChristianbeliefawayfrom theism and traditional doctrines. Currently, he hastens of thousands of supporterswho like to hear that hedoesnotknowwhotherealgodis,whatitislike,andthatitmaybeamysterynevertobetotallyunderstood.So,heasks for all religions and their followers to respect oneanotherandassertstheonlyreasonheisaChristianisthathewasborn to that traditionand it ispossible forhimtoapproachthemysteryofgodfromthattradition.

Spirituality helps with mental health, knownspeciIicallyasspiritualhealth,helpspeoplefromdifferentreligions come together, is Ilexible to individualperceptions of the mystery of god(s), and Iills theemotional void that humans need to Iill in order to Iindpurpose in life andmeaning in existence (Baynes, 2019).Onecanfollowculturaltraditionsofthereligionheisbornto if he/she chooses to, as this is commonly a matter ofidentityformation.However,abigmistakewouldbetorelyonlyonreligiousbeliefsforpolicymaking,whichcouldleadtodisaster.Someexamplesarethepolicyissuesrelatedtotherighttohaveanabortion,marriageanddivorce,LGBTrights,andreligiousdiscrimination.

References Aslan, Reza. (2013). Zealot: The Life and Times of Jesus ofNazareth.RandomHouse.Aslan,Reza.(2017).God,ahumanhistory.RandomHouse.Baynes,Robert.(2019).SpiritualHealth:UnderstandingtheKeytoSpiritualGrowthandtheFunctionofReligion. TellwellTalent.Brabazon, James. (2000). Albert Schweitzer: A Biography (2ndedition).SyrcauseUniversityPress.KamaliDehghan,Saeed.(2014).Iranexecutesmanforheresy.TheGuardian. Sep 29. At: https://www.theguardian.com/world/2014/sep/29/iran-executes-man-heresy-mohsen-amir-aslaniLanier, Gregory R. (2016). “ItWasMade to Appear Like that toThem:" Islam's Denial of Jesus' CruciIixion". Reformed Faith &Practice:TheJournalofReformedTheologicalSeminary.Orlando,Florida:ReformedTheologicalSeminary.1(1):39-55.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 21 London,Emily&Siddiqi,Maggie.(2019).Religiouslibertyshoulddonoharm.CenterforAmericanProgress.April11,aturl:https://www.americanprogress.org/issues/religion/reports/2019/04/11/468041/religious-liberty-no-harm/Maleki, Ammar and Pooyan Tamimi Arab. 2020. Iranians’attitudes toward religion: A 2020 survey report. Publishedonline, gamaan.org: GAMAAN. At: https://gamaan.org/wp-content/uploads/2020/09/ GAMAAN-Iran-Rel ig ion-Survey-2020-English.pdfRoose, Josh. (2020). Trump still enjoys huge support amongevangelical voters — and it’s not only because of abortion.October 30, at url: https://theconversation.com/trump-still-enjoys-huge-support-among-evangelical-voters-and-its-not-only-because-of-abortion-148174Schweitzer, Albert. (1936). The Ethic of Reverence for Life.ExcerptedfromCivilizationandEthics(PartIIofthePhilosophyof Civilization), translated by John Naish. Available at URL:h t t p : / /www. a n ima l - r i g h t s - l i b r a r y. c om/ t e x t s - c /schweitzer01.pdf

Bibliography Armstrong, Karen. (2004). A Short History of Myth. CanongateBooks.Armstrong,Karen.(2011).AHistoryofGod:The4,000-YearQuestofJudaism,ChristianityandIslam.BallantineBooks.Ehrman, Bart. (2009). Jesus, Interrupted: Revealing the HiddenContradictions in the Bible (And Why We Don't Know AboutThem).HarperOne.Ehrman, Bart. (2016). Jesus Before the Gospels: How the EarliestChristians Remembered, Changed, and Invented Their Stories oftheSavior.HarperOne.Spong, JohnShelby. (2009).ANewChristianity foraNewWorld:WhyTraditionalFaithisDying&HowaNewFaithisBeingBorn.HarperOne.Spong, John Shelby. (2011). Re-Claiming the Bible for a Non-ReligiousWorld.HarperOne.

Spiritual healthcare and mental health issues during the COVID 19 pandemic

-Dr.DhastagirSultanSheriff,FacultyofMedicine,BenghaziUniversity,Benghazi,LibyaEmail:drdsheriff@gmail.com

The coronavirus disease 2019 (COVID-19) pandemic isstressful for people. Fear and anxiety of getting infected,social distancing and stigma due to infection during theCOVID-19 pandemic can all lead to mental health issuesthat warrant speciIic coping measures, resources andcounter methods. The COVID-19 infection is associatedwithdelirium/encephalopathy,agitation,stroke,insomnia,loss of sense of taste and smell, anxiety and depression(Benjaminetal.,2020;Lingetal.,2020).

Anxietyisageneralizedresponsetoanunknownthreator internal conIlict, whereas fear is focused on a knownexternal danger. Emotions are deIined as “passions of a

short duration.” Emotions are intimately linked withorganic life that may lead to “abnormal excitation of thenervous network,” inducing changes in heart rate andsecretions, or interrupt “thenormal relationshipbetweentheperipheralnervoussystemand thebrain.”The fearofgettinginfectedorbeinginfectedalongwiththeanxietyofuncertainty due to lack of speciIic therapy for COVID-19remains a risk factor for mental health issues. Thesementalhealthissuesrequirespecializedbutholisticcare.

Palliative care is specialized medical care focused onprovidingrelieffromthesymptomsandstressofterminalillness. The goal is to improve quality of life for both thepatient and the family. Palliative care is provided by aspecially trained team of doctors, nurses and otherspecialists who work together with a patient’s otherdoctorstoprovideanextralayerofsupport.Palliativecareis based on the needs of the patient, not on the patient’sprognosis.Itisappropriateatanyageandatanystageinaserious illness,and itcanbeprovidedalongwithcurativetreatment.

Duringsuchanxiousmomentsofthediseasemanyseekspiritualguidanceandhealing.Itissaidthat“spiritualityisuniversal, deeply personal and individual; it goes beyondformal notions of ritual or religious practice to encompasstheuniquecapacityofeach individual. It isat thecoreandessence of who we are, that spark which permeates theentire fabric of the person and demands that we are allworthy of dignity and respect. It transcends intellectualcapability, elevating the status of all of humanity.” (McSherryandSmith,2012)

AccordingtoFlorenceNightingale'sphilosophyofcare,spirituality is inherent in humans and is the deepest andstrongestsourceofhealing.Thenursingcommunityneedstolearnmoreaboutspiritualneedsofthepatientsaswellas receive training on how to impart spiritual therapy tothewillingbutneedypatients.

An observational study of nurses regarding spiritualdimensions of nursing care reported that 84% of nursesidentiIiedpatientswithspiritualneeds,buyonly40%feltthattheywereabletomeettheirpatients’spiritualneeds.54% of the qualiIied nurses stated that they had notreceived any instruction into the spiritual dimension and73% felt that they did not receive sufIicient training intothisaspectofcare(vanMeursetal.,2018).

Thespiritualdimensionofhumanpersonalityiscloselylinked to one’s religious beliefs. It is stated that: “Thespiritualdimensiontriestobeinharmonywiththeuniverse,and strives for answers about the inSinite, and comes intofocuswhenthepersonfacesemotionalstress,physicalillness,ordeath.”(Murray&Zenter,1979).Religionisanorganizedand public belief system of worship and practices thatgenerally has a focus on a god or supernatural power. Itgenerallyoffersanarrangementofsymbolsandritualsthataremeaningfulandunderstoodbyitsfollowers.Themajorreligions practiced in India are Hinduism, Islam,Christianity, Sikhism,Buddhismand Jainism.Religionandspirituality are not the same thing, nor are they entirelydistinct from one another. Spirituality may incorporate

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)22certain elements of religion as it is generally a broaderconcept.

The practice of being compassionate and practicingcompassionate presence, i.e., being fully present andattentivetopatientsandbeingsupportivetotheminalloftheirsuffering includingphysical,emotional,andspiritualareways to improvethemindsetofaffectedpatients.Thevarious aspects of spiritual care include: “Listening topatients'fears,hopes,pain,anddream,obtainingaspiritualhistory, being attentive to all dimensions of patients andtheirfamilies:body,mind,andspirit,incorporatingspiritualpractices as appropriate, involving Spiritual Counselor asmembers of the interdisciplinary health care team”(MacLeanetal.,2003;Selbyetal.,2017).

The basic spiritual needs of a person could include ameaningful philosophy of life (values, love, peace,positivity,acceptance),comfort,forgiveness,hope,etc.andmoralsense),asenseof the transcendent(outsideofself,viewofGodandsomethingbeyond the immediate life), atrusting relationship with God (faith), a relatedness tonature and people (friendship), experiencing love andforgiveness and a sense of lifemeaning. The personmaynot verbalize their spiritual pain, so it’s important to beawareoftheirbehaviorandactionstoo.Forexample,theymay seemafraidofbeingaloneor refusehelpwhen theyappear to need it. Some of the methods for obtainingspiritualhistoryare:

1. FICAmodel talks about faith andbelief, importanceof faithorbelief inone’s life,supportsystemsintheformof communities (churches, temple,mosqueor likemindedpeople), and how to address these issues in a patient’shealthcare.

2. HOPE questions are used by physicians for formalspiritualassessments.HofthemnemonicHOPEreferstoapatient'sbasicspiritualresources,suchassourcesofhope,withoutimmediatelyfocusingonreligionorspirituality.Itleads to meaningful dialogues with a variety of patientswhose spirituality lies outside the tenets of religion orwithinthereligion(Anandarajah&Hight,2001).3. SPIRITmodel provides a framework for recording thespiritualinsightsofapatientorapathtoassessspirituality(Maugan(1997):

4.FACT:TheFACTtoolhelpstotakespiritualhistoriesin a clinical setting. It is said that a spiritual history tooldepends upon Iive criteria: brevity, memorability,appropriateness,patient-centeredness,andcredibility.Thechaplain-developed FACT stands for: F-Faith (and/orBelief);A-Active(and/orAvailable,Accessible,Applicable);C-Coping (and/or Comfort)/ConIlict (and/or Concern);andT-Treatment(Larocca-Pitts,2008).

S—Spiritualb e l i e fsystem

DoyouhaveaformalreligiousafIiliation?Canyoudescribethis?Doyouhaveaspiritual lifethatisimportanttoyou?Whatisyourclearestsenseofthemeaningofyourlifeatthistime?

P—Personalspirituality

Describe the beliefs and practices of yourreligion that you personally accept. Describethose beliefs and practices that you do notaccept or follow. In what ways is yourspirituality/religionmeaningful foryou?Howis your spirituality/religion important to youindailylife?

I —Integrationw i t h as p i r i t u a lcommunity

Do you belong to any religious or spiritualgroups or communities? How do youparticipateinthisgroup/community?Whatisyour role?What importance does this grouphave for you? In what ways is this group asource of support for you? What types ofsupport and help does or could this groupprovideforyouindealingwithhealthissues?

R —Ri tua l i z edp r a c t i c e sa n drestrictions

What speciIic practices do you carry out aspart of your religious and spiritual life (e.g.prayer, meditation, services, etc.) Whatlifestyleactivitiesorpracticesdoyourreligionencourage discourage or forbid? Whatmeaning do these practices and restrictionshave for you? To what extent have youfollowedtheseguidelines?

I —Implicationsfor medicalcare

Are there speciIic elements of medical carethat your religion discourages or forbids? Towhat extent have you followed theseguidelines? What aspects of your religion/spiritualitywouldyouliketokeepinmindasIc a re f o r you ? Wha t know l edge o runderstanding would strengthen ourrelationship as physician and patient? Aretherebarrierstoourrelationshipbaseduponreligiousorspiritualissues?Wouldyouliketodiscuss religious or spiritual implications ofhealthcare?

T—Terminale v e n t splanning

Are there particular aspects of medical carethat you wish to forgo or have withheldbecause of your religion/spirituality? Aretherereligiousorspiritualpracticesorritualsthat you would like to have available in thehospital or at home? Are there religious orspiritualpracticesthatyouwishtoplanforatthe time of death, or following death? Fromwhatsourcesdoyoudrawstrengthinordertocopewiththisillness?Forwhatinyourlifedoyou still feel gratitude even though ill?Whenyou are afraid or in pain, how do you Iindcomfort? As we plan for your medical carenear the end of life, in what ways will yourreligion and spirituality inIluence yourdecisions?

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 23 Questionnaire to take spiritual case history of apatient:

Some of the methods suggested for spiritual careinclude meditation, peaceful prayer practices, supportgroups and reading scriptures. Meditation is acontemplativepractice,engagedinacrossvariousreligiousand spiritual traditions as a means of quieting, focusingand transforming the mind. Meditation cultivates self-awareness and provides the optimum conditions forpracticing the skill of mindfulness. Generally, the goal ofmeditationistointensifypersonalandspiritualgrowth,inadditiontocalmingthemindandbody.

Of the different types of meditation, mindfulnessmeditation has been shown helpful for people withdepressionandanxiety,cancer, Iibromyalgia,chronicpain,rheumatoid arthritis, type 2 diabetes, chronic fatiguesyndrome,andcardiovasculardisease.

Prayermay elicit the relaxation response, along withfeelings of hope, gratitude, and compassion—all ofwhichhave a positive effect on overall wellbeing. There areseveral types of prayer, many of which are rooted in thebelief that there is a higherpower that has some level ofinIluenceoveryour life.ThisbeliefcanprovideasenseofcomfortandsupportindifIicultbelieve.

Yoga is a centuries-old spiritual practice that aims tocreate a sense of union within the practitioner throughphysical postures, ethical behaviors, and breatheexpansion.Thesystematicpracticeofyogahasbeenfoundto reduce inIlammation and stress, decrease depressionandanxiety,lowerbloodpressure,andincreasefeelingsofwellbeing.

Barrierstoprovidingspiritualneeds1. ThelackofUniversal languageofspiritualitymakesit

adifIicultconcepttodiscuss.2. Patient& familiesmaynotunderstand theconceptof

spiritualityorknowtohowtorespondtoquestionsofspirituality.

3. Nurses,Doctorsandotherstaffcaringforpatientmaynot feelcomfortableorcompetenttodiscussspiritualmatters.

ConclusionIfcareisshownwithcompassionandspiritualguidance,itmay prove helpful in tackling themental health issues ofpatients with COVID-19 infection, the physicians,associatedhealthprofessionalsalongwiththepublickeptunderlonglockdownperiod.

ReferencesAmbuel, B., Ed. 1999. Improving End-of-Life Care: A Resource

Guide for Physician Education, 2nd Edition. Milwaukee, WI:MedicalCollegeofWisconsin.

Anandarajah, G. and Ellen Hight. 2001. Spirituality andMedicalPractice: Using the HOPE Questions as a Practical Tool forSpiritualAssessment.AmFamPhysician.Jan1;63(1):81-89.

Benjamin L, Singh B, Lant S, Michael BD, Easton A et al. 2020.Neurological associations of COVID-19. Rapid review. LancetNeurol.;19(9):767–83. At https://www.thelancet.com/journals/laneur/article/PIIS1474-4422(20)30221-0/fulltext

SelbyD,DoriS,JimH,KristinK,MargaretF.(2017).Patientversushealthcareproviderperspectivesonspiritualityandspiritualcare:thepotentialtomissthemoment.AnnPalliatMed6(2):143-152.

GrifIith, JL, GrifIith,ME. 1997. Hope in suffering/pain in health:Talkingwithpatientsaboutspiritual issues.Presentedat the18th Forum for the Behavioral Sciences in FamilyMedicine,Chicago,Illinois.

Larocca-Pitts MA. 2008. FACT: taking a spiritual history in aclinical setting. J Health Care Chaplain.;15(1):1-12. doi:10.1080/08854720802698350.PMID:19424909

LiangL,RenH,CaoR,HuY,QinZ,LiCetal.2020.TheeffectofCOVID-19 on youth mental health. Psychiatr Q. (https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7173777/,accessed2October2020).

MacLeanCD,SusiB,PhiferN,etal.(2003).Patientpreferenceforphysiciandiscussionandpracticeof spirituality. JGen InternMed.18(1):38-43.

Maugans,TA.TheSpiritualHistory.1997.ArchFamMed,5:11-16.McSherry, W. Smith, J. (2012) Spiritual Care in McSherry, W.,

McSherry, R., Watson, R. (Eds) (2012) Care in NursingPrinciplesvaluesandskillsOxfordUniversityPress.

Murray, Ruth B & Zentner, J Proctor.1979. Nursing concepts forhealthpromotion(2ded).EnglewoodCliffs,N.JPrentice-Hal,

van Meurs, Jacqueline; Smeets, Wim; Vissers, Kris C.P., FIPP;Groot, Marieke; Engels, Yvonne. 2018. Nurses Exploring theSpirituality of Their Patients With Cancer, Cancer Nursing:7/841(4),E39-E45.doi:10.1097/NCC.0000000000000526

RELIGIOUSBACKGROUNDANDBELIEFSWhat religion did your family practice when you weregrowing up?How religiouswere your parents?Do youpracticeareligioncurrently?DoyoubelieveinGodorahigher power? What have been important experiencesandthoughtsaboutGod/higherPower?HowwouldyoudescribeGod/higherPower?

SPIRITUALMEANINGANDVALUESDo you follow any spiritual path or practice (e.g.,meditation, yoga, chanting)? What signiIicant spiritualexperiences have you had (e.g., mystical experience,near-deathexperience,drug-induceddreams)?

PRAYEREXPERIENCESDo you pray?When? In what way(s)? How has prayerworkedinyourlife?

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)24

Healthy lifestyle is the key for a healthy society

-RogelioP.Bayod,PhDroger.bayod@gmail.com-DarwinArnosadarwinarnosa@gmail.comCorJesuCollege,thePhilippines

AbstractHealthycitizensareimportantforahealthysociety.Whenpeople are healthy, they can not only enhance theircapability to Iight different virus outbreaks but alsoparticipateinthebuildingofbetterandhealthiersocieties.However,differentformsofsicknessasaresultofpeople’slifestyle are appearing in many countries. Ironically, in adevelopingcountrylikethePhilippines,policiesforhealth-enhancing activities have gained minimal support. Thispaper will argue that promoting a healthy lifestyle thatinvolves Iiveessentialelements– feet, fork, Iingers, sleep,andheart– isnecessary forahealthysociety.Thismeansthat peoplemust be physically active, eat pre-dominantlyplant-based food, avoid vices such as smoking and toomuch alcohol, get enough sleep, and establish deepconnectivity and reciprocity with their fellow humanbeings and the rest of creation as exempliIied by manyindigenous peoples. While some people choose to stayhealthy through their conscious choices, many carelesslybehaveunhealthily.Thisiswheregovernmentpoliciesandprograms for proactive health and wellness must becrafted and implemented. Instead of focusing much onprescriptive medicine, government should support thepromotionofhealthylifestyleasanimportantmodalitytoensurethatcitizensarehealthyandhaveastrongimmunesystem not only to Iight a pandemic but more so inpreparing them in their vital role to build better andhealthier families and communities necessary for amorereliableandhealthiersociety.

IntroductionPeoplearepredisposedtovariousdiseasesbasedontheirway of living and occupational habits (Sharma &Majumdar,2009).Thewayweliveourlivestodaymayleadtochronicdiseases,whichareproductsofhowwedesignour daily activities, from themovementswe do, the foodwe eat, and the quality of sleepwe take. Sickness due tounhealthy lifestyle results indeathsandadditionalhealthexpenditures. According to the World Economic ForumReport,60%ofalldeathsworldwidein2005(35million)resulted from noncommunicable diseases and accountedfor44%ofprematuredeaths.What'sworse, around80%ofthesedeathsoccurinlowandmiddle-incomecountrieslikeIndiawhicharealsocrippledbyanincreasingburdenof infectious diseases, poor maternal and perinatalconditions and nutritional deIiciencies (World EconomicForum, 2008). The report also points to countries likeBrazil, China,Russia and Indiawhich currently losemore

than 20 million productive life-years annually to chronicdiseases and the number is expected to growby 65%by2030 (WorldEconomicForum,2008). In2007,nearly3.1billion peoplewere economically active, and the Iigure isestimated to exceed 3.6 billion in 2020 (Sharma &Majumdar, 2009). Workplaces should make possiblehealthy food choices and encourage healthy lifestyle.Unhealthy diets and excessive energy intake, physicalinactivity and tobaccouse aremajor risk factors for non-communicable diseases, the report said (WorldEconomicForum,2008).Globally,lifestylediseasesleadtomortality.Almosttwo-

thirdsofthe57themilliondeathsin2008occurredinlowandmiddle-income countries (WHO, 2010). But the goodthing is, they are preventable, and can be lowered withchanges in diet, lifestyle, and environment (Sharma &Majumdar, 2009). Lifestyle diseases which are primarilycaused by bad habits of people as well as theirinappropriate relationship with other beings and withtheirenvironmentarerisingovertime.Whiletheonsetoflifestylediseasesisgradualandmaytakeyearstodevelop,once encountered do not lend themselves easily to cure(Sharma & Majumdar, 2009). Medicine for this chronicdisease would have been unnecessary if the lifestyle ofpeoplemeetsthehumanbody'sessentialneeds.Improvingour diet and lifestyle can prevent 80% of non-communicable diseases (heart disease, stroke, type2diabetes)and40%ofcancer(WHO,2019).Medicinescurediseases.However,shredsofevidenceon

the different adverse effect of drugs in our body haveswarmedhealth journals (Pijl&Meinders,1996;Keene&Davies, 1999; McGregor, Callaghan & Hunt, 2008).Seemingly,onemedicinecuresaspeciIicillnessbutcausesanotherailmentduetosideeffects.Medicinetreatsabodyin emergency cases. Pharmaceuticals may manufacturedrugs and convince the people that these are preventivemeasures to disease. Thus, the irony - medicine is notmeanttoprevent;itissupposedtocure.In recent years, the Philippines has experienced rapid

economic growth, but it has caused more damage to itspopulace than good. There may be an increase inpurchasing power formost people, but this consumptionhas not had a substantial impact on people's healthylifestyle. Vigorous economic activity certainly does notequate to quality of life. Most often than not, people arebuying because it offers convenience and instantgratiIication. One of the consequences of thisconsumeristic attitude of people is the proliferation ofdifferentlifestyledisorders.Thehealthcare systemof the countrywas testedas the

COVIDpandemicstruck.The"tipoftheiceberg"speaksofa fragile foundation.Thesystemworkstocure,butnot toprevent.HealthprogramandinitiativesoftheDepartmentof Health vaguely support the healthy lifestyle of thepeople.NoknownprogramfromthedepartmentexplicitlyhelpsFilipinosavoidnon-communicablediseases.What isstriking to know is that Non-Communicable Diseases(NCD)mostlyaffectpeopleintheirproductiveyears,from

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 25 45-60.What then is thegovernmentpriorityat this stageofdevelopment?Thispaperwillarguethatthereshouldbeashiftofparadigmonitspoliciesandprograms.The Philippine constitution provides for education of

everyFilipino.According to thisconstitution,education isfree for all regardless of economic, social status, religion,and ethnicity. Its fundamental objective is to provide aworkforcefornationaldevelopment,produceaprofessiontotaketheleadforthenation'sadvancementofknowledgeto improve the quality of life of Filipinos, establishing,maintaining, and supporting a wholly adequate andintegratedsystemofeducationrelevanttotheneedsofthepeopleandsociety.Everyindividualhastherighttoclaimthis from the government. There is no judgment on thegovernment.However, the failure of the state to actualizethis mandate is revealed in its failure to educateindividuals to become productive citizens and useknowledgetoacquireagoodqualityoflife.Thequalityoflifevariesfromindividualtoindividual.To

put this into context, quality of life in the 21st century ismostly dependent on the individual's health. “Health iswealth” is an adage, suggesting that the quality of life isbased on the health status. The health status of anindividualisanintegratedsystem.It’snotonlytheabsenceofdisease.Italsomeansenhancementofotherfactorssuchaspeace, freedomandcapabilities tobeable to face life’sdifferent challenges and take advantage from itsopportunities.The indicatorsof thequalityof life includenutrition, health, education, social, and leisure/recreation(Papageorgiou et al., 1970). These factors are highlyindividualized; this operates from the individual level. Ashuman beings, our freedom to choose for ourselves isinnateinus.OurabilitytoselectactionsusingthestimulusoutsideusisefIicient.Wemayhavethecapacity todecide,butourdecision is

also sometimes affected by how we interact with thenaturalandsocialenvironment.Thus,thispaperdiscusseshow individuals are sometimes reduced to just followinginstead of deciding. This attitude is detrimental to ourcapacitytobeatourbesthumanform,thatistodeterminedeliberately, especially when it comes to health andwellness.

HealthylifestyleasthemedicineA lifestyle of physical inactivity is frequently associatedwith chronic diseases. In sociology, the word lifestylereIlects an individual'sway of life, how he expresses andtranslateshisvalues,andforgesasenseofself.Alifestyleisformedbyagroupofpeopleorasocietywherepatternsofbehavior,inIluences,resourcespendingattitude,work,andactivity describe how they use their time and money.Therefore,lifestyleismainlydependentonthestructureofsociety(MoraRipoll,2012).

In the 20th century, humanity faced a signiIicantlifestyleshift.Oursocietyhassettledinthenestofcomfort.The industrial revolution was regarded as one of theconsiderableaccomplishmentsofhumans.Whileweenjoythis comfort, it subtly destroys our values and our

worldviewsabouttheinterrelatednessoflife–thatourlifeis a SONG: our relationshipwith Self, Others, Nature andGod. This concept of interconnectedness of differentmyriads of life forms was destroyed during the modernperiod. In the 21st century, the automation of almosteverythinghasdeclinedthenaturalnessoflife.Thelifestylethatwecreateleadsustoself-destruction.ForHuntington(1996),itiscultureratherthanwhatistruththatdictatespeople’s activities in the societies today. The capitalistculture that promotes endless consumption of goods,unlimitedentertainmentandtoomuchfocusonindividualachievements has destroyed not only our relationshipswithothers,natureandGodbutalsoourrelationshipwithself.Thishasresulted in theoccurrenceofmanydiseasesinhumanbeings.

TherisingcasesofchronicdiseasesaroundtheworldhavealsocreatedconcernsinthemedicalandalliedIields.Countless researcheswere done on how to combat thesediseases. They are creating formulation medicines toelevate the quality of life for those who are affected bythesediseases. Lifestylewaspointedout as the culprit ofthese diseases. Chronic disease is regarded as a lifestyledisease.

Lifestyle as a medicine is the idea that the way onelivescanpromoteinnerpeace,harmonyandwell-beingaswell aspreventionandcure tohealthproblems fearedbymost. The growing number of medical professionalsprescribing a lifestyle shift is remarkable. Doctors arestartingtorecommendalifestyleshift,startingonthefoodwe take, followed by physical movements, sleep andvarious relationships that we nurture. This shift ofparadigmgetsback tohoweach individual isempoweredtochoosealifestylethatismostfavorabletohimaswellastoothers.

Although lifestyle is affected by society and culture,humans have the freedom to design their lifestyle bybecoming informed and using this information for betterfood choices, activities, and rest. Living away of life thatrelies mostly on a plant-based diet, regular physicalmovement and good rest,managing stress efIiciently, andavoidingsubstancesthatalterthenaturalinteractionofthebodyaswellas livinginpeaceandharmonywiththerestofcreationmaybechallenging,butit isnotimpossible.Infact, many indigenous peoples who were considered bymodern people as primitive, have shown that they aremore advanced in terms of attitude and life values ascompared tomany “educated” persons.While the societymay judge them as lazy personswho are just content onwhat they have, Bayod (2018) argues that this is sobecause they are not so concerned with accumulatingwealth for the future. They generally live in the presentmoment. Since they are not capitalists but are“communists”byprincipleandbypractice(Bayod,2018),theyarenot intochasingwealth for theirownadvantage.Theyworktobeabletohelpthecommunity.Sincetheirlifeisintricatelyinterwoventotheirlandorancestraldomain,theynotonlydevelopa reciprocal relationshipwith theirland,butalsotreattheirlandasasacredbeing.Thus,they

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)26practice deep communion with their land. In addition,since they are livingwith trust to God’s providence, theyhave less stress in terms of exertingmore effort to chasewealth – an attitude that puts somuch stress to a lot ofpeopleintheurbancenters.

Inacountry likethePhilippines,aplant-baseddiet isstill possible, considering that it's anagricultural country.Thereisaclimatethatfavorsthegrowthoffoodthewholeyear-round.Regularphysicalactivityishighlylikelyforallwalksof life.A lifestyleshift ispossible foreveryFilipino.However, there is a prevailing mindset among manyFilipinosthateatingmeatisasymbolofhighsocialstatus.Driven by technological advances, many of the food theyconsume today is easy to grab food, energy-dense food,high in sugar or fat but low in nutrients. Many of thesefoods are available in almost every corner, convenient toget and commonly costing less. Hence consumersmindlessly bring this to their table. People also eatmorebut move less. The food environment takes a new formthese days. Food establishments that offer high sugarcontentaresprouting,andmanyyoungadults take itasahabit. For them, it's a fashion, a fad to get in regularly,affecting the lifestyle by promoting a high-calorie, low-nutrientdiet.

Highly effective advertisements on food and otherproductspromotetheseitemsanddeceiveconsumersfor-proIit purposes spreading in allmedia forms for all ages.Media exposure of the populace also has gone higher,especiallyinurbanareaswhereconnectiontotheinternetis faster andmore robust. This reality has continued fordecades,hencetheriseoflifestylediseases.

Ultimately, food consumption and movementengagement are highly dependent on individual choices.However, behavior changes occur only in a supportiveenvironment. In this time, affordable healthy food mustreplacefoodshelves ingrocerystoresandfoodstalls,andopportunitiesforregularphysicalactivitymustbecreatedororganizedformaximumparticipation.

SurveyofthelifestyleofFilipinocollegestudentsWeconductedasimpleon-linesurveytocollegestudents.Therewere250collegestudentswhoansweredthesimplesurveyquestionnaire.Theiranswersareshownbelow:

The results show that a lot of Filipino students are

livinganunhealthy lifestyle.Mostof themthink that theyare more stressed now with the “new normal” mode ofeducation.However,alotofthemstillhaveregularprayerandagood relationshipwith their families as a sourceofstrengthduringthispandemic.ThiswasalsoconIirmedinthe study of Arnado&Bayod (2020) on the help-seekingbehavior of young Filipino students. They found out thatspirituality and thepresenceof their familymembersarethemajor sources of strength of the students. Because ofthese, they become resilient in the midst of challengesbroughtaboutbytheCOVID-19pandemic.

But what is striking in the result is that many youngFilipino students are really living an unhealthy lifestylestarting from the food they eat, their lack of regularexerciseandtheactivitiestheyindulgein.WhatisaffectingFilipinos over living a healthy lifestyle is the policies andsupport of the government. As pointed out, lifestyle isaffected by the structure of society. People's activity andconsumption behavior can be inIluenced by policies orgovernance to support the lifestyle shift proposed in thispaper.

RoleofgovernmentinpromotionofhealthylifestyleThegovernmentmustconsidertheevidencethatahealthypopulace is an asset to progress and development. Aspointedoutearlier, lifestylechoicesare largelydependenton each person; however, the ecological frameworksuggests that there are multiple inIluences affectingindividuals' behavior, such as social circumstances, thesurrounding physical environment, and wider socio-polit ical forces (Biddle, 2015). This approachacknowledges that social and environmental factorsimpact individuals' behavior, especiallywhen informationin social media can travel in split-seconds around the

Questions&Responses(%) Yes No

Idoa30-minuteexercise (walking,jogging,cycling)everyday

12% 88%

I prefer to eat Iish and vegetablesrather than meat products likepork,beefandchicken

25% 75%

I do not usually eat junk andprocessedfoods

31% 69%

On the average, I sleep more thansixhourseverynight

31% 69%

Most often I am facing screen(computer,laptopsandcellphones)

96% 4%

Ihavemyregularprayerschedule 45% 55%

I have very good relationship withmyfamiliesandfriends

79% 21%

Ispendtimegoingoutinmyhousetoinhalefreshair

36% 64%

IthinkIammorestressednowthanbefore

46% 54%

Ismokecigarettes 16% 84%

Idrinkalcoholicdrinks 57% 43%

Ihaveenoughtimetorest 39% 61%

IbelieveIhaveahealthylifestyle 39% 61%

IbelieveIhavethepowertochangemycurrentlifestyle

74% 26%

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 27 world.GonearethedaysthatpeopleconIinedthemselvesintheir immediatenaturalhabitat.Theworldhasbecomea"smallvillage".Wearenotonly inIluencedasamemberofasmallcommunitybutalsoofthewholeworld.Withoutthe government supporting policies and innovations forthehealthandwellnessof thepeople, citizenswill followan unhealthy lifestyle. In terms of programs and policies,the government must promote and support healthylifestyleofitscitizensthroughthefollowing:1. Encouragetheuseofbicyclesforhealthycitizensandahealthyplanetbyconstructingbicyclelanes.

2. Require Local Government Units (LGU) to have “eco-parks” where people can have space for exercise,meditation, to breathe fresh air and to commune withothersandwithnature.

3. Encourage a vegetable diet by creating a system toensurethatvegetablesarefreefrompesticidesandotherchemicals. There are technologies that can detect thelevel of pesticides and formalin that are present in thevegetablesandeven Iish.Theycanusesuch technologyandmake itmandatory thatallvegetablesand Iish thatenterintothemarketwillbesubjectedtotesting.

4. Require work establishments to have health andwellness programs for their employees. Included in theprogram(amongothers)mustbebicycleparking spaceandshowerroomfortheemployeeswhousebicycles.

5. Allocate a budget for promotion of healthy lifestylerather than spending billions in buying syntheticmedicines from pharmaceutical companies. Only thosethatareveryimportantshouldbepurchased.The problem is that the government is reactionary or

reactive in itsprogramsandpoliciesespecially inmattersof people’s health and also public health. This is moremanifestduringtheCOVID-19pandemic.Thecountryhasnoexplicitprogramtoproactivelypromotethehealthandwell-beingofitscitizens.Thus,whenCOVID-19strikes,thecountryis facingdifIiculty intermsofensuringthehealthand wellness of its citizens. Instead, it spends billions tohelp thosewhohavebeencontaminatedby thevirusandto provide Iinancial support to thosewho are affected bythe imposed lockdowns. These expenses could have beenavoided if the government had a functional health andwellnessprogramtoensurehealthylifestyleofitscitizens.

PhysicalactivityenvironmentPhysical activity is a way for prevention of lifestylediseases. Systematic analysis has revealed its compellingeffectonthehumanbody.Theneighborhooddesignshouldfacilitate walking and bicycling for transportation. Publicparks,playgrounds,schoolvicinity,andrecreationcentersshould bewell designed to invite users. The governmentsectors,includingtransportation,cityplanning,andprivateenterprise must create an environment that promotesphysical activity as a consolidated effort of the healthsectors and all essential government units. Crafting oflegislationandordinancestocompelindividualstoadhereand develop their habit of physical activity follows theclaim that social, cultural, physical environment and

policies are essential factors inIluencing a person'sbehavior (Carlson, Dean & Sallis, 2017). Ordinances thatpromotephysicalexerciseofpeoplemustbeaccompaniedwithconcretesocialandinfrastructuresupports.

Moreover,interventionsintherisingnumberoflifestylediseasecasesshouldbedoneinmulti-levels.Forinstance,the transportationsectorcanhelp improvewalkwaysandroad intersections close to schools (environmental level),supportschooltransportsandrequirespeedlimits(sociallevel) and convey instruction projects to encouragewalking and bicycling to class (individual level). SchoolsandofIicesmustprovideparkingareasforbicyclesthataresafe and secure and o shower room for peoplewhomaywanttotakeabathbeforeattendingtotheirdailyworkinofIicesandschools.Avarietyofmeasuresareexpectedtoassesstheecological,social,andpersonalchangescreatedbythisintervention(González,Fuentes&Márquez,2017).

Theroleofthegovernmentisverycriticalindesigningphysical activity environment. Its features must hold thepromise of increasing physical activity. Governing bodiessuch as the Center for Disease Control, American HeartAssociation,World Health Organization all recommendedthese environmental changes to reduce the impact ofchronicdiseaseonsociety(Carlson,Dean&Sallis,2017).

RoleofschoolsinthepromotionofhealthylifestyleDespite the support of research proving the beneIits ofphysicalactivitytoschoolchildren,thePhilippineshasnotdone reforms to respondpositively to these Iindings.Theinability of educational leaders to prioritize changesfavoring the increase of children's physical activity isevident in multiple ways. One is the time allotment ofphysicaleducationinthecurriculum.Physicaleducationisa subject area wherein school children learn andexperience physical movement necessary for their fulldevelopment (Fairclough & Stratton, 2004). Aside fromother liberalarts subjects suchasphilosophy,psychology,humanities and religious studies, physical education is asubjectwhere studentsmust understand the unity of thebodyandmind.TheygainaheapofbeneIitsasidefromthefuntheyencounterintheclassbymoving.Thecurriculumfor physical education in the Philippine allots only 45-60minutes per week, instead of at least 240 per weekrecommended by the World Health Organization (WHO)andtheCenterforDiseaseandControl(CDC).

Next is training sufIicient number of teachers forphysical activity, especially grade schoolteachers, grades1-6.Thestageofdevelopmentwherethesechildrenbelongis crucial in attaining their maximum growth anddevelopment. Teachers' professional training to enhancethephysicalactivity levelofstudentshasnot increasedinnumberandsubstance(Figueroa,Lim&Lee,2016).

Anotherissueistheschoolculturethatprohibitsyoungchildren from physical activity. In many schools in thePhilippinestoday,teachersarediscouragedtoaskstudentsto help in the cleaning of the school surroundings. Mostoften,publicschoolsasktheparentstohelpinthe“BrigadaSkwela”,ayearlyprogramoftheDepartmentofEducation

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)28to clean and beautify schools for opening of classes.Throughouttheyear,theyhire janitorstodothecleaning.Whileyoungchildrenshouldfocusontheirstudies,givingthematleast30minutesinthemorningand30minutesinthe afternoon a chance to clean their room and beautifytheir school surroundings through gardening and treegrowing activitieswill not only provide opportunities forphysical activity and exercise but also an opportunity todevelop friendship and camaraderie among their fellowstudents. In addition, it will also help them becomeresponsiblecitizensandnatureloversinthefuture.

The next issue is insufIicient facilities and equipment.Almost all schools in the countryhave a standard facility,providingatleastagymnasiumtypeofbuilding.Somehaveasophisticateddesign,butmanyare justastandardopencourttypegymnasiumand,mostofthetime,arevenuesforotheractivitiesandschoolprograms.

These problems in schools need support from thegovernment and the constitution to take the lead for thenation's advancement of knowledge and improving thequality of life of Filipinos. Reforming the educationalsystem by providing quality physical education is vital insupport of healthy citizens in the country. The leadingexpert inobesityDr. JohnForeyt,stressedthatdevelopinghealthy lifestyle habits should start with the young topreventobesity.Thehabitofphysicalactivitybytheyoungcanstartinphysicaleducationclasses.

FoodchoicesA policy that addresses the environment that improvesfood choices is an effective preventive solution. In part, aperson'sfailuretochoosehealthyfoodandactivitycanbeblamed on the environment when it is not conducive tofood choices. The changes in this environment needpolicies and practices necessary for effective obesityprevention(Boothetal.,2001).Aroundtheshelves in thegrocerystores, theydisplayhighlyprocessed foodpackedwithenergyandpreservatives.75%ofthedisplaycontainshigh calorie but is low in nutrients. With its colorfulpackages and lowprices, they lure the costumers to grabandbringithome,someofthemareevenmindlessaboutthenutritionalvaluethesefoodscontain.

The role of the environment in promoting healthyeatingisessential;althoughfoodchoicesareprofoundlyanindividualmatter,thefacilitationofthesechoicesisgreatlyaffected by the environment. This is where policydeterminants of eating behavior can come in. There is agrowing literature on the inIluence over food choices byfamily peers, social networks, the physical environment,socioeconomicstatus,culturalnorms,andvaluesexaminedasdeterminantsoffoodchoices(Larson,2009).

Thedepartmentofhealthshouldgetaccess thesedatatorespondappropriatelytotheconcernoverfoodchoicesofFilipinos,especiallytheschoolchildren.Schoolchildrenare not capable of defending themselves from thepersuasionofadvertisementsandcheapfoodcommoditiesfrom grocery stores and convenience stores. Most oftenthan not, they choose food with the price as the Iirst

consideration; second is the convenience and third isnutritionalvalue.Thiswayofchoosing isan invertedwayof choosing. Food stalls along the school vicinity haveincreasedinnumber,displayinghighfatandsugarcontentfoods. While we encourage entrepreneurship from thepeople,thereshouldalsoberegulationsofthefoodchoicesthey offer to their consumers. The Ecological SystemsTheorypossessesastrongmodelforthisregulation.

HealthasconnectivitytothesourceI would like to advance our thesis that health is alsoenhanced when we are always connected to an ultimatesource. This is where, mediation, yoga, mindfulnessexercise and prayers, are important resources inestablishing inner peace and harmony, and therefore,healthandwell-beingofpeople.Butwiththeadvancementof secular culture, spiritual and religious aspects in thelives of people are put into the sideline. Instead ofconnectingtothesourcethroughmeditationandprayer,alot of people go to entertainment activities when theyexperience boredom, anxiety or problems. Instead oftalking to their families or spiritual directors or qualiIiedprofessionalsoreven trusted friends,manyof themgo tobars and parties to enjoy and drink hoping that theiranxiety will vanish. However, they forget that anxiety orproblemsarepartofbeinghuman.Infact,JoyceRuppsaysthat anxieties, problems and griefs arepart andparcel ofexistenceashumanbeings(Rupp,1988).Sincewearenotonlycomposedofbodybutalsospirit,ourIinalhomeisnothereonearthbussomewherebeyondthisphysicalreality(Bayod,2020).Thus, there is always somethingwithinusthat is yearning for something beyond our physicalrealities.Prayerasconnectivitytothesourcewillhelpustoachievepeaceandserenityinthetimeofdistress.

ConclusionHealth and economy have a vital relationship. The risingincidence of chronic disease places great pressure on thecountry'shealthcare system.Healthy lifestyleasmedicineneedstobepromotedbythegovernmentasaparadigm.Ifthis happens, there will be a trickle-down effect tocommunities, families and individuals. Investing in anenvironmentthatpromoteshealthasnotonlyanabsenceof disease but also enhancement of capabilities is timelyandrelevantduringthispandemicandaswemoveintotheso-called new normal. Today's generation should beprepared to thrive in a seemingly fast-paced world,sublimedinasedentarylifestyleofthepeople.Theimpactof health on the economy should not be underestimated.ThegovernmentmustprioritizehealthoverproIit(Frank,2004).

Healthy lifestyle as amedicine is amore cost-effectivestrategycomparedtothecurrentapproachesofpreventionand treatment. Practical application of lifestyle medicineenableshealthcareprofessionalstoshowtheirconcerntotheailingpopulation.Theywillbedirectedtowhatmattersmost in the healthcare system,which is health instead of

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 29 proIit. Notably, lifestyle medicine reduces total costs andincreasesthequalityoflife

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Overcoming death: the state of man in the midst of a pandemic

-ChristopherRyanMaboloc,PhDAteneodeDavaoUniversity,thePhilippinesVisitingProfessorforGlobalJustice,AUSNEmail:ryanmaboloc75@yahoo.com

AbstractThis paper is a philosophical inquiry about the state ofmanduringthepandemic.Byphilosophy,Imeanarationalinvestigationofprofoundandcriticalquestionsthatseekstoaddressfundamentalissuespertainingtothemeaningoflife.Thisstudyattemptstounderstandhowthesovereignruleof thestate iscontrollingthepopulation inthemidstof the coronavirus crisis. It argues that political power,through fear, has isolated human beings away from eachother in thenameofpublichealthprotocols. Statepowerplaysonthevulnerabilitiesofthepeopletotakeadvantageof the situation.Thestateapparatus isexercising full andunprecedenteddisciplinarymeasures as an extreme formof bio-power purportedly meant to mitigate the crisis.However, what is not seen is the reality that unjuststructures and the unequal situations of individuals inhumansocietyhaveresultedtomorehardshipsonthepartof thepoor, therebydiminishingtheirsenseofself-worth.The most profound question when it comes to thepandemic, thispaperargues, is existential – the realityofdeath.

ThewilltoliveInthemidstofdeath,thepoorhavenootherchoicebuttoaccept the possibility of losing everything. The reality oflivingduringthepandemic isdeIinedbyfear,control,andanxiety.Buttheabove-mentionedarenotalwaysborneoutoftheterribleconsequencesfromanaturaldisaster.MichelFoucault (2007) reminds us that “such a spectacle isinducedby thepowerof thestateapparatuswhopossessabsolutecontroloverthephysical,social,andeconomiclifeof thepopulation.”During thisCOVID-19pandemic,everyhumanbeing is forced to separatehimself fromothers inthe name of public health. It is an extreme form of bio-power, according toDanielMishori (2020),which reveals

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)30an“unprecedentedauthoritariancontrol.”Thepandemicistellingpeoplethathumanfreedomcannotbeabsolute.

The new normal seeks the re-organization of society.Butgoingback intoouroldwaysandpractices isnot justabout comfort or convenience. People also need tomakecruelchoices ifsocietymusterase inequalitiesandunjustpracticesthatunderminethedignityofthepowerless.Thepriority of rich countries is the re-establishment ofneoliberalpoliciesthatreinforcethesocio-economicdivideintheworld.Bigcorporationsaremoreconcernedaboutareturn to their rent-seeking ways and proIitmakingactivities. The Iinancial muscle of powerful companiesallows them to continue to make money while smallbusinesses fail. It short, only those who are in theperipheries of society are truly affected by the impact ofthecoronavirus.

Whatcanphilosophyteachusinthemidstofthislackofreasonability insociety?Howcanone truly live inapost-pandemicworld?Philosophyhassomethingtodowiththeway we put our experiences into question. It is not justaboutexplainingrealityandacceptingthingsforwhattheyare.Wisdom,Aristotle (1958) reminds us, has somethingtodowithpraxis.Philosophy,inthisway,seekstoaddresssomething that ismore fundamental.While thepandemichas put us in a position to see naked life as primordial,criticalreIlectionopensupthataspectofourlivesinwhichwe realize the need to put an end to our negativeprejudicesandultimately,dismantleunjuststructuresthatunderminethelivesofothers.

Hartsell et al. (2020) tells us that every philosophicalinquiry takes “a presumptive position and an optimisticsocial view aboutwhat political and social arrangementswillbecreatedduetotheCOVID-19pandemic.”Thisstudyisawareof thetendencyofphilosophytobeeccentric.Assuch, we must be wary of the “dominant discourses ofmorality, especially the kind of ethics that are associatedwith the Western and European modernity” (Mansueto,2020). Inthissense, itmattersto lookintotheconditionsonthegroundorperipheries.Theordinarymancantellusstories that reveal the state of being in themidst of thisemergency.

For example, the latest typhoon to hit the Philippines,Ulysses,hasworsenedthealreadydifIicultsituationoftheFilipino people due to the pandemic. But an issue hasemerged. Some non-government organizations (NGOs)have attempted to question the resilience of the Filipinopeople. By questioning the idea of resilience, some arm-chairanalysts forget that theyaremakinga frontalattackagainst the Filipino spirit of “bayanihan”, which can beloosely translated in English as a formof heroic deed forone’s fellowmen. It isa typeof solidarity inwhichpeopleseethemeaningandvalueofone’scommunity.

The ultimate concern of every man out there is hissurvival. Butwhat is themeaning of survival? Is survivalabout escaping from an imminent physical danger? Themeaningofsurvivalinthispublichealthemergencyisnotamatter that is purely biological or economic. Commonsensetellsusthatthereisanexistentialmeaningtoallour

problems.The“willtolive”isrootedinthewayweputrealmeaning into our lives and the courage to pursue thingsdespite all. Life canmeannothingwithout the courage tobe. Precisely, even in the midst of a great disaster, theability to overcome every hardship, including death,dependsonthehumanwill.

TheapparatusofpowerThe pandemic makes manifest the paralysis of humansociety. This paralysis is not natural but man-made.Globalizationisoneoftheculpritsastowhyweareinthissituation.(Tanabe,2020;Maboloc,2020;Sable,2020)Theworldisinterconnectedbywayoftradeandmigration.Yet,the real thread that holds everything together is thehegemonic political order in the world. Powerful andafIluent nations control international trade rules andpolicies.For this reason, thepoor in theDeepSouthhavenomeansbuttoliveinaccordancewiththeunjustrealitiesthattheyareforcedinto.Whatthisresultsinistherealityofpoverty,diseases,andviolence.

Global inequality has been exacerbated by thepandemic.While lockdowns have been imposed in NorthAmerica and Europe, at least the citizens of afIluentnations have received a considerable sum of money assubsidy from their governments. In contrast, the poor incountriessuchasthePhilippineshavetoendurelonglines,missing lists,andexposuretothevirus just toreceivethesmallsubsidythatthegovernmentdolesouttothepoororthose who have lost their jobs (Bayod, 2020). But thequestion of accountability when it comes to the terribleimpactof thepandemic shouldbeglobal in scope.Unjustglobal structures have contributed to the difIicult lives ofthepeople intheThirdWorldbefore,during,andevensoafterthispandemic.

AccordingtoThomasNagel(2005),“wedonotliveinajustworld.”Butwhile citizenship is thebasisof justice inthedomesticaffairsofeverystate, itshouldbenotedthatthegreatertragedyhappenselsewhere.Theconsequencesofpolicies like“AmericaFirst”showthatmigrantworkersare the least in terms of government priorities. It alsomeans that thepoor in theThirdWorldhave to continuelivingtheirmiserablelives.Whentheglobaleconomycameto a halt, the top 10% in the economic ladder have notbeen affected by the cataclysmic nature of the presentCOVID-19pandemic.

It is not nature but bio-politics that has separatedindividuals from each other. Local experiences have beenwell-documented (Tudy,2020).Strictmeasuresare Iirstlyinthenameofpublichealth,whichisthegoalofthestate.The rules imposedby the statearemeant tobe followed,like military orders. They come in the form of curfews,street lockdowns, and general restrictions to travel. Toensure that this strict discipline is observed, themilitarymightofthestateismadevisibletothepubliceye.Ardentpoliticalcriticsarecallingoutgovernmentsforstiffpoliciessince in democratic countries such as South Korea andJapan,thepeoplehavenotbeenstrippedoftheircapacitytomakeautonomousdecisions.

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

the state as an apparatus of power. For Foucault (1977),the spectacle has been transformed from the visibletorture of the human body to the invisible reality ofdiscipline in society. Institutions systematically take awayfrom thepeople their freedoms, reducinghumanpersonsinto docile bodies that are manipulated by the powerful.The state of emergency due to the coronavirus givespoliticianstheopportunitytotakeadvantageofthepublic.The fear and anxiety induced into the minds of peopleforce themtobelieve that thedifIicult sacriIices that theyhavetoendureeverydayareallworthit.TheabolitionofmanThe coronavirus pandemic abolished the human being.Manhasceasedtobecomeafellowtotheotherman.Theworst enemy in a disaster is hopelessness. Thishopelessness is exacerbated by the prejudice of peopleagainst each other. For Karl Gaspar (2020), what hashappened is that populist regimes have dictated howpeoplearesupposedtobehave.EchoingGiorgioAgamben,the eminent anthropologist from Mindanao thinks thatillegitimatepoliticalpowernowdisguisesitselfasaformofscientiIicexpertise.Gasparbelievesthatwhatishappeningis lockdowns serveas apretext for thewithdrawalof therightsofcitizens.

Surveillancedetermineshowpeopleinthesocietymustmove. Some rules hinder people from cooperating witheach other in a spontaneousway. Health experts preventpeoplefromseeingeachotherbecauseofthehealththreatbut bureaucrats often forget the fact that people actuallydrawstrengthfromeachother,notfromsomegovernmentruleorpolicy.Peoplewhoaresufferingduetothevirusaredyingwithoutevenseeingtheirfamily,deprivedofthecareandattentionfromthepresenceofone’s family,deniedofthe loveandattentionasone faces theultimate realityofdeath.RaymundoPavo(2020)exploresthispointwhenheasks: “is it possible for people to remain indifferent, oreventuallyslipintoindifference?”

What worries Gaspar (2020) is the lack of resistancefromthepeople.He isnotquestioning theroleofexpertsor the power of any government to manage the crisissituation that the population is into. Rather, he is simplymakingthatobservationastotheutterlackofvoiceofthepublic. It is not a political formof resistance but amoralone, grounded in the respect for the dignity of humanbeings. People have continued to go on with theirmonotonouslivesunderthethreatofmentalfatigueduetothe lack of meaningful activities. Millions of ordinarypeople are living in thedarkpit of life’s absurdity due totheuncertaintyofthetimes.

Governments are sometimes making the lives of thepeople more difIicult. Whole families are in a difIicultsituationwith the loss of a permanent source of income.The lack of safety nets is a result of government neglectand irresponsibility. The problem is the culture ofcorruption in some governments. What people complainabout when their movement is being restricted is not

something physical. It also has something to dowith thevalue of human freedom. Lockdowns imprison peopleinside their heads. Therein, it is no longer the virus thatthey will fear. They will fear losing the meaning of theirlives.

Human life cannot be reduced into a biological thing.Thebiggest threatout there is the lackofhopeofpeople.The pandemic, as an existential issue, puts to task themeaning of being human. People have nothing to dependon except the strength of their will. According to MartinHeidegger (1996), man’s being is a “being-in-the-world.”What this means is that the being of man is about hispower to be in the world (Dy 1986). This potential isrevealed in man as a being-towards-death. Man, in thisway,isan“unIinishedproject”(Sartre2007).Weareintheprocess of a constant unfolding. For Heidegger (1996),deathistheIinalityofthisunfolding.

ConclusionIn conclusion, the most important question about thepandemic is something that cannot be answered solelyfrom the perspective of the health expert. There is anexistential question that ultimately each person mustconfront himself if he wants to overcome these tryingtimes.Peoplehavetoappeal tophilosophicalreIlectiontoIindthelight.Overcomingdeath,inthisrespect,isamatterof putting meaning into our lives. People do not see thereality of dying. They will choose comfort over wisdom,money over peace of mind, and pleasure over realhappiness. They see human suffering or death assomethingthat is “notmine”(Dy1986).Butdeath,as thepandemicreveals,istheIinalityofhumanexistence.

ReferencesAristotle. 1958. Nichomachean Ethics. New York: Washington

SquarePress.Bayod,R.2020.“EthicsofCareandPhilippinePoliticsduringthe

COVID-19 Outbreak.” In Eubios Journal of Asian andInternationalBioethics,30(3):69-75.

Dy, M. 1986. Philosophy of the Human Person. Manila: GoodwillBookStore.

Foucault, M. 1977. Discipline and Punish. New York: VintageBooks.

Foucault, M. 2007. Security, Territory, Population. Translated byGrahamBurchell.London:PalgraveMacmillan.

Gaspar,K.2020.“ExtractiveIndustries.”InEthicsinContemporaryPhilippineSociety.EditedbyCRBMaboloc.DavaoCity:SMKCPublishing.

Hartsell, L. Krabbe, A. & Pastreich, E. 2020. “COVID-19, GlobalJustice,andaNewBiopoliticsof theAnthropocene”InSocialEthics Society Journal of Applied Philosophy. Volume 6 (2):1-31.

Heidegger, M. 1996. Being and Time. Translated by JoanStambaugh.NewYork:SUNYPress.

Maboloc,C.R..2020.“GlobalizationandConsumerCulture:SocialCostsandPoliticalImplicationsoftheCOVID-19Pandemic,”InEubios Journal of Asian and International Bioethics, 30 (3):77-80.

Mansueto,M. 2020. “Enrique Dussel’s Philosophy of Liberation:Philosophical ReIlections at the Time of the COVID-19

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)32Pandemic.” In Social Ethics Society Journal of AppliedPhilosophy,6(2):173-208.

Mishori,D.2020. “MedicalTechnocracy,ExtremeBio-power,andHuman Rights.” In Social Ethics Society Journal of AppliedPhilosophy,6(2):230-266.

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Pavo, R. 2020. “Camus’ The Plague and COVID-19: SomePhilosophical ReIlections.” In Social Ethics Society Journal ofAppliedPhilosophy,6(2):209-229.

Sable, S. 2020. “The Ethical Flaws of Globalization.” InEthics inContemporary Philippine Society. Edited by CRB Maboloc.DavaoCity:SMKCPublishing.

Sartre, J.P. 2007. Existentialism is a Humanism. New Haven,Connecticut:YaleUniversityPress.

Tanabe, J. 2020. “Exploring a Post-COVID-19 Sustainable PeaceModel.”InSocialEthicsSocietyJournalofAppliedPhilosophy,6(2):73-103.

Tudy, R. 2020. “The ethical dilemma among healthcareprofessionals in themidstofCOVID-19pandemic.” InEubiosJournalofAsianandInternationalBioethics,30(5):259-264.

A century with agony or death with comfort

-SamreenSiraj(Correspondingauthor)Email:samreen.verasiya@aku.edu-ZainishHajani(Email:zainish.hajani@aku.edu)-AfsheenHirani(Email:afsheen.hirani@aku.edu)-ShyroseSultan(Email:shyrose.sultan@aku.edu)-NasreenRaSiq(Email:nasreen.raIiq@aku.edu)-SalimaSiraj(Email:salima.siraj@aku.edu)AgakhanUniversityHospitalPakistan

AbstractTheelderlypopulationisincreasingworldwide.Autonomyisanabstractconceptandwhenitcomestotheautonomyofanelderlypatient, itbecomesmorecomplex.Moreover,there are some cultural traits in some communities thatinIluencetheprovisionofautonomyinolderpatients.ThesigniIicance of familial clout in decision making usuallyoverrides the geriatric person’s autonomy. Elderly peoplemostly prefer the quality of life (QOL) versus prolonginglife, so it is essential to give special consideration to theQOL rather than mortality. However, there are somesocioculturalfactorswhichcanobligehealthcareprovidersto give futile medical treatments despite knowing itsineffectiveness. As the medical technology advances, therank of old increases which leads to more intensecompetitionforscarceresources.Despitescantyresource,theusageofresourcesontheelderlycaninIluencethecareoftheothermembersofthepopulation.Financialscarcityin healthcare organization calls for setting limits onhealthcare resources and instituting priorities amonghealthcare services. However, the concept of age-basedrationingmaypromoteinequalitytowardsbasicgoodsandservices for the geriatric population. The followingstrategies: fostering patient empowerment, providing

patient care partnership, care counselling, cost-effectiveanalysis (CEA), advance directives, and raising awarenesscanhelp inpromotinghighqualityandethicalbasedcareinthegeriaticpopulation.IntroductionA99-year-oldfemalepatientwithalanguagebarriercamefromChitral;shewasabouttocompletethecenturyofherlife when diagnosed with a sarcoma in the right upperlimb. The family members admitted the patient to thehospitalwheretheonlyoptionwithsomehopeforsurvivalgiven by the doctors to the familywas amputation of theright arm. The family member didn’t tell the patient butconsented to this and asked the doctors to proceed. Armamputation was done. The patient was depressed whenshe discovered this and said that the suffering of cancertreatment was making her feel worse rather than thedisease itself. She got discharged and readmitted againafter one week with complaints of fever and purulentdischargefromthewound,wasdiagnosedwithsepsisandshifted to thespecial careunit.The familymemberaskedthehealthcareprovidertouseaggressivetreatmenttosavethe life of the patient despite the fact that she herselfcomplained of miserable existence and continuoussuffering.

Therewillbetwobillionpeopleagedsixtyandoverby2050, outofwhich75%will live in thedevelopingworld(Lunenfeld and Stratton, 2013). As medical technologyadvances, the rank of old increases, which makes thecompetition more intense for scarce resources. Thisscenario leads to so many questions that need to beanalyzedthroughthelensofethics.1. Do older patients have any right to choose their

treatmentoptions?2. Doesmedicalfutilityactuallyimpairpatient’squalityof

life?3. Whydiddoctorsgiveonlyoptionsthatareaggressivein

nature?4. In Pakistani culture can only children decide about

theirparents’healthinoldage?5. InattemptingtoprovidebeneIicence,towhatdegreeis

thefamilyviolatingtheelderly’srighttoautonomy?6. Towhatdegreeiscoercionpresentinthissituation?7. Iscoerciontowardstheelderlypopulationacceptable?8. Towhatextenttheharmimposedbysurgeryoutweighs

thebeneIit?9. Doesthepatient’sautonomydecreaseasageincreases?10. Ifresourcesarescarce,whichgroupofpeopleshouldbe

privileged?11. Ishealthcarearightoraprivilege?12.Shouldagebethecriteriaforrationingallocation?13.Doesrationingbyageviolatetheconceptofjustice?

This paper will reIlect on this scenario based ondifferentethicalprinciplesandtheories.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 33 Ourpositionversuscounter-argumentsAutonomyversusdeontology“I want to go when I want. It is tasteless to prolong lifeartiIicially.Ihavedonemyshare;itistimetogo.Iwanttogoelegantly”.(AlbertEinstein)

Forseveraldecades,respectforpersonalautonomyhasbeen a cornerstone in bioethics. The term autonomy iswidely used in the healthcare profession. It is actually averyabstractconceptandwhenitcomestotheautonomyofanelderlypatient,itsomewhatbecomesmorecomplex.Autonomy actually implies that every person irrespectiveof their age, gender, race, and colour has a right tomakedecisions about one’s life. There are some external andinternal factors that may desecrate the autonomy of thepatient; examples are age, gender, and culture. Olderpeople are mostly the victims of ageism. Due tostereotypical thinking, like less cognitive thinking andphysicaldeterioration,somanygeriatricpopulationshavetostrugglewithfamilymembersandhealthcareprovidersregarding theirautonomy inhealthcaredecisions. Indeed,older age may carry physical instability and cognitiveimpairment, but it is not the dependency, instability, andvulnerability that threaten the autonomy of an olderpatient, but the sociocultural context and institution thatrestrict their exercise of autonomy. The concept ofadaptationfromanindependentlifetodependenceismostchallenging for older people. Moreover, there are somecultural traits in some communities that inIluence theprovision of autonomy in older patients. Families play aprotuberant role in the life of geriatric populationparticularlyinAsianculturebecauseoftheconceptoftheextendedfamilysystem.ThesigniIicanceoffamilialcloutindecisionmakingusuallyoverridesthepatient’sautonomy.

The family'sdecision for theaggressive treatmentwasbased on the attachment with the person. Most of thefamily members think in term of beneIicence and do allpossible ways to keep that person alive. In Asian cultureandmostlyinIslamicperspectiveitisthedutyofthechildto take careof their parents in older age. Sometimes thisconcept of beneIicence overrides patient’s autonomy andcauses paternalism. Moreover, when an individual lackscapacity especially in the elderly and has no concept ofadvance directive, healthcare providers usually seek asubstituted judgment from the surrogate decisionmaker.Literature reveals that surrogate decisionmakers (familymembers)arethebesttounderstandanddecideregardingpatient treatment (Blackler, 2016). However, some otherstudiesdivulgethatsurrogatedecisionmakingisbasedonfalse assumptions regarding patient’s values.Moreover, itis challenging for thesurrogate tomake theirownbeliefsandinterestdistinctfromthoseofthepatient.

Qualityoflifeversusfutiletreatment“Ihatepersonswhowouldprolongtheirlivesperverting nature's course to keep off death” (Euripides,500 B.C.). The progress of current technologies andtreatment approaches has prolonged the life or thefunctioningof thephysical being, but it hasprovoked the

necessityofdealingwithsomeessentialethicalissues.Oneofthemajordilemmasinthisconceptis“whetherphysicalexistence is synonymous with living” (Burkhardt andNathaniel,2008,p.232).Qualityoflife(QOL)isasubjectiveand individual construct.Nobodycan judge thequalityofanother’s life based on their own values. Elderly peoplemostlypreferthequalityoflifeversusprolonginglife,soitisessentialtogivespecialconsiderationtotheQOLratherthanmortality.(Bornet,Truchard&Rochatetal.,2017).Inaddition, advancement in treatment approach has giventhe opportunity to sustain life but without meaningfulexistence in the geriatric population (Karnik & Kanekar,2016).Furthermore, futilemedical treatmentsareuselessas they produce no positive results, increase pain andsuffering,upsurgeIinancialburdenonthefamilyandlastlyprolong the process of death with suffering. Moreover,Hippocratic Oath proclaims to evade aggressively ornihilistically treating patients whose recovery isquestionable.

However, some school of thought believe that thephysicianisobligatedtoeludemaleIicenceandendeavourforbeneIicence;consequently,physicianauthorityismoreessential than thepatient'sautonomy.Nevertheless, somebelievethatprovidingfutilemedicaltreatmentinfringeonthe ethical principles of non-maleIicence. However, therearesocioculturalfactorswhichobligehealthcareprovidersto give futile medical treatments despite knowing itsineffectiveness.Duetosomereligiousandculturalbeliefs,most Asian families may request for continuity oftreatment, expecting a miracle from God. According toIslamicperspective,lifeisadivinemercyandhumanshavenorighttodecideaboutdeath.Moreover,familiesalsoareI i gh t ing w i th the i r consc ience and cons iderdiscontinuation of treatment as a sense of negligence fortheir loved one. Thus, a continuation of futile treatmentsometimes helps the families to cope effectively andprovideanopportunity tobewith their lovedoneduringthelasthours.

Nevertheless,sometimesfamiliesdooptforthesefutiletreatments because they consider “cure is equal to care”whichmeanstheythinkthatcessationoftreatmentcausessuspension of care. Therefore, the persistence on futiletreatmentisessentiallyarequestforgettingcare,notcure.(Aghabarary&Nayeri,2017)

Age-basedrationingversusfairopportunityrule“Whentheynolongercanservetheland,theyoughttoquitthis life, and clear theway for the youth” (Euripides, 500B.C.).Highermortalityratesincreasethelengthofstayandupsurgethecostofcareintheelderlyascomparedtotheyoung.Theelderlyconsumesa largenumberofresourcesdue to having the most complex illnesses. Allocation ofresourcesinadevelopingcountrylikePakistanisthemostchallenging task. Despite scanty resources, the usage ofresourcesontheelderlycaninIluencethecareoftheotherpopulation. Financial scarcity in healthcare organizationscalls for setting limits on healthcare resources andinstitutingprioritiesamonghealthcareservices.

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)34According to Beauchamp and Childress (2013),

distributive justice plays an essential role in countrieswhereresourcesarelimited.DistributivejusticeisdeIinedas the fair and equitable distribution of beneIits andburdensbecauseof inadequateresources; it is impossibleto divide the resources equally. Now the question arisesthatwhichpopulationgroupshouldbegivenapriority?Intheabovescenarioloadsofhumanandmaterialresourceswerespentwhichgavenothingbutadeathwithsufferingto a99-year-oldpatient.Age couldbeusedas a criterionfor rationing in prioritizing healthcare. On the basis ofquality-adjusted life years criteria, the young will farebetter than the older in allocation (Beauchamp andChildress, 2013). Besides, the utilitarian view also favorsthatthedistributionofhealthcareresourcesshouldbeinamanner that maximizes the overall beneIit. The socialutility of resources to the young population can bemaximizedbydenyingaccesstohealthcaretosomeofthevulnerable population, particularly the elderly. Daniels’prudential lifespan also argues that age rationing isjudicious and suggests that the unbiased person wouldchoose to shift resources that prolong the lives of theelderly to the treatment of the younger person(Beauchamp&Childress,2013;Brauer,2009).

The concept of age-based rationing perpetuates theconcept of injustice by stereotyping the elderly anddevalues the status of older people. The anti-ageismcounter-argueagainsttheuseofage-basedcriteriaforthedecisionoflife-prolongingtreatments.ThefairopportunityrulefromRawlsassertsthatindividualsshouldnotreceivebeneIits on the basis of unjustiIiable advantages anddisadvantages (Beauchamp and Childress, 2013). Thelotteries of biopsychosocial life donotprovide a Iloor formorally acceptable discrimination in resource allocation.Moreover, the egalitarian view also promotes the idea ofequaldistributionofresourcesasarighttohealthcare.

JustiEicationforourpositionsanditsconsequencesOur perspective is in favor of giving patient autonomy apriorityatallstagesoflife.Webelievethattheinvolvementof the patient in a treatment approach enhancesdetermination towards health-seeking behaviors.Moreover, in order to provide patient-centred care, it isessential to preserve the dignity of the person throughmaintaining autonomy. Besides, violating the autonomymay lead to forced choices that are inconsistent withpersonal wishes and cause depression as evident in ourcase. In addition, autonomy cherishes the sense ofindependence among the elderly which further improvestheir quality of life. Furthermore, promoting individualityincreases the chance of successful ageing. Likewise, theimpact of decrease in autonomy can cause increasevulnerabilityforfutilemedicaltreatment.

However, in order to provide equitable distribution ofresources,theprincipleofautonomyandjusticemaybeinconIlict in the case of the elderly. But spending adisproportionate amount of money at this age isimprudent. Rationing by age is a non-discriminating

strategyandmorallyacceptablebecauseeachpersonwillreceive some share at some point in time (everyone isyoung and later gets old). So, it is logical to spend theresources based on anticipatory life expectancy and toavoiddeliberateprolongationof life at all cost.Allocationof resources which are not cost-effective and producefewer beneIits in elderly would have been used in adifferent population. Saving the life of the young willprovide more quality-adjusted life years (QALYs) ascomparedtosavingthelifeofanolderperson.So,agecanbe used as a clinical indicator for making a decisionregarding aggressive treatment. Moreover, society alsobeneIits from the increase in economic productivity bhydiverting the healthcare resources from an elderly withcomplexillnessestotheyoungerpopulationwhocanworktoupliftthesociety.

Thenegativeconsequencesatourpositionwouldbethedenial or guilt of family members that they could havedone somethingdifferently.Moreover, the conceptof age-based rationing may promote inequality even towardsbasic goods and services. Furthermore, it may causepatient dumping and demarketing of services. It is thehospital practice of relocating or repudiating to treat apatientwhoisuninsured,impecuniousandundesirabletoadmit. Elderly would become more often the victim ofpatientdumping.Moreover,promotingqualityoflifemightignoretheinterestandclaimsoftheelderly.Furthermore,they will bemore victimized by ageism and will have tosacriIiceforthebeneIitofothers.

ConclusionandrecommendationsElderlypeoplearethemostvulnerablegroupofpeopleinterms of practicing autonomy. In eastern cultures, thefamily mostly overrides the autonomy of the elderlyperson. So, it is essential for the healthcare provider toadvocateonbehalfofthepatientespeciallynursesastheyarethefrontlineinprovidingcaretothepatient.Moreover,it is essential for the society to confront the issue ofhealthcarerationingespeciallywhenresourcesarelimited.Moreover,somestrategiesneedtobedevelopedinordertobalancetheneedofthechangingpopulation.Thefollowingrecommendationcanbeimplementedinordertopromoteapositivechangeateverylevel:

Fostering patient empowerment: It is an interactiveprocess between healthcare providers and the patient inorder to enhance his capacity for decision making.Healthcare providers especially nurses can advocate andthefamilyneedstoresignpowerandembracethepatientasanequivalentpartner.

Provide patient care partnership: The hospitalmanagementmay provide a brochurewhich includes therights of the patient and the things they could expectduring their hospital stay. This should be in differentlanguages.Thisalsoincludesinformationregardingpatientcareandtreatmentmodalities.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 35 Carecounselling:Theconceptofcarecounsellingshouldbe included in thehospitalpolicyespecially in thecareofthe geriatric population. This team should include thepatient, physician, geriatrics nurse’s practitioner, familyandthehospitalethicscommittee.

Cost-effective analysis (CEA): Cost-effective analysisshouldbedoneforrationingallocation.Inthis,therelativecost and the outcome (beneIit) of a different course ofactionneedtobeanalyzedeffectively.

Advance directives: The concept of advance directiveneeds to be introduced especially in the geriatricpopulation. The nurses need to explore patient personalvalues, understand their disease process and signiIicantcultural traits that can inIluence their decision-makingcapacity.

Raisingawareness:Moreover,asahealthcareprovider,itis essential to increase public awareness regarding theconceptofadvancedirectives,elderlyrightsandautonomythrough community education, research and througheducationofnursesandotherhealthcareproviders.

ReferencesAghabarary,M.,&Nayeri,N.D.(2017).Reasonsbehindproviding

futilemedicaltreatmentsinIran:Aqualitativestudy.NursingEthics,24(1),33-45.

Beauchamp, T., & Childress, J. (2013). Principles of BiomedicalEthics(10thed).NY:OxfordUniversityPress.

Blackler, L. (2016). Compromised autonomy: When familiespressurepatientstochangetheirwishes.JournalofHospice&PalliativeNursing,18(4),184-191.

Bornet,M.A.,Truchard,E.R.,Rochat,E.,Pasquier,J.,&Monod,S.(2017). Factors associated with quality of life in elderlyhospitalized patients undergoing post-acute rehabilitation: across-sectional analytical study in Switzerland. BMJOpen,7(10),e018600.

Brauer, S. (2009).Age rationingandprudential lifespanaccountin Norman Daniels’ Just health. Journal of MedicalEthics,35(1),27-31.https://en.ppt-online.org/105100

Burkhardt, M. A., & Nathaniel, A. (2008). Ethics and issues incontemporarynursing.(3rded).NelsonEducation.

Karnik,S.,&Kanekar,A.(2016,May).Ethical issuessurroundingend-of-life care: A narrative review. In Healthcare 4(2), 24.MultidisciplinaryDigitalPublishingInstitute.

Lunenfeld,B.,&Stratton,P. (2013).Theclinicalconsequencesofan ageing world and preventive strategies. Best Practice &ResearchClinicalObstetrics&Gynecology,27(5),643-659.

Transgender Realities in the Context of COVID-19 In Bangladesh

-NazneenAkhter,MBBS,MPH,DLSHTM,MScFellowUppsalaUniversity,Sweden,GoodenoughCollege,London,AsianHealthInstitute(AHI),Japan,.Founder & Managing Director, VAALO avant-garde Ltd,Bangladesh[https://vaalo-avgl.com/)Email:nazakhter705@gmail.com

Abstract“Transgender” is the historically adopted appellation as“hijra” in Bangladesh. From the ancient period till the1980s their identity remained a great questionmark andthey were a forgotten cohort of the society oftendiscriminated andmarginalized.Many years of dedicatedwork, researchandadvocacyefforts fromdifferent actorslikeNGO,CBOs,HumanRights&AdvocacyNetworks andothernationalandinternationalpublicandprivatesectorsactive engagement to Iight for the rights of transgenderultimatelybroughtsomechangesintheirsocietalandlegalidentity as humans. Government of Bangladesh allowedand approved the proposal from the Ministry of SocialWelfaretogivetransgenderasocialidentityandstatusquoas “Third Gender” in Government issued documents.However, when this COVID-19 global pandemic appearedin the country their existence became more challengingand vulnerable too. The livelihood of this community toearntheirlivingbecamemoredifIicult,thelockdownmadethemhomeboundwhichwas difIicult for them for longerwhen they are used to staying outside most of the timeeither on the streets or in the park, garden, market, orrailwayandbus station.Theywereunable to go for theirhealth care needs, testing and diagnosis of STI, otherdisease including COVID-19 which was supported earlierbytheNGOandcommunityorganizationwhoalsostoppedtheir Iieldwork activities during this high-risk lockdownperiod. It ishightimeto investigateandIindoutthefactsandIindingsofthetransgendercommunity torevealandadvocate for their access to humanely important basicneeds like health care and hygiene, testing facility, food,social safety net and other needs to be ensured andsecured during this essential social distancing andlockdownperiod, so that theydon’t become thevictimofthis COVID-19 exposure and vulnerability. There healthcare, hygiene, social safety are essentially and equallyimportant like all other citizens of society to keep themsafe, well-fed and infection free in this COVID-19distressingreality.KeyWords:Transgender,COVID-19,ThirdGender,Hygiene,Social safety,Socialamenities.Marginalized,Discriminated,Hijira.

IntroductionandBackgroundIn Bangladesh, “transgender” is the historically adoptedappellationas“hijra”whichisoftentranslatedtomeanthis

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)36transgender,which isbasically thepersonswhosegenderidentity and expression differ from their sex identity atbirth,thelexiconof“transgender”moreknownwordintheSouth Asian context for portraying the hijra community(bothmale& female).1,2 In thecountryaccording to theMinistryofSocialWelfare(MSW)ofIicialstatisticsaccountfor 10,000 transgender persons but the total numberexceeds half a million, and they were mostly a forgottencohortofcommunityintheearly1980s.Theirexistenceinthe society is always viewed upon, as if they are born tolive with an isolated communal existence under a guru(leadership) who tend to be always more connected,powerful,andstrongalsosettherulesforthatcommunityand encourage them to follow a kinship and hierarchicalexistence.3,4From an ancient legacy to follow through ages, the

transgender community is portrayed to play anentertainingroleeitheronthestreetinvariousform,oratthehousewhere anewbornbaby isblessedget snatchedby them from the mother’s lap to ask for money.Sometimestheyevengoforfurtheruncivilengagementfortheirearningandlivelihoodmanagementeitherbysellingsexorsnatchingthingsorbeggingonthestreet.

DiscussionAresearcherexplainedtoHumanRightsWatchthatsuchinteractionscanescalateifindividualsrefusetogivehijrasany money: Collecting money is not always a pleasantinteraction as it can become abusive. Hijras often useabusive words, or the colloquial to express anger andfrustration or the body language they use while askingmoney from people, the person gets easily offended orirritated and tend to avoid them and their presencenearby.5,6 Ditiya, a hijra in Dhaka, told Human RightsWatch: “The public thinks that hijras are awful. ‘The wayhijrasspeakisdisgusting.Theydon’tknowhowtobepolite.They’ll take off their clothes for no reason.’ How is this[perception]entirelymyfault?5,6Overtheyearscontinuedeffortsandadvocacyactionby

the national and international Transgender (TG)communityactorsnetworkandthedevelopmentagenciesand thehuman right groupwho are the spine to supportthe transgender self-help community and also graduallysucceeded to some extent in the solidarity claim on thevery realization of the rights and realities of thesemarginalizedcommunities.Inreality,thetransgenderareamarginalizedpeoplewho

are often discriminated and devoid of their basic socialamenitiesespeciallyhealth,housing,andeducationaswellas inareassuchasemploymentand immigrationbecauseoftheirtransgenderidentity.7,8,9,10Rupa,a34-year-oldhijraexpressed, “Once Iwent to the

doctorinthehospital,Isawpeoplehesitatetositneartome.Everyonewas staring atme. Iwas keptwaiting for a longtimetoseeadoctor.Alltheotherpeopleinthewaitingroomhadalreadybeenseen.Isthisnotdiscrimination?”11Kanta, a 42 year old Hijra who lives from the sex

business, said, 11“Inmy passport, bank account and voter

ID,everywhereIammentionedasawoman,sowhat is themeaningofrecognitiontome?However,IwillkeepSightingfortherightsofthehijracommunity.”Pinkya32yearoldHijrashared,“Iamgratefultoour

governmentformakingspaceforus.However,wehavealongjourneytogo.”11One big milestone was when the Government of

Bangladesh approved and allowed the proposal from theMinistry of Social Welfare to give transgender a socialidentityandstatusquoas “ThirdGender” ingovernment.documentsincludingpassport,nationalvoteridentity,landregistration document, and bank applications, includingother relevant ofIicial and legal identity as a citizen ofBangladesh.Also, theBangladeshi constitutionprovides aguarantee of equality before the law on the basis ofcitizenship,notonthebasisofsexualidentity.Pakhi,a38-year-old hijramentioned: Iwas so happy to hear abouttherecognition!Atleastnowwehaveanidentityinthissociety.Nevertheless, the situation remained the same.11,12,13,14Subsequently in 2014-15 budget the government also

expanded transgender relevant programs in 35 districtsand also created provision of employment for only 18persons.SomeNGOsandprivatesectororganizationsoffera non-discriminatory job, an offer like Ready Madegarments(RMG)industrybutherethemaincomplexityisthat they canwork at the garment factory but recruitersonly keep the option of male and female in their jobapplication offer, so if they join by hiding status, once itgetsdisclosedtheyarediscriminatedandquiteoftenhavetoquitthejob.11,12,13,14Alsothesejobopportunitiesseemvery nominal in comparison to a large number oftransgender people who still remain outside the formallaborsectorandtheytendtocontinuetheirsamepracticeof livelihoodmanagementaswas inthepast.Theearningknow-how and skillsets of the community is very limitedto, mostly selling sex, which even morally blamed andoftentheyareheavilydiscriminatedandstigmatizedinthesociety,thusliveinanunstableeconomicsituation.To state more loudly, in this 21st century modernized

world their fate is still entrapped into their ancestorsinherited basic unskillful engagement for instance on thestreet showbiz,sellingsex,andstealingnewborntoearnlives or entertaining people in any cultural occasion.Because of this they often become the victim of manyviolent activities by the people in public spaces, in thepolice station and inside theprison , sometimesby otheradministration,alsobyhooligan/gangster,orevenathomeby the family members too. These have become anacceptablepractice since thesocietyand the lawadoptedthis since this third gender the community does notcomplywiththeheteronormativestructureofBangladeshsociety4,7,8,9Pinky a leadership of Badhan Hijra Sangha (self-help

Group)statedinoneofthestudyinterview1“Sometimeswewant to visit a specialist because of a critical medicalsituation, but we cannot. We are often informed that thedoctorsarenotpresent.Therefore,weoftenhavenochoice

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 37 but to take careof ourmedical issues ourselves, even ifweareincriticalmedicalneed.”Tomeasure the economic impact of COVID-19 crisis on

the Third Gender community in Bangladesh, an impactstudywasdonebyInnovisionconsultingBangaldeshon51Transgender.82%oftherespondentsdidnotearnasinglepenny in the last two weeks and only 18% of therespondents earned an average amount of BDT 1,444 inthelast14days.7,9,15,A total of the respondentswho used to sendmoney to

theirhomehavestoppedsendingmoneyduetothecrisis,59% of the respondents did not get any kind of supportduring the crisis period. 86.36%need to defer their loanpayment due to low income during the crisis period, 9%will borrowmoney to repay the loan, 5%will sell theirassetstopaybackloans.7,9,15Among the total of 51 persons, 41% respondents

receivedsupportduring the last twoweeksofanaverageamountofBDT940fromtheGovernmentandfromprivateindividualand initiatives.Among them,81%donot thinkthe support will continue. Respondents are counting onreliefsfortheupcomingdays.Somewilltrytolookforjobsandsomewillstartbegging,Alloftherespondentswantedfood and monetary assistance for the remaining crisisperiod.7,9,15Duringthelockdownandsocialdistancingperiodallthe

transgenderpersonsurgentlyneedfood,cleaningsupplies,medicine, safe housing, and general economic support.Although Social distancing is one of the proven scientiIicoptions of preventing COVID-19 by stopping the rapidspread of COVID-19 but for many of the poor inBangladesh’s cities and towns, living and workingconditions make distancing impossible and the wordremains more as jargon to them rather a practice.BangladeshPrimeMinisterSheikhHasina inher31-pointdirectiveonBangladesh’sresponsetoCOVID-19,calledfor“special attention” and relief for “themost disadvantagedpeople”includingthehijracommunity.8,10,15.AlsoaccordingtotheUNHighCommissioneronHuman

Rightsstatement, lesbian,gay,bisexual, transandintersex(LGBTI)peoplemaybeparticularlyvulnerableduring theCOVID-19pandemic. It evenappearsmore severelywhenthe people have co-morbidity or compromised immunityespeciallythePeoplelivingwithHIV/AIDS,tuberculosisorany other communicable and non-communicable illnesslike diabetes, Blood Pressure or cardiac illness. In manyinstances the homeless people, the population thatincludes many LGTBI people, are less able to protectthemselves through physical distancing and safe hygienepractices,increasingtheirexposuretocontagion,accesstohealth services, de-prioritization of required healthservices, Stigmatization, discrimination, hate speech andattacks on the LGBTI community, domestic violence, andabuse,accesstoworkandlivelihood,arethemajor issuesto look into in this COVID-19 realities since manytransgender communities are of a great disadvantageoussituationwithCOVID-19.Lockdown,socialdistancingandalso with other prescriptive health and lifestyle

maintainingissueswherethesedaystheyhaveonasinglepennytoliveon,littlefoodtofeedthemselves,andevenasafespacetostaysafeandhealthy16,17Iwillhavetogotothestreetandstartbegging.Idon’tsee

anyotherway.-Lara(27);JatrabariWeareall lookingtowardstheGovernment.Howwillwe

survivewithoutanyrelief?-Ghuji(26);RayerBazar.11,15,Very recently, through the apex foundation MJF

( Manusher Jonno Foundation) the socially excluded andmarginalized community were supported by a cluster ofNGO and community organizations, namely: BangladeshYo u t h L e a d e r s h i p C e n t e r, L EDARS , B a n dhuSocialWelfareSociety, VAFWSD, BGS, ESDO, JSKS, BASA,Ghashful,IED,FIVDBandGUKwhohavedistributedsoaps,sanitizers, and masks disinfectants kits among 12000marginalized individuals including food support (rice,lentil,potatoesandoil)among 5328householdsofwhomtherewerea certainnumberof transgendercommunitieswhowerealsoinclusiveinthissupportlist.9,10,11,18

ConclusionsHere it very important and pertinent to pay attention onthese special community who are already positioned asmarginal ized and isolated due to st igma anddiscrimination, while this COVID-19 invaded the countrytheir existencebecamemore at stake and vulnerable too.Since thesepeoplecannotearn their livelihoodanymore,thelockdownmadethemhomeboundedsincetheycannotbeathomeforlongerrathertheyspendmostoftheirtimeoutsideeitheronthestreet,orinthepark,garden,market,or railway and bus station. Now in this homeboundenvironment which is much taxing for this communitysince they cannot go for their health care, testing, anddiagnosis of STI, other disease including COVID-19whilethey used to be supported earlier by the NGO andcommunity organization who are also remained stoppedfrom their Iieldwork activities during this lockdownperiod.It is high time to pay due attention to the government

development partners, and NGO, CBO and private sectoragenciesincludingHumanrightsactivistsandnetworkstothis special communityperson alongwith the otherpoorcommunity whom the Govt is already trying their besteffortstokeepthemsafe,well-fedandinfectionfreeinthisCOVID-19distressingreality.

References1. Kalra, G. & Shah, N. (2014). The Cultural, Psychiatric, andSexuality Aspects of Hijras inIndia, International Journal ofT r a n s g e n d e r i s m , 1 4 : 4 ,171-181,DOI:10.1080/15532739.2013.876378

2. Nanda, S. (1999). Neither Men nor Women: The Hijras ofIndia.London:Wadsworth

3. Khan, S. I., S. Islam, M. I. Hussain, S.Parveen, M. I. Bhuiyan,G.Gourab,G.F.Sarker,S.M.Arafat,andJ.Sikder.(2009).Livingonthe Extreme Margin: Social Exclusion of the TransgenderPopulation(Hijra)in

Bangladesh. Journal of Health, Population and Nutrition 27(4):441–451

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)384. Sharful Islam Khan, Mohammed Iftekher Hussain, ShailaParveen,et.alLivingon theExtremeMargin: SocialExclusionofthe Transgender Population (Hijra) in Bangladesh : J HEALTHPOPUL NUTR 2009 Aug;27(4):441-451ISSN 1606-0997 | $5.00+0.20

5. HumanRightsWatchInterviewwithexpert,[locationwithheld],April[datewithheld],2016.

6. Human Rights Watch interview with Ditiya, Dhaka, April 2,2015.

7. “IWanttoLiveWithMyHeadHeldHigh”AbusesinBangladesh’sLegal Recognition of Hijras HUMAN RIGHTS WATCH |DECEMBER2016:ISBN:978-1-6231-34341

8. Godwin, J. (2010). Legal environments, human rights and HIVresponsesamongmenwhohave sexwithmenand transgenderpeople in Asia and the PaciSic: An agenda for action.Bangkok:UnitedNationsDevelopmentProgramme.

9. Khan, S. I., et al. (2009). Living on theExtremeMargin: SocialExclusionof theTransgenderPopulation (Hijra) inBangladesh.Journal of Health, Population and Nutrition, 27(4), 441-451.www.ncbi.nlm.nih.gov/pmc/articles/PMC2928103/

10.Stenqvist, T. (2015). The social struggle of being HIJRA inBangladesh - cultural aspiration between inclusion andillegitimacy. https://dspace.mah.se/bitstream/ handle/2043/18568/Stenqvist-T-DP15%20Sinal.pdf?sequence=2

11.Abdul Aziz and Sameena Azhar, 2019 Social Exclusion andOfSicial Recognition of Hijra in Bangladesh Journal of ResearchonWomenandGender,Volume9,Pages3-19

12.Ahsan,F.,&AlAmin,Z. (2015,1September).Celebrationof thethird gender. Daily Star. www.thedailystar.net/op-ed/politics/celebration-the-third-gender-135667thirdgender

13..www.bandhu-bd.org/third-gender-is-not-a-word-it-is-a-gender14.THE “THIRD GENDER” IN BANGLADESH: Global InformationSocietyWatch2015, Sexual rightsand the internet,Associationfor Progressive Communications (APC)and Humanist InstituteforCooperationwithDevelopingCountries(Hivos)

15.KyleKnightMay2020SeniorResearcher,Lesbian,Gay,Bisexual,and Transgender Rights Program, Bangladesh Should SupportHijra,TransUnderCOVID-19,PublishedinTheAdvocatehttps://www.advocate .com/commentary/2020/5/07/most-vulnerable-people-world-right-now

16.TOPICS IN FOCUS COVID-19 AND THE HUMAN RIGHTS OFLGBTIPEOPLE17April2020,SeeopenletterbytheIndependentExpert on Sexual Orientation and Gender Identity: https://www.ohchr.org/en/issues/sexualorientationgender/pages/index.aspx

17.COVID-19:How to includemarginalizedand vulnerable peoplein risk communication and community engagement, SourcesIFRC OCHAWHO Posted 15 Mar 2020 Originally published 15Mar2020

18.MJF support to Transgender community , http://www.manusherjonno.org/latest_stories/caring-for-the-community-during-corona-crises/

COVID-19 pandemic and its impact on the socio-economic context of Bangladesh

-ShamimaAkterRozyDepartmentofHumanitiesandSocialScience,BangladeshUniversityofTextiles(BUTEX),Dhaka,BangladeshEmail:Shamimarozy737@gmail.com-MuhammadAli,M.S.S.Ex-studentofDepartmentofSociology,JagannathUniversity,Dhaka,BangladeshEmail:aliemonjnu8@gmail.com

AbstractThe COVID-19 pandemic is causing a variety of socio-economicchangesaroundtheworld.ThereisawidespreadoutbreakofcoronavirusinBangladesh.Duetothisterriblesituation,variouschangesaretakingplaceinthecontextofthepeopleofBangladesh.Inthispaper,thesocialchangescaused by coronavirus economically and socially such asfood habits, communication system, communicationrituals, online education activities, online shopping,unemployment, economical threat, and changes ofmarriagepatternhavebeenhighlighted.Thiscommentaryalso reveals the challenging issues of Bangladesh due toCOVID-19. This commentary reveals the context of howpolitical and social organizations have stood by thehelplesspeopleindealingwithcoronavirus.AttemptshavebeenmadetoIindoutthesocial impactandchallengesofCOVID-19 for the Rohingya refugees who came toBangladeshfromMyanmar.Aboveall,themaingoalofthiscommentary is to highlight the huge changes that havetakenplace in thesocioeconomicconditionofBangladeshduetotheCOVID-19pandemic.

IntroductionOnDecember31,2019,theIirstcoronavirusoutbreaktookplace in Wuhan, China. Maintaining a safe distance toprotectagainstcoronavirus infection,wearingmask,handwashing with soap and avoiding the touch of eyes, noseand mouth have been given more importance. It is alsoimportant to stay at home to prevent COVID-19 (WorldHealthOrganization,2020).Coronavirusoutbreaksusuallycause fever, cough, aches, and shortness of breath.Coronavirus also causes headache, chills, vomiting,diarrheaandnasalcongestion.

Schools, colleges, workplaces, public gathering havebeentemporarilyshutdowntoprotect fromtheoutbreakofCOID-19.Coronavirusinfectspeopleofallagesbutputsmore at risk especially those with heart disease, chronicdisease,canceranddiabetes(WSJ,2020).ItisverydifIicultto maintain social distancing for a densely populatedcountry like Bangladesh where most people use publictransport. Also due to Iinancial difIiculties, many peoplecan’taffordservicesofautorickshawandtaxi.Inaddition,manypeopleliveinslumsinextremelycloseproximity.So,the coronavirus is a big threat to them (Aljazeera, 2020).

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 39 Theoutbreakofcoronavirushascreatedapanicsituationamongpeopleandatthistimepeoplefrommanysectionsof the society are cooperating with foods, masks, handsanitizers,andsoaps.Itispossibletocontrolthespreadofcoronavirus through social distancing and quarantine.Nowadayspeopleareusingsocialmedia,electronicmediaandotherdigitaldevices to spreadvarious rumors in thesociety which later create various problems. For manyeconomicallyvulnerablepeopleinsociety,regularsoapuseand living in a separate room is actually much moredifIicult(DhakaTribune,2020).

The IirstCOVID-19 inBangladeshwas foundonMarch7.ButmanypeoplethinkthatBangladeshwasaffectedbycoronavirus longbefore this.With theoutbreakofcoronain April, 803 people tested positive and 39 people died.Bangladesh cancelled all Ilights byMarch 15with almostallcountriesexceptUnitedKingdom.Thegovernmentalsobanned all kinds of political, social, cultural, religiousrallies and gatherings. It was very difIicult to maintainsocial distancing in Bangladesh within the protocol,especially in the capital city of Dhaka where about 1.1millionslumdwellersareliving.Coronavirushascausedalotofstressandanxietyonpeople(Anwaretal,2020).ThecoronavirusisnotconIinedtoanyspeciIicborderandhasalready become a pandemic. Healthcare systems inmanydeveloped countries around the world are struggling tocontrolcoronavirus,soitisabigchallengeforBangladesh.HospitalsalsodonothaveenoughPPE.Doctorsandnursesalsodonothaveenoughtrainingtodealwiththevirus.

ThegovernmentofBangladeshstartedalockdownfrom27March2020tocontroltheoutbreakofcoronavirusandhasdoneutmostefforttokeepthepeopleathome.Insucha difIicult situation for Bangladesh, there aremanymoreunprecedented problems (Siddika & Islam, 2020). Themost vulnerablepeople inBangladeshhavehumanitarianneeds due to the coronavirus. Currently, business andeconomic activities are being managed through socialdistancing and public health guidelines. At present, thenew normal and the standard of life is actually possiblethrough maintaining health guidelines and socialdistancing.Depression,unemployment,joblessness,fallingof RMG export, remittances, socio-economic developmentprojects, insecurity,povertyandmanymoreareoccurringinsociety.(Shammietal,2020).

Impactsonthesocio-economiccontextofBangladeshTheimpactsoftheCOVID-19Coronavirusonvarioussocio-economiccontextsinBangladesharehighlightedbelow.

TheimpactonthetransportationsystemThetransportsectors inBangladesharelosingaroundTK5 billion (85Bangladeshi taka is about 1 $US) everydayduetotheimpactofcoronavirus.Thereareabout4millionvehiclesinthecountrysuchasbuses,trucks,coveredvans,pickupvans,threewheelersandeasybikesandtheyhave50 million associated workers (The Independent, 2020).Comparing coronavirus time with before, only 25% ofbuses are working on long routes and 50% in Dhaka.

People used long route transports only for emergencywork. In addition, public transport busesmay now carryonly50%ofthepassengersincompliancewiththehealthguidelines but for this the passengers have to pay a 60%higherfare(DhakaTribune,2020).About5millionpeopleinthetransportationsectorarefacingadifIicultlifeduetothe coronavirus pandemic. Those low-income people,especiallydrivers,helpers,workshopmechanicsaregoingthrough a miserable life because of the pandemic.Nevertheless, trucks, covered vans, emergency servicevehicles in the lockdown have been kept running (TheBusinessStandard,2020).

Impactonthemiddle-classsocialsystemEverysectionofthesocietyisfacingvariousproblemsdueto the coronavirus pandemic. The middle class ofBangladeshsocietyislivingalifeofhardshipwhichcanbecalledasa“noway-outsituation”.Manypeopledonothaveenoughmoneytodealwiththissituation,buttheyarenotable to talk about this difIicult reality. In addition, manypeople are getting half-salary due to the coronavirus,which is inadequate to manage their lives. On the otherhand, due to this difIicult reality, many of them have toreturn to their village from the capital city ofBangladesh(Bangladesh Post, 2020). Socially poor and migrantworkers bear the most brunt of coronavirus inducedlockdown;theyincludelowermiddleclasssuchasunpaidprivate school teachers, ofIice assistants, salesman,receptionists, data entry operator, beauticians, mobilephoneservicemen,repairshopswhohavingtogothroughthemostdifIiculttimes(TheAsianAge,2020).

ImpactonthemigrationsystemThere are about 10 million migrants in Bangladesh whoplay a role in about 7% of Bangladesh’s GDP. Due to theimpact of coronavirus, remittances from previous year inBangladesh have decreased by 25% (World EconomicForum,2020).About200,000workershavenotbeenabletojointheworkforceduetolackoflegalworkpermitsandnecessary documents since the global lockdown began.Duetosuchproblems,thepovertyrateinBangladeshmaybe 20.5% to 44% and 16-42million peoplemay becomepoor.TheBangladeshgovernmenthasdecided toprovidetwo million TK returns and 200 million TK in cashincentives for workers to get out of this situation. Inaddition, various organizations have provided supportsuchasTheUnitedNationsaccesstoinformationprogramservices inSaudiArabia “ProbashBondhu” throughwhichmedicine services were provided (UNDP, 2020). 60,000workers go to different countries for different jobs everymonth but due to the impact of coronavirus workers indifferent countries are losing their jobs and the numbermayincreasefurtherinthecomingdays(Rashid,2020).

ImpactongovernmentandsocialorganizationsSuccessfulmanagementdependsheavilyonpoliticalorderin any difIicult time in society. Also state capacity, socialtrust, and leadership play a big role. The government of

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)40Bangladeshhasalsomadeefforts tokeeppeopleathometo prevent coronavirus. Government also tried to keephospitals, kitchen, markets, drugstores and essentialservices open. On the other hand, it has shut downeducational institutions and made essential businessesonline to reduce the spread of the coronavirus andcancelled the public programs of Pohela Boisakh andoutdoor activities ofEid-Ul-Fitr (The Independent, 2020).Government and non-governmental organizations haveprovidedvariousformsofassistancetohelpthepoorandvulnerable people. But the roles of non-governmentalorganizationsneedtobefurtherenhanced(E-InternationalRelations,2020).

ImpactonthecommunicationsystemSincetheoutbreakofthecoronavirus,peoplehavebecomeincreasingly confused about some of the latest phrasessuch as stay at home, social distancing, quarantine, andlock-down. But the government and non-governmentalorganizations provide different types of information tohelpunderstandthesephrases.Lackofcommunicationhasoften led to complication in handwashing andmaskuse.There are different interpretations on different TVchannels.

ImpactontheruralsocialsystemThecoronavirushasalsohadamajor impactontheruraleducation system in Bangladesh. The rural educationsystemhashadtofacevariouschallengessuchasthelackof electricity and inadequacy of computers and smartphones (UCA news, 2020). In the case of the outbreak ofcoronavirus, thereisoftenanegativereactionintheruralsociety over maintaining the correct procedures of theWorld Health Organizations. Misinformation andunawareness have also created various problems in therural society for a long time (reliefweb, 2020). TheCOVID-19 pandemic has a huge impact on the incomeopportunities of rural society in Bangladesh. Unavailabletransportation system has caused huge losses in theagricultural sector.Thenegative impactof coronavirusontheagriculturalsectorhasreducedGDPfor14.10%.Otherprofessions in rural society have also seen a reduction ofabout65%.Toaddressthisproblem,workersandfarmersneed free food, medicine, cash grants, and low interestloans(LightCastlePartners,2020).

IncreasinginterestinbecominganonlineentrepreneurSmallbusinesseshave facedmultiplechallengesandrisksbecause of the Coronavirus pandemic. They struggle tomake ends meet. However, online small businesses haveserved as critical and recovery solutions (Youth BusinessInternational, 2020). The coronavirus outbreak posed aserious threat to small shops and factories (IkeaFoundation, 2020). On the other hand, COVID-19coronavirus can actually be called a blessing forentrepreneurs, because 85%of the commerce companiesthat closed startedworking online again. Fashion relatedproducts,medical equipment,masks, and hand sanitizers

have created a huge market (The Business Standard,2020).

ImpactontherisingunemploymentrateEverygroupofpeopleintheworldhassufferedphysicallyand mentally from the effects of coronavirus but thevulnerability in the life of the unemployed is extremelydeplorable.AccordingtotheILO,coronaviruscanwipeout7.20%ofworkinghoursor125millionfulltimeworkers.Ifsuch a situation continues for a long time, the economicsituationwill bemore deplorable (The Financial Express,2020). Along with the coronavirus, Iloods, landslides,monsoonrainhavecreatedmoreunemploymentproblemsinvulnerablecommunities.About72%ofthepeoplewereunemployedduetomovementrestrictionsandtheclosureoftheirworkplaces.Anotherreasonbehindtheoccurrenceofunemploymentis lackofseeds, fertilizers, Iloods,homeisolation, lack of resources, lack of knowledge andguidance (Concern world-wide, 2020). 20 million peopleworkingintheinformalsectorhavealreadylosttheirjobsduetocoronavirus.Thereareabout60.8millionpeopleintheformalandinformalsectorsand27millionpeopleareself-employed. Unemployment has also affected thereadymade garments sector. They have to depend onforeign buyers. The Bangladesh Garment Manufacturersand Exporters Association said on March 31 that 1048factories reported that 907.14 million PCS worth $2.87billion export was cancelled/ held up (E-Prothom Alo,2020).

ImpactonmentalhealthTo cope with the dreaded situation, people have to facevariousmentalchallenges.Infact,theviraloutbreakinthemediaandsocialmediahasinmanycasescreateddifferenttypesofsocialpanicamongpeople.Inquarantinethereareoften victims of self-harm and emotional outburst due tohelplessness,depression,andsleepingdisturbance.Togetrid of this situation, we need to have regular physicalexercise, healthynutritional foodsandmental strength. Itis better to avoid social media, limit browsing news andavoidunnecessarythinking(Hossainetal,2020).Currentlyourdailylives,relationships,workplace,andmentalillnesshaveahugeimpactonemotionalexhaustion,exacerbation,ofpre-existingcondition,poorsleep,lackofconcentration,etc.(reliefweb,2020).

ExpansionofonlinelearningactivitiesEducational institutions in Bangladesh have been shutdown since March 26 due to the rapid spread of thecoronavirus.So,manystudentsarestaying in theirnativetown/villageandvarioussurveyshavebeenconductedforonline teaching of the student at college and university.The surveyhas found that34%of studentswere in ruralareasand66%wereinurbanlocations.Ontheotherhand,these surveys found that 55.3% of students could accesslaptop, PC or tablet but 44.7% said they could not (TheBusiness Standard, 2020). Due to coronavirus, theeducationsysteminBangladeshisgoingthroughastrange

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 41 situation.Homeschoolingandonline learning lessonsarebeingorganized tohelp children control their risk in thisdifIicult situation. Institutions are creating studentassessmentthroughprevioustestscores,andassignments.Institutionsarealsotryingtoprovideproperguidelinestostudents using Google classrooms and Google meet (TheDailyStar,2020).

IncreasedinterestinonlineshoppingAsa resultof thecoronaviruspandemic,peoplearemoreinclined towards online shopping and all the maximumproducts of small fashion in Bangladesh are going online(UNB, 2020). But issues of low-quality products, delayed,complicated refunds and selling fake products areincreasing. Facebook is oftenused for these tasks (DhakaTribune, 2020). Facebook based shops are facing variousproblemsintheirproductcollectionbecausetheindustrieswereclosedforalongtime.Theyalsohavetofacepracticalconstraints like shipment suspension (The BusinessStandard,2020).

ImpactonfoodhabitsPeoplearestrugglingalottoadjusttothecurrentsituationbecause.Therestaurants,hotels,businesswereshattered.Human food purchasing habits suffer the fear of beinginfectedbythevirus.Foodavailabilityhasalsoundergonemajorchangesduringthistime(CGIAR,2020).InasurveyoftheCOVID-19pandemic18%ofurbanrespondentsand10% of rural respondents said no food was stocked. Inaddition, inthecurrentdifIicultsituation,theconditionofnutrition in the livesof adolescents canbeabigproblem(gain,2020).

IncreasingdomesticviolenceViolenceagainstwomenandchildrenincreasedduringthecoronaviruslockdowninBangladesh.Theseviolationsaredue to social activities and Iinancial pressures. At least4249 women and 456 children have been victims ofdomesticviolenceduringthisperiod.Inaddition,thelevelof violence is increasingdaybydaydue to theirhusbandbecomingmorefrustratedinthissituation.AsurveybytheManusherJonnoFoundationshowed848casesofphysical,2008 mental, and 85 sexual violence cases and 1308Iinancial restrictions. In addition, criminal activities likerape,kidnappingarehappeningatthistime(DW,2020).

ImpactsonearlymarriageandmarriagesystemThe coronavirus pandemic has caused a number ofchanges to the wedding ceremony and cancellation oflargescale ceremonies to prevent the transmission of thevirus.Theweddingsareheldinafamilyatmosphere(UNB,2020).Duetothereportofcoronavirus,catholicmarriagesin Bangladesh have dropped. While in average there are1700unionscelebratingmarriageonlocalchurcheseveryyear, 2020 has less than 200. Expenses have also beenreduced due to restriction on attending weddings(AsiaNews.it,2020).Ontheotherhand,manyparentsaretakingadvantageofthespreadofthevirustomarrytheir

daughtersatanearlyage.Theycaneasilydothiswithoutinforming anyone in the community. Besides, many aretryingtoreducetheirpovertybymarryingtheirdaughtersduring this difIicult situation (Dhaka Tribune, 2020). Astudyof theBRAC interviewed557people in11districts,72ofwhomsaid73childmarriageshappenedduringthecoronavirus pandemic. Plan International said about 40child marriages had already taken place in Kurigram(FinancialExpress,2020).

ImpactonRohingyarefugeesRohingya refugees from Myanmar started living inBangladesh since August 25, 2017. Currently 1.1 millionpeople are in needof humanitarian assistancedue to thecrisisof coronavirus in theRohingyarefugeecamps.FirstcasesofCOVID-19wereseenin19RohingyarefugeesandconIirmedand29casesof860,000refugees intheperiodof June became positive (World Vision, 2020). TheRohingyarefugeecamps inBangladesh,where1.1millionRohingyapeopleliveindenselypopulatedareas,aregoingthrough a much more vulnerable situation due to thecoronavirus. The lackof potablewater, runningwater fortoilets, lack of proper health treatment, lack of medicalfacilities, shortage of testing capacity, low informationsystem, crowded houses are the cause of vulnerablesituation(reliefweb,2020).

Among the Rohingya refugee camps in Bangladesh,variouspreparednessandresponsesissuehavebeentakenup forCOVID-19.Among the sectorsofpreparednessandresponses are the health sector,water, sanitation hygienesector, nutrition sector, food security sector, protectionsector, education sector, and logistics sector. 44,972washfacilities and public buildings were disinfected in thecamps. The government has also arranged isolation forsurveillancetestingandcasemanagementforCOVID-19inRohongya camps and has provided 21 Bangladesh CivilService doctors at Ramu and Chakaria upazilla healthcomplexes. Also working for the camps and hostcommunity are 289 staff and volunteers on mobilenutrition(ISCG,2020).

ThetrendofsocialrumorsandliesisontheriseMany people have already been arrested by the DigitalSecurity Act for spreading rumors about the coronaviruson social media and television channels (Human RightsWatch, 2020). In March, 79 people were arrested forspreading rumorson socialmedia inBangladesh.Also17people including Upazilla Chairman, UP member, districtcouncilmember,municipalcouncilorhavebeensuspendedfor not distributing governmental aid among the helplesspoorpeople(UNB,2020).

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

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)42many challenges to overcome these social changes. Sincesocietyischangingsofast,wecaneasilyseethesechangesduetocoronavirusandthestructureofoursociety.Duetoglobalization, urbanization and reIlexive modernization,various types of risks and uncertainties are increasing inthe society. So, developing countries should pay moreattention to these issues. The country’s disastermanagement needs to be more robust as well as raiseawareness about coronavirus among the people. Sincemost of the people in Bangladesh are still facing variousproblems, the government should take various steps topreventthecrisis.Also,everypersoninthesocietyshouldhelptoprevent itontheirowninitiativeactivities.Peoplemust take care of theirmental health, dealwith anarchicsituations, think positively, gather accurate information,and effectively counter various social rumors caused bycoronavirus. Since the coronavirus is already causingvarioussocialchanges in thesociety, it canbesaid that itcanbringaboutfurtherchangesinoursocio-economiclife.

AbbreviationGDP-GrossDomesticProductILO-InternationalLaborOrganizationPC-PersonalComputerPCS-PersonalCareServicesRMG-Ready-madeGarmentsTK-TakaUNDP-UnitedNationsDevelopmentProgrammeUP-UnionParishad

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Banking against all odds: concerns of government bank workers in the Philippines amid the COVID-19 crisis

-GerosonC.Reginio(Correspondingauthor)LandBankofthePhilippines,Philippinesgeroreginio@gmail.com-RandyA.TudyCorJesuCollege,Philippinesrandytudy@gmail.com-RexB.BuacCorJesuCollege,Philippinesrbbuac@gmail.com

AbstractThe COVID-19 crisis has been affecting workers from allwalks of life all over the world.While other governmentagencies in the Philippines made drastic changes in the

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)44delivery of services, the government-owned bankscontinued to provide needed services, for these are veryimportant for the people and the economy. However, thebankemployeesfacedmanyanxietiesandinconveniences,knowingthattheyhadtofaceclientsduringthepandemic.Thepurposeofthisphenomenologicalqualitativestudyisto understand the concerns of government bankemployees in their job as an essential workforce thatsafeguardsthepublic'sIinancialneedsamidtheCOVID-19crisis. It employed a descriptive phenomenologicalqualitativeresearchdesign.Tengovernmentbankworkers,seven regular and three contractual employees,participated in the semi-structured key informantinterview (KII). Results revealed two themes for theirstruggles:psychologicalpressuresandphysicalexhaustion.Asregards theircopingmechanisms, theyreliedonsocialsupport,prayer,andresiliency.Althoughbeingpublicbankservantscontinuedtobeachallengeduringthispandemic,the informants found ways to serve the clients andremainedcommittedtotheirbankingprofession.

IntroductionAlong with the adverse economic effects due to theCOVID-19 pandemic, government bank employees facemany difIiculties and challenges while still providinguninterrupted Iinancial services. Despite having anassurance of security of tenure in their jobs, manyemployeesfearthechillingconsequencesofbeinginfectedwithCOVID-19disease and can cause in their lives.As ofNovember 2020, the number of recorded positive casesalreadybreachedthe50millionmark.Withtheabsenceofa vaccine, this pandemic is causingmisery to all humans(Yamin, 2020), not counting the effect on the economyworldwide.Howmuchmoremaybeexpectedtothefront-liners?For example, healthcareprofessionals experiencedboth physical and psychological pressures. They had todealwith the fear of viral infection to oneself and family,increasedworkload, newwork arrangements, and caringfor patients and colleagues (Walton et al., 2020). In thePhilippines, somepeoplewere feeling fearfulandanxiousintheirdealingswithpeople,whichmadethem,especiallyhealth care professionals (HCP), hesitant to go to work(Tudy, 2020). Non-clinical professionals performingessential roles also experienced the same distress(Williamson&Greenberg,2020).Theincreasingreportsofpositive cases forced the government to limit economicactivities to essential ones, affectingmany Filipinos' lives(Nicomedes et al., 2020). Hence, the pandemic did notspareanyoneoranysectorwithitsdevastatingeffect.

As the employees and workers worldwide struggledwith the physical and psychological pressures, theysomehowdevelopedcopingmechanismsthathelpedthemsurviveduringtheCOVID-19crisis.For instance, frontlinestaff are advised to seek social support, and areencouragedtoaccessandseekCOVID-19informationfromveriIied and reliable sources only (Williamson &Greenberg, 2020). Some people who were exposed to amoral and traumatic event, aside from having a

psychological injury, somehowdevelop a degree of "post-traumaticgrowth(Greenbergetal.,2020).Severalstudieshavealreadybeenpublishedontheeffectsof COVID-19 pandemic, although the Iindings are stillsubjecttoin-depthanalysisandvalidationasthepandemicis still ongoing. However, very minimal literature lookedintothelivedexperiencesofthebankfront-liners.Actually,somepeopledonotconsiderbankemployeesasessentialfrontlineworkforcedespiterenderingservicesvital tothesustainabilityofthecountry'seconomy.Hence,thisstudy'sIindingscanprovideaglimpseofhowbankemployeesdealwith the difIiculty brought about by the pandemic.Moreover, the Iindings contribute to the literature as tohow bank employees deal with the challenges during apandemic.Tounderstandthegovernmentbankemployees’experiences in their job amid COVID-19 pandemic, wepresentaliteraturereviewfocusingonthephenomenon.

ThebankindustryThe Philippines recognizes the vital role of banks in itseconomy. Banks should be globally competitive, dynamic,and responsive to the demands of a developing economy(R.A. 8791, "The General Banking Law of 2000").Government bank employees have a commitment andpassionforservingeventhroughtoughtimesbecausetheyhaveasworndutytotheircountrymen.Asidefromhavinga legal decree, government banks also have a socialmandate to spur countryside development and alleviatepoverty.AccordingtoaPhilippinesgovernmentbank,theirvision is “to promote inclusive growth, especially in theunbankedandunderservedareas, through thedeliveryofinnovative Iinancial products and services powered bydigital banking platforms” (Land Bank of the PhilippinesofIicialwebsite,2020).

PsychologicalandphysicaleffectsofthepandemicMaintainingworkers' psychological andphysical health isan essential ingredient in winning the Iight against anypandemic. The quarantine, isolation, and other forms ofrestrictions imposed on individuals create a loss offreedom, boredom, stress, anger, and anxiety (Sharma, &Verma, 2020). Consequently, these psychological effectswillhavealong-termandnegativeimpactonanindividualif not appropriately addressed. A study conducted duringtheEbolaoutbreakshowedthatmentaldisorderssuchasstress, anxiety, andpost-traumatic stressdisorder (PTSD)couldoccurevenaftertheyearoftheoutbreak(Sharma&Verma, 2020). In the same study, lack of information andmisinformation can also cause further mental injury.Moreover, a pandemic's psychological effects includedepression, worry, anxiety, and poor quality of life(Restuboget al., 2020). Indeed, exposure to thevirus canalso lead to immense physical and psychologicalexhaustion(Nagesh&Chakraborty,2020).Thisonlyshowsthatthiskindofpandemicreallyaffectsaperson'sphysicalandmentalhealth,whetherduring,or/andafteradiseaseoutbreak.

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 45 Challenges of non-healthcare workers performingessentialrolesHealthcare professionals are not the only onesexperiencing vulnerability to the COVID-19 pandemic.Non-healthcare-relatedessentialworkershadalsofelt theeffectsofthiscrisiswhenrequiredtoperformtheirjobsina risky manner and dealt with it daily. For instance,employeesfeltahigherriskofviralinfectionduetoalackofresourcesandsupportandnoclearcompanypoliciesorguidelines,whichmade them feel that theywere ignoredby their employers (Williamson & Greenberg, 2020).Overcoming psychological pressures without socialsupportisnoteasywhensocialsupportstructuressuchaschurches,schools,andworkplaceshavebeenclosed(Jung&Jun,2020).AnotherchallengeforworkersworldwideisasigniIicantreductioninworkhours,lossofjobs,andotherrelatedeffects(Restubogetal.,2020).

Asidefromthestrugglesthatgovernmentbankworkersare experiencing in their regular and normal job routine,the effects of COVID-19 have added up to their existingluggage.Governmentbankworkersarealsosufferingfromanxietyandstressdue to the fastspreadof thevirus thatmakes their jobsevenmoredifIicult.Banksensured theiremployees and customers' safety by implementing socialdistancing measures, thereby limiting over the counterservices and shortening banking operating hours (Khoo,2020). This health safety protocol contributes to theburden of fears and anxieties that bank employeesexperience. In another study, working from home had adownward effect on employee performance and teamperformance(vanderLippeetal.,2020).Undeniably,thereare several areas to understand the potential adverseconsequences of this phenomenon. Government bankworkers face so many pressures, whether internal orexternal, particularly from fear of the virus and workproductivityandefIiciency.Thus, theCOVID-19pandemichinders banking employees' satisfactory performance(Sembiring et al., 2020). Another study conducted inNigeria showed that some economic agents declined towork for fear of acquiring the COVID-19 disease (Ozili,2020).Hence,thesituationofgovernmentbankemployeesisunderstandablyadifIicultone.

The concerns of non-healthcare-related essentialworkers amid COVID-19 pandemic should be discussedandaddressedbythegovernment.ThefocusshouldbetomitigatetheadverseimpactoftheCOVID-19pandemiconthevitalworkforce,likethebankemployees,becausetheyarecontinuouslyworkinghardandexposingthemselvestoalife-threateningrisktohelpstabilizetheeconomy.

MethodsResearchdesignInthisstudy,weemployedaqualitativephenomenologicaldesign. Phenomenology is about studying people's livedexperiences (Creswell, 2007), way of going deeper intotheir world. SpeciIically, we followed the descriptivephenomenological approach to understand governmentbank employees' lived experiences in their job amid the

COVID-19 pandemic. We dig into their struggles andstrategies.Ourgoalwas to seewho thegovernmentbankemployees are and how they live in the context of theCOVID-19pandemic. Listening to their stories allowedusto have a glimpse of how bank employees as essentialworkers went through their routine work amid thepandemic.

StudyparticipantsandsampleThe participants of the study were employees of agovernmentbank.Wesetupcriteriafortheparticipantssothat we can ensure that we could draw out the livedexperiences based on the objective of the study. Thecriteriaincludedthefollowing:(a)TheinformantsmustbeFilipinogovernmentbankemployeesoccupyingofIicerorrank-and-Iile position whether permanent or contractualemployment status; (b) They must be in the category of"in-active-duty,”meaningtheyarecurrentlyinservice,and(c)Theymusthavebeenwiththebankformorethanthreeyears.Welimitedtheinclusiontoaminimumof3yearsinservicebecause,belowthreeyearsinservice,governmentbank employees might not have adjusted well to theirsituation and might not have in-depth knowledge andcompetency in their job. In theend, tengovernmentbankemployees, composed of seven men and three women,were able to participate in the Key Informant Interviews(KII). The number was within the range suggested byMorse(1994).

Due to the nature of the study and the difIiculty ofgetting informants, we utilized purposive sampling. Thissampling technique enabled us to select the informantswhohadtheexperienceofthephenomenonandcouldgivecredible information (Creswell & Plano Clark, 2011). Weselected the informants who were government bankworkers andwork in the Davao Region and the NationalCapitalRegion.

DataCollectionThemain sourcesof thedatawere from the responsesofthe Key Informant Interviews (KII). According to Kumar(1989), KII is usually chosen since a limited number ofparticipants are needed to provide information about thephenomenon. We decided to use this technique becausetherewereveryfewwhosatisIiedtheinclusioncriteria.Weaskedthemface-to-faceorthroughsocialmediaplatforms.Wealsomadephonecallsandaskediftheywerewillingtoparticipate. We received several denials from somegovernmentbankworkers, andothers refused to reply toour private social media request. After accepting ourinterview request for those willing, we wrote and sentletters to them asking for their participation. For thosewho gave their positive responses, we then set theinterview immediately. Due to the COVID-19 pandemic, aface-to-faceinterviewwasdonewithsocialdistancingandwearing a face mask. Social media interviews were alsocarried out with delays in the question and responsebetween the main questions to follow-up questions. We

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)46hadtoconsidertheinformant'savailability(onlinestatus)inhis/hersocialmediaaccount.

We followed the data collection circle identiIied byCreswell(2007).First,welocatedourintendedinformantswhosatisIiedour inclusioncriteriabyaskingandseekingtheir permission. Before asking them according to theinterview guide, we Iirst established good rapport withthem.Theywereallowedtouseanylanguagetheywanted.Second,weconductedthekeyinformantinterview(KII)asthemaintechniqueincollectingthedata.Wedependedonthe choice of the participants where the interview couldhappen. However, due to the pandemic, most of theinterviewswerethroughsocialmediaplatforms.Third,forsocial media platforms, we copied in a word Iile for thetranscription while for a face-to-face interview werecorded the information and transcribed it later.Fortunately, we were able to deal with social distancingissues except for some response time delays. Fourth, westored data safely. Fifth, we did the analysis andinterpretation after the interviews using the methodsuggestedbyColaizzi(1978)andthetechniqueappliedbyTudyandGauran-Tudy(2020).

AnalysisandinterpretationofdataIn the analysis of the data,we followed Colaizzi’s (1978)method.ThesevenstepsinColaizzi’smethodare:1)Eachtranscript shouldbe readand re-read toobtain a generalsense about the whole content; 2) For each transcript,signiIicant statements that pertain to the phenomenonunder study should be extracted; These statementsmustbe recorded on a separate sheet noting their pages andlines numbers; 3) Meanings should be formulated fromthese signiIicant statements;4)The formulatedmeaningsshould be sorted into categories, clusters of themes, andthemes;5)The study's Iindings shouldbe integrated intoanexhaustivedescriptionofthephenomenonunderstudy;6) The fundamental structure of the phenomenon shouldbe described; 7) Finally, validation of the Iindings shouldbe sought from the research participants to compare theresearcher'sdescriptiveresultswiththeirexperiences.Forstepsoneto4,weusedtablesintheanalysisasappliedbyTudyandGauran-Tudy(2020).

TrustworthinessToensuretrustworthiness,westrictlyobservedcredibility,transferability, dependability, and conIirmability, asassertedbyGuba (1981).Weexperiencedpressures fromwork,co-employees,andfamilymembers.Wecouldeasilyrelate to their experiences. Moreover, we subjected ouroutputs to member checking and debrieIing. We showedtheinformantstheIindingsofthestudyandaskedfortheirapproval to ensure the correctness of the data. FordebrieIing, we asked experts to review our papers andconsideredtheircommentsandsuggestions.

Transferability refers to theapplicationof the Iindingsintosimilarsituations.Forinstance,wewrotethestoriesofgovernmentbankemployeessothattheirexperiencescanbe relatable to other contexts. As Merriam (1998)

explained, transferability is about using the results in adifferent situation. In promoting transferability, weprovided a detailed description of government bankemployees' phenomenon in the Philippines by followingstandards method in phenomenological research. Wediscussedhowwe recruited theparticipants andhowwecollected, analyzed, and interpreted the data. In thediscussion of the themes, we also provided actualresponsesfromtheparticipants.

Dependability refers to consistency. We provided anaudittrail,includingoursocialmediaconversations,audiorecording, research committee notes, experts' comments,andpeerreviewers'suggestions.Wesubscribedtotheideathat thesharedexperienceof the informantswouldmakethestudyverydependable.Wedidthistoanalyzethedata,making sure we identiIied common themes from theirresponses. In the discussion section, we providesupportingliterature.

ConIirmability is the linking of the Iindings to thesourcesofthedata.Toachievethis,researchersmustshowthat the Iindings emanate from the source and not fromtheirpredispositions(Shenton,2004).Wekepttheoriginaltexts of the interviews and provide audit trails of theprocess of data gathering. We ensured Ilexibility andsubjectivitythroughmemberchecking.

EthicalconsiderationsWe secured permission to conduct the study from themanager and ofIicers of the chosen government bank,whereourpotential informantsbelonged.Weassured theprospective informants that we would upholdconIidentiality and respect their rights. We also securedtheir informed consent by asking them to sign the formbeforeproceedingwith the interviews. In theencodingofnames,weusedpseudonyms toprotect theirprivacy andto ensure conIidentiality. We kept conIidential any otherinformation, such as the place or the department wherethe informants worked.Wemade adjustments subject totheir pleasure if they felt uncomfortable during theinterview. As a protocol, we were mindful of issues thatwerecriticaltodisclose.

Struggles of government bank employees in theirjobsamidtheCOVID-19crisisBasedon thestudy'spurpose,wepresent theresults intotwo clusters: discussion on government bank employees'struggles in their jobs amid COVID-19 crisis and theircopingmechanisms. Our Iirst line of questioning focusedonthestrugglesoftheinformants.Aftertheinterviews,weanalyzed the data, and two themes emerged. Thesewerepsychologicalpressuresandphysicalexhaustion.

PsychologicalpressuresOne of the shared experiences among government bankemployees was the feeling of fear. The perceived chillingeffectsoftheCOVID-19pandemiccreatedanxietyontheirpart. Most informants said that reporting to work wasscarybecausetheymightgetinfectedwiththevirus.They

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 47 wereuncomfortablebeinginconstantcontactwithclientsandhandlingcash,checks,orbankdocuments.Lourdes,a40-year-oldbankemployeewhohadbeenworking in thebankformorethan15years,expressedherexperiencebysaying:“Ifearbeinginfectedwiththevirusthroughourdaytodayinteraction with various clients and transmitting it to ourfamily at home. Handling of cash, checks, and otherdocuments from various clients whom we did not knowwhether they are infected, asymptomatic, or exposed toCOVID-19makesusanxiouseverytimeweareattheofSice”.

Mostof the informantsconsideredthemselvesa threattotheirfamilies.Theyknewtheywereincontactwithalotof people atwork.Oneparticipant sharedher experiencein thismanner: “It is a struggle towake up each day, notknowingifyouwillcatchthevirusornot,thatyoumaytakeithometoyourfamilyandcompromisetheirhealthaswell”.

Based on the informants' sharing, people, especiallyclients of the bank, are considered carriers of the virus,thus creating an anxious situation for government bankemployees. They felt horriIied when dealing with clientsand handing or receiving money, checks, or other bankdocuments.Thoughthesearepartoftheirsocialmandateand commitment to serve, their effect was dreadful. Inshort,theyfeltfearful.

PhysicalExhaustionGovernmentbankemployeesexpressedhavingdifIicultiesintravelingfromresidencetoplaceofworkandviceversa.Added to that is the necessity of buying food,medicines,and ofIice supplies. Since the scenario where ourinformants live and work included a lockdown orquarantine having tight security checkpoints, they felt ittoughtosurvive in thiscrisis.Forexample,Vincent,a26-year-old bank employeewhohad beenwith the bank formore than three years, shared his struggle regardingtransportation: “I amhavingdifSiculties in traveling to theassignedbranchor ofSice.During the enhanced communityquarantine, people traveling to different barangays,municipalities, and provinces were required to undergostrict checking through multiple checkpoints. Even thoughwewere essential government employeeswith IATFpasses,some checkpoints havedifferentprotocols. Somewouldnoteven allow these IATF passes and would require providingother documents before entering their barangay ormunicipality”.

Ourinformantsalsosaidtheyfoundithardto lookatandbuyfood,hygieneproducts,andofIicesupplies.Someof them expressed their sentiments at work. They alsodescribed scenarios wherein they found it difIicult toperformtheirrole.Forexample,someoftheirco-workerscomplained of lack of supply of alcohol and face masks.They attributed this factor to the limited supply, the vastdemand,andonlyahandfulofestablishmentsthatopened.Alice,a45-year-oldBankOfIicerwhohadbeeninserviceformorethan20years,wasmorespeciIicinnarratingherown experience: “There is a shortage of food supply,availability,oraccessibilityofsomeofourbasicneeds.There

is also a shortage of supply ofmasks and alcohol, and thecostsaresuperhigh.Thereare limitsofgoingout likeusedcodes,andcurfewswerebeingimplemented.”

These narratives provide a bird's-eye view ofgovernmentbankemployeeswhoarehavingatoughtimeduring the COVID-19 pandemic, affecting them not justmentallybutalsophysically.Undeniably,thestrugglesandconcerns were real experience for the informants. Itappeared that for them surviving in this crisis is not aneasyfeat.

CopingmechanismsWe asked the informants how they managed all thestruggles they experienced. After analyzing all theirresponsesusingColaizzi’smethod,threeemergingthemeswere identiIied. These were social support, prayer, andresiliency.

SocialsupportGovernment bank employees learned different strategiesand devised effective measures in dealing with theirstruggles. There were instances in the ofIice where theywere confrontedwith the fear in dealingwith clients. Allthe informants supported and followed the government’sguidelineswhichtothemservedasalightthatguidesthemthrough thedarkness.Lourdes, a40-year-old seniorbankemployeewhohadbeeninserviceformorethan15years,sharedherwayofsurviving thiscrisis: “Foras longaswefollow the government’s COVID-19 protocols and keepourselveshealthy,wecangoonwithourcustomaryroutine.”

Accordingtotheinformants,theyprotectedthemselvesbywearingfacemaskandshields,handwashingfrequently,andmaintaining social distancing to avoid being infectedby the virus. Also, they tried to organize themselves anddevisemeasures to counter the spread of the virus. Theyhelped each other. Alice described it thisway: “StrategiesbeingimplementedincludedisinfectingtheofSiceasoftenaspossible.Weputupplasticbarriersandwearfacemasksandshields to protect ourselves and practiced social distancingbetween ourselves and the customers. We buy tablets ofVitamin C for less exposure to the virus and boost ourimmune systems, and some of our branches do skeletalworkforcemechanism”.

Informants also noted that putting all their support,conIidence, and trust to government authorities and co-employeeswerenotenoughtocounterthosepsychologicalpressuresandphysicalexhaustiontheyexperienced.First,they tried to stay connected with their families and co-workers in the government. JeePat, a 26-year-old bankerwho had just been in service for four years, shared hermindset: “You cooperatewith your co-employees and voiceoutyourconcerns.Suggeststrategiesthatmayhelpthebankoperation, especially in crowd management. Take care ofyour mental and physical health. Maintain goodcommunicationwithyourlovedonesandpray”.

Thesestatementsshowthekindofcopingmechanismsgovernmentbankemployeesapplytosurviveinthiscrisis.Socialsupportandclearcommunicationfromgovernment

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)48authorities and co-employees, and deep connection withfamilies and friends put the informants’ situation on thebrighter side. Government bank employees managed tosurvivethisordeal,andtheyfoundwaystokeeponliving.They employed effectivemeans not to be infected by thevirus. In other words, they would instead cooperate,support, and help government authorities and co-employeesratherthanbeingfearfulandquerulous.

PrayerFortheinformants,thiscatastrophiceventallowedthemtoexperience the feeling of gratitude and amplify theirspiritual connectedness to God, knowing that manybusinesseswerenot able to sustain their operations, andmany employees lost their jobs. Being governmentemployees, they were lucky enough to keep their jobs.They felt fortunate as compared to those in the privatebusinesssectors.Jeepatsaid:“Bethankful(toGod)becauseyouarepartofa company that iswell establishedandcantakeablowevenduringpandemic.Manypeoplewentjoblessin a blink of an eye. Businesses closing down due tobankruptcy. But you are part of a government institutionthatcantakecareofitsemployeesevenonglobalcrisis.So,itislikeapushandpullfeelinginmyeverydaylife.”

They get their strength by putting their trust in God.Prayer had been their powerful weapon. For instance,Mark, a 45-year-old security guard of the bank, narratedhis trust inGod in thisway: “Wehave tobe carefulnot tocontractthevirus.Wehavetoprayeverydaybecausewedonot seeourenemy.Wecouldbedead inan instant.Then, Ipray that Godwill help people understand towhatwe aredoing. They do not get angry. I hope we understand eachother.”

Informantsalsosuggestedthatothergovernmentbankemployees live a simple and quiet life and surrendereverything to God. They needed to focus on things thatmatter,intangiblethings,andthethingsthatnourishedthesoul. Alice shared her thoughts in this way: “I learned tolive a quiet and simple life. No lipstick, no wearing ofmakeup ingoing to theofSice, eathealthier foodwhicharegoodboosterstokeepmyimmunitystrong.Ilearnedtofocuson things that are more important and useful. Thateverything, frombasic needs down to other life's essentialsandevenlife itself, is justbeingborrowedandthatone-dayGod,thegiveroftheseall,willtakethemawayfromus.”

Theparticipantsfeltblessedandspirituallynourishedthrough their contribution to their community, and theirself-worthwas realized by providing Iinancial support totheir countrymen. Their suggestion to other governmentbankemployeeswastorestoreahealthyandbalancedlife.Thereisaneedtofocusonactivitiesthataddvaluetoone'sexistence, thus Iinding God’s divine purpose andmissionsetforusinourlives.

ResilienceUndeniably, bankers should adapt and institutemeasuresto mitigate the impact of COVID-19 and sustain theireverydayjobs.Thisisaboutresilience.Theyneedtoentice

clients to use digital banking channels to do bankingtransactions to sustain its operations. For example,whilelimited banking hours reduced the level of servicesprovided, the informants introduced the use of digitaltechnology to counter the difIiculties induced by thispandemic. Restie, a 36-year-old government bankemployeewho had beenwith the bank formore than 10years, shared his game plan: “Government services andbanking transactions must be accessible throughtechnologicalandonlinemeans for the efSiciencyof servicedelivery and peoplemust aswell be introduced to the saidmethods.”

Moreover,theinformantspracticedtheartofpositivityin which they realized that dwelling in the past will justmake thingsworse. Instead, theypracticed theattitudeofacceptingadversitiesasopportunitiesandbeingpreparedto deal with it accordingly. Jemar, a 34-year-old utility/messenger of the bank formore than 5 years, shared hismechanism to survive in this pandemic: “I work double-timeandhaveasideline job likeairconcleaning,computer,andelectronicservicestoaddressandcopewithmySinancialneeds.”

Despite their situation, government bank employeesremained positive. They stayed hopeful by putting theirtrustontheircolleagues,havingconIidenceingovernmentauthorities,constantcommunicationwith lovedones,andsurrendering their fate in God. With these mechanisms'help,theinformantsdidnotlosehopeandkeptonIightingto overcome the crisis that COVID-19 had brought them.Similarly,despite the informants' struggles thatpromptedpsychological pressures and physical exhaustion, theywere immensely proud of being at the forefront in thebattle against theCOVID-19pandemic.They realized thattheircommitmenttoserveduringthispandemicafIirmedtheir obligation or their oath of ofIice as public servants.JeePat, when asked about her insights as a governmentbank employee, shared her views, saying: “We had to beextracautiousforustoprotectourselves.Atthesametime,we continue the same passion for work as stated in ourmandatetohelppeoplegrowSinancially.Wearethechannelof Sinancialassistance fromthenationalgovernmenttotheLGUs.So,ouroperationisvitalduringthistime.”

Also,someinformantsexplicitlyarticulatedtheircallofdutydespiterisking theirown lives in thenameofpublicservice. As government bank employees, they weremandated to continue their operations as their servicesbecomemorevitalandessentialinthiscrisis.Forexample,Vincent shared how he observed resilience in his job:“Workingamidst theCOVID19 crisiswasmore than just ajob.Itwasmoreofsocialwelfare.Itwasgivinggoodpublicservice.Itisriskingone’slifedailyandfacingthepossibilityofgettingthedisease.Someareforcedtolivefarfromtheirfamilies.”

Government bank employees showed how dedicatedthey were to their chosen profession. Their commitmentwasbeyondquestion.TheyfeltfulIilledandproudoftheircontributiontotheircommunity,andtheirself-worthwasrealized by providing Iinancial support to their

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 49 countrymen. Also, they were able to be resilient byoutweighingthecostofriskingone’slifewiththebeneIitofhaving a senseofpurpose andmeaning in lifeby servingandhelpingtheircountrymenduringthisdifIiculttime.

DiscussionWe learned good insights from the participants' sharing,such as their concerns and struggles during the presentpandemic.Wealsolearnedfromtheircopingmechanisms,particularlyabouttheimportanceofsocialsupport,prayer,and resilience in government bankworkers' overallwell-being.Theirstrugglesandcopingmechanismswerepiecesofinformationforus,othergovernmentbankworkers,andsociety.

COVID-19 pandemic is a global phenomenon, and it ismuch felt in thePhilippinesconsidering thehigh increaseinthedailypositivecasesasdaysandmonthsgoon.Withlittle or few attempts to study this phenomenon in thecountry,particularlyonbankemployees' livedexperience,this study provided a glimpse of how the essentialworkforcecopewith theadverse impactof thepandemic.Being a banker, and at the same time, a public servant isnot a comfortable journey for these workers. TheyidentiIiedtheirstruggleswithpsychologicalpressuresandphysical exhaustion. The said struggles were expected,considering the psychological and physical toll on theparticipants.COVID-19isnotjustahealthpandemic,butitis rapidly becoming a global economic crisis (McKee &Stuckler,2020).Fearingforone’slifecreatedpressuresforgovernmentbankworkers.Understandably,theinformantsexperienced different degrees of hardship. Althoughlimitedstudieswereconductedon this topic, governmentbank workers and healthcare professionals in othercountries did have similar experiences and struggles.Healthcare workers in Sardinia, Italy, for instance,experienced physical and mental exhaustion. The fear ofpassing the disease to their families has added to thehardshipstheyarenowfacing(Bellizzietal.,2020).Thesegovernment bank workers, though not showing seriousmental fatigue, still shared the same sentiments broughtaboutbythepressuresfromtheCOVID-19pandemic.

Governmentbankinformantsfeltthefearofcontractingthe disease. Several studies about the impact of theCOVID-19pandemiconmentalhealthshowedthatfearisaby-product of disease outbreaks. Moreover, fear of theunknownraises’anxietyeveninhealthyindividuals(Usheretal., 2020).Forexample,peopleare rushing togohomeearlytoavoidfurtherexposuretothevirus,whichgreatlyaffects their job, such as low productivity or/and poorquality of work output. Likewise, there are unveriIiedinformation that causes misinformation, which createspsychological havoc among the people. Indeed, theCOVID-19 pandemic does bring health and life risks andpsychological pressures, which contributed to increasedanxiety(Caoetal.,2020),arealityfeltbybankemployees.

Working in a bank and serving the public amidCOVID-19pandemic isnotonlyscarybutdifIicultaswell.This was how psychological pressures and physical

exhaustion came in as experienced by the informants.Government workers struggled to cope with the mentaland physical hardships. Nevertheless, all informantscontinuetoweatherthestormsoflivingwiththepandemicbecause their trust and support in/from the governmentseemedtoproducepositiveresults.

We found interesting responses from the informantsfacing hardships how to avoid being caught up in thescourgeoffear.Theyresortedtoprayer,socialsupport,andresilience tactics. They looked for ways to escape frompsychological pressures and physical exhaustion. Theyseek guidance and protection from God. They also askedfortheattention,help,andsupportofsociety,families,andcolleagues. Social support diminishes the psychologicalpressures during a pandemic, and effective and robustsocialsupportisneededtosurviveinanyhealthcrisis(Caoet al., 2020). They managed to handle themselves insituationswheretheywereveryvulnerabledespitementaland physical fatigue. They tried Ilexible tactics to reducethe likelihood of contactwith the virus. Some informantsapplied the “Eudaimonic Approach” to human resilience,“eudaimoniaperspectiveemphasizesmeaning-making,self-realizationandgrowth,qualityconnectionstoothers,self-knowledge, managing life and marching to one's owndrummer. These qualities may be of importance in theconfrontationwithsigniIicantlifechallenges”(Ryff,2014).InSouthKorea,thegovernmenthighlightstheimportanceof getting reliable information, maintaining socialnetworks, expressing negative emotions, continuing dailylife activities, and pursuing pleasant experiences to copewith mental health problems (Jung & Jun, 2020).Nonetheless, the informants developed copingmechanisms thatwere important andnecessary for themto avoid the adverse emotional, physical, and mentaleffects.

The informants had their ways of resolving theirstruggles by clinging on to the intangible form of trustacquired throughsocial support.Trust isakey ingredientamongorganizationsandworkerswhoarewillingtoworkduring a public health crisis; trust among organizationsand professionals can be realized through the frequentprovision of information. It suggests that regularcommunication and encouragement to workers from thegovernment and employers make them feel protected(Imai, 2020). Certainly, trust will foster harmoniousrelationships between organizations and individuals,promotingcooperationandteamworkthatwillhelpdefeatthisCOVID-19pandemic.

Socialsupportandcommunicationarecritical in thesetryingtimes.SocialconnectednessandcommunicationaredifIicult during this time because there is a need tomaintain physical distancing while lack of socialconnectedness can cause physical, emotional, andmentalissues. Thus, setting up regular phone calls or videoconferenceswithfamily,friends,andcolleaguescanbridgethe gaps brought on by social distancing (Usher et al.,2020).Associalbeings,peopleneedeachother.

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)50Moreover, the informants consider resilienceasoneof

their coping mechanisms. Filipinos are known for theirresilience.Theycanadapttolifeinanypartoftheworld,asmanifested by the Overseas Filipino Workers (OFW)scattered worldwide (Quito, 1994). Although theirstrugglesmay seemendless, theyaredetermined to copewith the crisis. According to Smith et al. (2020), theyviewed the word resilience as an individual's ability toendureadversity;thus,theinformantsembodywhatitistohaveresilienceintheirworkamidCOVID-19pandemic.Wefound it inspiringbecause evenour informant, a contractworkerwithminimumsalary,hadbeenwith thebank formorethan Iiveyears,wasworkingdouble timeandhadasidelinejobaddressingandcopingwithhisIinancialneedsduetoreducedworkperhourpay.Hismonthlyhouseholdincomehaddiminished,yethestillhadtopaythebillsandfeedhisfamily.Hissituationislikethosedisadvantagedorlow-income workers who have essential jobs with nooptions for working from home, and alternative workarrangements(Shawetal.,2020).Agovernmentemployeemay have to accept delivery services or similar contractsafterhishalf-dayregularworkshift.Still,governmentbankworkers remained optimistic, coupled with theiradaptability to the ever-changing situation that helpedthem survive this pandemic. According toMogaji (2020),individuals must survive and adapt to change, especiallyIinancial and emotional stress. Expectedly, none of theinformants feared of losing their jobs as the governmenthas this "security of tenure" principle, and they areconsidered an essential workforce for Iinancial stabilityandsecurityinthesetryingtimes.

ImplicationsofthestudyThestudyIindingsprovideessentialpiecesofinformationforgovernmentbanks.Ontheonehand,governmentbanksmaymaximize their employees' commitment andpassionfor serving. They can channel the energies of theseemployees to be more productive in work. On the otherhand, government workers continue to rely on socialsupportandstrengthentheirfaithandresilience.

The Iindings of the study are also a good source ofinformationforbankclients.EverybodyishavingdifIicultyat this time. Understanding and cooperation are mostwelcome, especially forbankemployeeswhoare there torender service despite the pandemic's limitations anddangers.Thisstudywidensourunderstandingofthelivesof the informantsandopensotherareasof interest todigdeeperintotheworldofgovernmentbankemployees.Forexample,howdoesthepandemicaffectthewholebankingindustry?What about the experiences of those in privatebanks?Also,anin-depthstudyonpeople’sperceptionsandreactions towards government bank workers could beanotherinterestingtopicthatwouldpaintabiggerpictureofthisphenomenon.

ConcludingremarksThisstudyhighlightsthestrugglesandcopingmechanismsof government bankworkers. The Iindings describe their

struggles of psychological pressures and physicalexhaustion during the COVID-19 crisis. However, socialsupport, prayer and resilience are their copingmechanisms. They continue performing their job despitefear, inconvenience, and stress. They consider being apublic servant a plus factor in termsof having a senseoffulIillment. They even advise other government bankemployees to be proud and thankful of their situation.Moreover, the results of the study may serve as aninspiration to other government bank workers becauseworkingamidCOVID-19pandemicisnotanapocalypseforthembutrather,itisachallengeandawayoflifethattheyare supposed to live. Finally, the Iindingswould not onlybeneIittheinformants,butalsoothergovernmentworkersand other professionals, inside or outside of the bankingindustry.Theymightconsidertheircopingmechanismstocontinue living a happy and meaningful life while at thesame time being committed and having the passion toserve.

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COVID-19 and food security: The Eastern Visayas State University experience in the municipality of Burauen

-SheldonIvesG.Agaton,Ph.D.EasternVisayasStateUniversityBurauenCampusBurauen,Leyte,thePhilippinesEmail:shelds_just@yahoo.com

AbstractThe COVID-19 global health crisis has affected numerouslives, jobs, and properties. The virus is infectious anddeadly, and the most vulnerable are the poor and theelderly. Due to its contagious nature, businesses wereforcedtoshutdowncausingtremendousdamagetomanyworkers. Themunicipality of Burauen in Leyte aswell asitsneighboringtownsarenotexemptfromtheviruswrath.People perished andmany lost their livelihood, disablingthemifnotlimitingtheirpurchasingcapacityforfoodandsustenance.TheEasternVisayasStateUniversityBurauenCampus is primarily an agricultural school. With theexistenceandpersistenceofCOVID-19, such campus roseto thechallengebyelevating its foodproductionwith thehopeofprovidingfoodsecuritynotonlyinthetownwhereit is located but also to neighboring municipalities. Thispaper will delve into the problems and challenges theschool faced, and likewise its methods and strategies tohurdlethedifIicultiesithandledtohelpprovidecheapbuthealthyagriculturalproductsforthepeople.

IntroductionCOVID-19 has brought considerable disturbance to thewhole of humanity. It began in China but rapidly spreadthroughout the globe as the virus was considered highlycontagious.ThispromptedtheWorldHealthOrganizationto assess the situation as a pandemic (World HealthOrganization, 2020). Countless lives perished and thecount continues. Countries imposed shutdown, hoping tomitigate its further spread. Health experts suggested

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)52methodstolessenitstransmissionlikefrequentwashingofhands, wearing of face masks, and physical distancing(World Health Organization, 2020). Despite thesemeasures imposed, the COVID-19 continued its transferamong hostsmaking it almost impossible to stop. This isbeside the fact that there those who elect to ignore thepracticeofthesehealthmeasures.Thespreadwasuncontrollable,andthePhilippineswas

not spared from the virus wrath. The moment it begancrawlingoutofChina, thePhilippinegovernment issuedalockdown beginning on March 15, 2020 (Staff, 2020).Manila, the capital of the Philippines and the mostpopulous among the country’s cities, implementedlockdown and immediately followed it with other localgovernment units. The strategywasmeant to slow downthe transmission of the virus because the lesser themovement of people, the lesser would be the transfer ofthedisease.The disease may have slowed down, but for various

reasons,itstransmissioncontinued.Anumberofreturningresidents from various parts of the countrywent back totheir homes encouraging local government units tointensify border control and the usual health protocols(Inter-AgencyTaskForcefortheManagementofInfectiousDiseases,2020).Itwillbeinhumanetobarthesereturningresidents fromgoingbackhomebecause their lives awayfrom home was already difIicult and risky, and denyingthemfromreturninghomewillbetragic.However,theriskwasalwayspresentthattheymightbecarriersofthevirus.The possibility that the virus would reach the provinceswasrealandimminentandifthishappens,lives,jobs,andthelocaleconomieswillbeindanger.TheEasternVisayasStateUniversityBurauenCampusis

an academic institution, and its Ilagship is agriculture. Ithas a landareaof approximately33hectares, big enoughso that when utilized up to maximum capacity, it canproduce agricultural products to supply food in the localmarket and hopefully stabilize the food demands ofconsumers. Food is essential for human survival, andshortage of it has negative implications to his socio-economiclife.Thecampushasenvisionedthatifthisunfortunateevent

reachestheplace,itwouldbewisetopreparebeforehand.The dreadful virus started in December of 2019, andhaving learned of its high transmissibility, EVSU BurauencampustriedtoanticipateitseffectsbeginningFebruaryof2020.

COVID-19andfoodsecurityTheCOVID-19hasinterruptedvariousfacetsofhumanliferanging from jobs, businesses, trades, commerce,production of goods andmany others. These distractionshave resulted in closure of businesses, job losses, hunger,and despair plunging revenues of billions of dollars fromvariousbusinesses(Maboloc,2020).Governmentsfromallover the world addressed these concerns by imposinglockdownsandstricterhealthprotocols,whileaddressingrepercussions thatmay affect economic activities. This is

anextraordinaryphenomenonasitisafactthatmanneedstowork inorder to survive.Thepandemic is affecting allfour pillars of food securitywhich are availability, access,utilization,andstability(FAO,2008).Among the effects of community quarantine being

imposedbythePhilippinegovernmentisforpeopletostayhome. This strategy lessens movement of social life thusminimizingcontactsamongpeople.Physicaldistancingcanbe properly imposed since few people will be going out(Devereux, Bene, & Hoddinott, 2020). Agriculture in thePhilippines is not highly mechanized even in theproductionofthecountry’sbasicstaplefood,rice.Humanlaborisstilltheprimaryforceinriceproduction,andthisisfurtherevidentinruralareas.Limitingthemovementofpersonsaswellasimposingphysicaldistancingdiminishesthe availability of food, and gravely affects poor farmersfrom earning their usual income (Laborde, Martin,Swinnen, & Vos, 2020). However, the same governmentinitiatedamethodinordertosafeguardthefoodnecessityof Filipinos. They presented the P17.5-billion refocused2020 DA budget and the proposed P24-billion stimuluspackageforagricultureunderthe“BayanihantoRecoverasOneAct”or“Bayanihan2”(DACommunications,2020)Closure of business establishments has both affected

owners and workers. Bigger establishments like foodchains resorted to take out of food only. Shopping mallslimit theentranceofshoppers inorder toavoidcrowdingand to maintain health standards. These scenariosillustrate laying off of employees, causing them greatdiscomfort where majority of them are minimum wageearners(Maboloc,2020).Theusualnumberofwaitersinarestaurantisnolongerpragmaticforaveryfewcustomers.The rampant job losses experienced by a number ofFilipinos resulted in shortage of purchasing power. Foodmay be available but, if the purchasing power of anindividual is impaired, food insecurity is possible. Theextentoftheincreaseofpovertyduetothepandemicmaystill be incalculable considering that the phenomenon isstill ongoing, but the reality of it is certain (Laborde,Martin,Swinnen,&Vos,2020).Utilization is another pillar of food security that also

needstobeaddressed.Aretheconsumerstakingtherightnutrients in their food intake? Food does not have to bedelicious to be nutritious. The basic food nutrition of Go,Grow, and Glow is a decent guide for a person to livehealthily. Laborde (2020) mentions a recent survey inEthiopia that shows the pandemic has caused poorhouseholds to reduce nutritious food intake and redirectthe loss of less nutrient food, making consumerssusceptible to adverse health problems (Laborde,Martin,Swinnen, & Vos, 2020). The Philippines is a developingcountry,andtherearemanypoorfamilies.Ifthepandemicperpetuates, then food utilization will be a factor in thecountry’sfoodinsecurity.Thishealthcrisisposesgreaterriskon foodstabilityor

sustainability. There is no guarantee that if this situationsustains, agricultural activities continue. There is alwaysthepossibilityof interruptionwhenever there is infection

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 53 among workers. For instance, in the harvesting of cropslikesweetpotato,socialdistancingcanbeappliedimplyinglowerriskofvirustransmission.Butthisisnotthecaseinriceproduction. In thePhilippines,plantingrice ismainlydonebyhumanhandsandplentyofhandsatthat,andtimeis always essential. Here, social distancing is a remotepossibility,andthedangerofvirustransmissionishigh.Insuchcase,productionwillbehamperedcausingworkerstobe isolated under quarantine resulting in low or non-production(Laborde,Martin,Swinnen,&Vos,2020).

The agricultural production of Eastern Visayas StateUniversityBurauencampus: striving towards cheaperandhealthyfoodsustenanceThe Eastern Visayas State University Burauen Campus isundertheauspicesoftheEasternVisayasStateUniversityMain Campus of Tacloban City, Leyte, Philippines. TheBurauen Campus is located 46 kilometers from TaclobanCity.ItismainlyanagriculturalschoolwhereitsIlagshipisBachelor of Science in Agriculture. It covers a vast landareaconsistingofapproximately33hectares.COVID-19IirststruckinWuhanCity,ChinainDecember

2019 (World Health Organization, 2020). From there, itspread rapidly to other countries due to its highlycontagious nature causing alarm among nations. Besidesitshighinfectiousrate,itwaslikewiseinitiallyperceivedasdeadly, but later data showed that it was particularly soamong the elderly. When quarantine measures wereimposed, the Iirst reactionwas how to gather foodwhilecitizenswere limited from going out of their houses. Themost vulnerable in this situation are the poor. Citizens inthe upper class have savings, so food hoarding is not aconcern.Butforthepoor,toIindmoneyisonething,andtobudgetthefoodtheybought isanotherthing(Abellanosa,2020).Theriskof losingone’s jobwascriticalsinceasidefrom the limitations imposed, business ownerswere alsoforcedtoclosedownforfearofcontractingthevirus.Foodsecuritybecamethemajorconcernfortheadministrationof EVSU Burauen. In February of 2020, it immediatelydirected its focus on cultivating as many land areas aspossible.With the virus’ communicability, the school perceived

thatitwasonlyamatteroftimethatthisdreadeddiseasewould infect some inhabitantsof the town.Unfortunately,themunicipalityofBurauenwastheIirstamongthetownsin Leyte to register its Iirst COVID-19 patient and untiltodaythenumberisgrowingbutrecoveryrateisalsohigh.The campus since then has planted various agriculturalproducts like rice, corn, eggplant, bottle gourd, sweetpotato, cassava, squash, upland spinach,watermelon, andmanyothers.RiceisthebasicstaplefoodamongFilipinos,so it was the Iirst priority. Vegetables have always beengenerally considered as nutritious and good source ofvitamins and minerals. These farm goods have a goodchanceofhelpingstabilizefoodsupplyintheareaandeventhroughneighboringtowns.Budgettoinitializetheendeavorwasinitiallyadeterrent

for the campus because it only caters to a thousand

studentsduringthatsemester,andthemoneyitgeneratesfrom such number is minimal. There are also otherIinancial matters that needed to be addressed likepurchasing of antiviral measures, l ike alcohol,disinfectants,washareasandthermalscanners,salariesofemployeesandfarmworkers,andothermiscellaneousandoperating expenses. But themeagre budget coupledwithhardworking individuals made the propagation of theseagriculture products a reality. Another hindrance thecampusfacedwasmanpower.Stricthealthprotocolswerestrictly monitored by government ofIicials. For instance,thecompliancewithsocialdistancingandwearingof facemasks at all times in workplaces was a concern in riceproduction. On the one hand, a bigger number of farmworkers isnecessarybut ifone is infected, itwillhampertheentireprocedure.Ontheotherhand,asmallernumberofworkerswillfaithfullycomplywiththeseprotocols,butthiswillimpairthetimeelementintheproductionofrice.Workingunderthewarmthofthesunwithfacemasksonis hard. This conditionweakened the farmworkers bodyprompting them to ask for break from time to time. Theadvantagewas that sinceworkersworkedalternately, theproduction was complying indirectly with protocols. Theproduction of farm products other than rice was not anissue and health standards were carefully exercised. Forinstance,plantingofcornseedsneedsproperspacingfromoneseedtoanother.Duringharvesttime,farmworkersdonotcrowdsincegrowncornplantsarealreadydistantfromeach other, so health standards are followed. Healthprotocols were the major concern, but they wereaddressedwellthroughinitiativeandcreativity.Databasedonthereportsubmittedbytheschoolshows

that the area for rice production increased from 0.7hectaresin2019to1.6hectaresin2020.Asaresult,therewasasigniIicantincreaseofriceproducefrom9,240kilosto 25,760 kilos in 2020 (Eastern Visayas State UniversityBurauen Campus, 2020). As a basic staple food amongFilipinos, there should be a substantial increase for thisparticular product in order for it to be catered to themarket(EasternVisayasStateUniversityBurauenCampus,2020).In order to coincidewith the concepts of food security

and catering nutritious food primarily to the people ofBurauen, vegetables and fruits plantation was enhanced.Vegetableand fruitproductionwassecondamongthe listofpriorities.From0.4hectareoftilledlandin2019,itwasincreased to 1. 3 hectares in 2020 resulting in 7,212.85kilos of various vegetables harvested and sold for humanconsumption at a low price (Eastern Visayas StateUniversityBurauenCampus,2020).Theseweretheinitial fruitsandvegetablesplantedand

harvested for the Iirst half of 2020. There are othervariationsthathavebeenplantedthatawaitharvestinglikejackfruit and guyabano. Meanwhile the administration isstillplanningonothervariantstoplant.Root crops are also good sources of nutrition. In rural

areas, several types of root crops are grown in thebackyard amonghouseholds. These types of foodmay be

Citrus

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)54eaten during breakfast, lunch or dinner and even snacktime. They are so rich in nutrition that sometimes localsreplace ricewith theseproducts.Theschool increased itsroot crops production from 0.2 hectare in 2019 to 0.4hectare in 2020. The increase in land area cultivatedgenerated1,435kilosandtheproducewasmadeavailable

toconsumersinsideandoutsideoftheschool.Inaddition,corn production was likewise ventured but only on aminimalextentharvestingonlyatotalof400kilosfortheentiretyof2020(EasternVisayasStateUniversityBurauenCampus,2020).

There isnocertaintyyetas towhen thispandemicwillend. Vaccines are already on their advanced stage ofhuman trial, while some pharmaceutical companies havealready applied for emergency use authorization of theirproducts in some countries. Vaccines are primarilydevelopedbywealthy countries, and it is likely that thirdworld countries like the Philippines will be at adisadvantage. Hence, multilateral agreements amongcountries must be at stake for humanitarian purposes(Maboloc,2020).However, anewvariantof thevirushasbeen discovered in some countries like the United

Kingdom which is again another challenge for scientists.Thisnewunfortunatedevelopmentwillbeanotherpuzzleon the human mind as to until when this unfortunateoccurrencewill last and then return back to normal. ThecontinuousriseofCOVID-19casesallovertheworldisstillevident despite promising results of several vaccines.Everyone probably hopes to go back towhere ourworldused to be without the need for masks and physicaldistancing; the freedom to go shopping in malls withoutgoing through strict measures; and the liberty to holdconferences,socialgatherings,meetingsandevenreligious

Rice

UplandSpinach

Watermelon

Squash Ampalaya

Citrus

BottleGourd

Eggplant

DragonFruit

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 55 assemblies. The challenge continues for the EasternVisayas State University Burauen Campus, but theopportunitytoriseabovethehardshipremainssteadfast.From agricultural products, EVSU Burauen will expand

helpingthemunicipalityandeventheprovincetoachievefood security. It has started to venture into farm animalproducts.Atpresent,itowns4waterbuffalosand2cows,butalreadyintendstopurchase1malewaterbuffaloand1bull.Thiswillallowthefemaleanimalstopropagatetheirown kind. Additionally, the campus recently purchased 1setof chicken layers, severalnativechicken,andapairofgoats. A piggery is next in line, but since it needs morepreparationlikeaconcretepigpenandacomfortableandclean place, it will take a few months before it can berealized.Further,sinceporkisafoodgenerallyfavoredbyFilipinos,theEVSUBurauenadministrationwillpursueforitsrealization.The challenge was enormous, but hard work pays off.

Thisobjectiveisfoundedonthecampus’altruisticconcern(Bautista, 2020) for the people. The sight of remarkableharvest of all these agricultural crops coupled with theservicetheschoolofferstothegeneralpublicishumbling.The school does not intend to compete with the samegoods in themarket. Itsproximategoal is to increase thesupplyoffoodatanaffordablepriceatthistimeoftragedy.Thegeneralmoodanddispositionatthistimeisdownandtakingadvantageofthesituationlikeincreasingthepricesofcommoditieswillnothelpwiththeburden,buttodotheexact opposite will. Its ultimate goal is to stabilize foodsecurityintheimmediatemunicipalities.

ConclusionCOVID-19 is here to stay even with the availability ofvaccine. In fact, even before it reached the market forhuman consumption, a new variant of the virus wasalreadydiscovered.Expertsscrambletotestwhethertheirnewly created vaccines will combat the new variant.Promising signs of these vaccines’ efIicacy and safety aredocumented,andsignsofabettertomorrowmightbecomea reality. people need to be pragmatic to life’s approach.Food is a necessary element in human survival, and itsproduction must be sustained. COVID-19 will not be thelastvirusthathumankindwillface.Realistically,therewillbe more and they might be deadlier and extremelycontagious. Health protocols will be upgraded to protecthumanity and cheaper but healthier food must be madeavailableforhumanconsumption.

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DACommunications,G. (2020,September4).TheWayForward,Level Up Philippine Agriculture! Retrieved fromDepartmentof Agriculture: https://www.da.gov.ph/da-refocuses-remaining-2020-budget-to-ensure-food-security/

Devereux, S., Bene, C., & Hoddinott, J. (2020). ConceptualisingCOVID-19’simpactsonhouseholdfoodsecurity.InternationalSociety for Plant Pathology and Springer Nature, 769-722.doi:10.1007/s12571-020-01085-0

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Inter-Agency Task Force for the Management of InfectiousDiseases. (2020, July 21). Retrieved from OfIicial Gazette:https://www.ofIicialgazette.gov.ph/downloads/2020/07jul/20200721-IATF-RESOLUTION-NO-57.pdf

Laborde, D., Martin, W., Swinnen, J., & Vos, R. (2020, July 31).COVID-19 risks to global food security. Science, 369(6503),500-503.doi:10.1126/science.abc4765

Maboloc,C.R.(2020).GlobalizationandConsumerCulture:SocialCosts and Political Implications of the COVID-19 Pandemic.Eubios Journal of Asian and International Bioethics, 30(3),77-79.

Staff, C. P. (2020, March 12). News. Retrieved from CNNPhilippines: https://www.cnnphilippines.com/news/2020/3/12/COVID-19-Metro-Manila-restrictions-Philippines.html

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Changes of health care practice in the field of ophthalmology during the COVID-19 pandemic

-SibelInan,MDAssociate Professor of Ophthalmology, AfyonkarahisarHealthSciencesUniversity,FacultyofMedicine,TurkeyEmail:drinan33@gmail.com

AbstractThe new coronavirus SARS-Cov-2 (COVID-19) hasdisrupted all aspects of medical care around the world.Ophthalmology practices have also been affected by thispandemic all over the world. Due to this pandemic, newregulationswere introduced inophthalmology forpatientexaminations and surgical practice. Ophthalmologicprocedures requiring close examination and physicalcontact have been reported to pose a high risk for SARS-CoV-2 transmission for ophthalmologists. Guidelines onmeasures to prevent the risk of contamination related toCOVID-19 have been published in this regard, and itwasstated that all treatments should be stopped, except foremergency situations. The number of patients has been

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)56reduced. It was recommended to pay attention toexamination rooms and sterilization of instruments anddevices. It was recommended to provide personalprotectiveequipmentduringexaminations, tomake theseexaminations as short as possible focusing on diagnosis.Non-urgent procedures were postponed. In addition,breathing shields were placed on biomicroscopes toprotectagainstcontamination.In an assessment of the American Society of RetinaSpecialists (ASRS), it was reported that a signiIicantpercentage of retinal patients were at risk of vision lossand required regular intravitreal injection therapy. At thesametime,theagerangeofthispatientgrouphasbecomeone of the special groups because it is included the agerange above 65 years of age,which is deIined as the agerangeathigherriskoftheCOVID-19epidemicworldwide.Alsothesepatientswerefoundtobethegroupatrisk forhighermortalityandmorbidityinthisepidemicduetotheprevalenceofotherpre-existingsystemicdiseases.Amongthesepatientsintheriskygroup,therewerethosewhodidnotwanttocometothehospitalwiththeirownrequests,thosewhose treatmentwas disrupted, and therefore alsoexperienced vision loss. The patientswere recommendedto continue their treatment and their treatments werecarried out in order to prevent vision loss, by arrangingexamination and operating rooms in a way that thepatientswere least likely tobeexposed tocontamination.It is important toplan the treatmentand follow-upof thepatientsinawaythatminimizestheriskofcontaminationasmuchaspossibleandatthesametimeconsideringthesituations that require emergency treatment. These aresomeoftheethicalissuesIwilldiscuss.Keywords:COVID-19,examination,ophthalmology,practice

IntroductionThe new type of Severe Acute Respiratory Syndromecoronavirus2(SARS-CoV-2),whichwasIirstseeninChinainDecember2019andspreadrapidly to theworld, is thecauseofthecoronavirus(COVID-19)disease[1].The World Health Organization (WHO) declared theCOVID-19virusoutbreakapandemiconMarch11, 2020,anddesignedguidelinesandstrategicresponsestocontaininfection worldwide. Proactive efforts and lockdownsdesigned to contain the spread of the virus have beenimplementedinmanycountries[2,3].

Governments have established wide-ranging controlmeasures to reduce COVID-19 transmission and thusreduce the pressure on health systems. Most countriesinitially imposed travel bans from certain locations (e.g.China), followed by the establishment of quarantinemeasures. Movement of people was restricted except fornecessity,workingandhealthconditions[4].

TransmissionRiskInOphthalmologyOne of the Iirst to announce the COVID-19 outbreak inChina was doctor Lin Wenliang. Lin Weliang was anophthalmologistwhowas infectedwith COVID-19 from aglaucomapatientheexamined.Dr.LinWeliangdiedweeks

laterduetoCOVID-19.HewasoneofourIirstcolleaguestodieduetoCOVID-19.Ophthalmologyspecialtyisoneoftheriskyareas forCOVID-19 transmission so concerns in theophthalmology community have grown.Ophthalmologistsare also included in the group of high-risk healthcareprofessionals, such as dentists, otolaryngologists, andanesthesiologistswhoareroutinelyexposedtoaerosolizedrespiratory secretions, especially because they are veryclose to patients during the examination. It has beenreported that ophthalmologists are particularly at risk ofinfection in terms of interaction with a large number ofpatients, close contact with patients, and spread throughcontactwithinfectedsecretions[4].

In the study of Loon et al., it was stated thatophthalmologistsandotherhealthcareprofessionalsworkclosetopatients'eyesandthiscanbeasourceofinfection.Seitzman and Doan stated that occupational exposure tothe virus in the healthcare industry is mostly due toairborne transmission through infected droplets. Theyreported that for biomicroscopic eye examination andophthalmologic procedures involving face-to-face contact,the risk of exposure to this infection is high because theviralloadisparticularlyhighinthenasalcavity[5,6].

Ontheotherhand,sincetheophthalmologicalpracticeincludesmorethanoneexamination,itcanbesaidthattherisk of cross infection to other patients and healthcareprofessionals increases as a result of the longer hospitalstays[7].

In our country, in the guidelines of the Ministry ofHealth,ophthalmologicalexaminationandoperationshavebeen classiIied amonghigh-risk procedures for COVID-19transmission[8].

COVID-19diseasecausedbythenewcoronavirusSARS-Cov-2hasdisruptedallaspectsofmedicalcareallovertheworld.Ophthalmologypracticeshavealsobeenaffectedbythispandemicallovertheworld.

Toavoidpossibleviralautoinoculationbytouchingthemucousmembranesof the face, theUnitedStatesCentersforDiseaseControlandPreventionrecommendedtheuseof protective glasses over contact lenses or a face shield[9]/

Transmission Protection Recommendations andPrecautionsinOphthalmologyAlthoughthepossibilityofviraltransmissionthroughtearsislow,ithasbeenemphasizedbytheAmericanAcademyofOphthalmologythatpersonalprotectiveequipmentshouldbe used to cover the mouth, nose and eyes forophthalmologists.Inmostophthalmologicalexaminations,highriskofSARS-CoV-2 transmission toophthalmologistshas been reported due to close distance and physicalcontactbetweenpatientsanddoctors.[10]

Therefore, it has been reported that ophthalmologicexaminationproceduresshouldnotbeperformedwithoutthe use of personal protective equipment. Sterilization ofdevices and instruments should be part of the routineexamination. In addition, it has been stated that patienteducation isalso important indisinfectionof thesurfaces

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 57 thatpatientscomeintocontactwithduringtheirvisitsandto prevent infection through the ocular surface. It wasstatedthatpatientsshouldwashtheirhandsproperlyandavoidanycontacttofaceandeyes.Inaddition,ithasbeenrecommended to pay attention to hygiene rules whenusingcontactlensesandtouseglassesifnecessary[11].

Duringthepandemicperiod,withtherecommendationoftheMinistryofHealth,allexaminationsandprocedureshave been postponed except for eye examinations thatrequireurgencyandeyediseasesthatmayresultinvisionloss if not done urgently. The Turkish OphthalmologyAssociation has published information on diseases thatrequire urgent intervention, with the opinion of its sub-specialtiesand inparallelwith thepractices in theworld.Thus, it is aimed not to neglect the treatment of patientswho may be harmed if they are not treated due to thepandemic,thatthesepatientsbeneIitfromhealthservicesprimarilyand that there isnoadditionalhealthhandicap.In health services, these guidelines, which were createdwiththesecriteria,weretriedtobefollowed[12].

Despite this, in our ophthalmology practice, when theIirst peak of the pandemic passed and ophthalmologyexaminationsincreasedintherelaxationphase,wenoticedsome patients who did not come to the hospitalenvironment voluntarily despite having symptoms in therestriction phase and some of these patient haveexperiencedirreversiblevisionlosswithdifferentdegrees.Infectionprecautionsaredividedintothreecategories.1-UseofpersonalprotectiveequipmentThe American Academy of Ophthalmology published areport forophthalmologistsadvising them towearmasksand eye protection when caring for patients with thepotential to become infected with COVID-19. Reportshighlighted that COVID-19 can be transmitted by aerosolcontactwith theconjunctiva if eyeprotection isnotused.Inaddition,patientsshouldbeaskedtoavoidspeakingasmuch as possible during the slit lamp examination[10,13,14].2-EnvironmentalControlIn biomicroscopic examination, protective breathingshields should be added to biomicroscopes to preventcontamination throughdroplets due to the closedistancebetweenthepatientandtheophthalmologist.Thepatientand the physicianmustwear amask, and talk should beavoided during the examination. After each examination,the protection shield of the biomicroscope unit and thesurfaces in contact with the ophthalmologist and thepatients should be disinfected frequently. Lai et al.,reportedtheimportanceofventilationinwaitingareasandsuggestedtakingmeasurestoachieveahigherproportionoffreshairwithimprovedairdilution[15].3-AdministrativeControlForeverypatient,thebalancebetweentheneedtoprovidepatient care and vision protection and the risk oftransmission of COVID-19 must be considered. In theguidelinesoftheAmericanAcademyofOphthalmologyandin a review of Lai et al. about ophthalmology practiceduring the COVID-19 outbreak, itwas recommended that

thepatientbeexamined inemergencysituationsandthatappointments be postponed for individuals suspected ofCOVID-19 [15]. In general, elective visits and electivesurgery should be delayed. Medical care should only beprovided in emergencies. In recent studies, it has beenreported that most patients with COVID-19 wereaccompanied by fever Iindings. For this reason,temperature measurement should be done at theophthalmologyclinicadmissions.Ifeyeconditionsarenoturgent,patientswithfevershouldbedirectedtonecessaryplacesandtheireyeappointmentsshouldberearranged.Atriageprocedureshouldbeperformedto identifypatientswho may beneIit from telemedicine or internet-basedvisits,andwhoseappointmentscanberescheduledsafely,except for patients who need to be seen urgently by anophthalmologist[16,17].

It has been stated that teleophthalmologywill emergeasanimportantpartofclinicalpracticeastechnologythatprovides opportunities in the digital environment,especiallyforexaminationtechniques,advances[18],

Inadministrativecontrol,effortsshouldalsobemadetoprevent crowding of waiting areas. For this purpose,measures should be taken by paying attention to socialdistance inwaiting areas [17], Throughout thepandemic,eachhospitalhascreated itsownalgorithmsandensuredcontrolintermsofinfectioncontrolmeasures,adheringtothecircularsissuedbytheMinistryofHealthandrelevantauthorities.

HealthServiceDelivery InOphthalmologyDuringThePandemicPeriod(Determinationofthegroupstobetreated)TheAmericanSocietyofRetinaSpecialist(ASRS)reportedin its March 2020 assessment of COVID-19 that asigniIicant percentage of retina patients are at risk ofvisionlossandshouldreceiveregularintravitrealinjectiontherapy.Forthisreason,ithasbeenreportedthatthereisaspecialgroupinthispandemicperiod.TheriskyagerangedeIined by this worldwide pandemic is over 65 years ofage.Thepatientgroupwhoreceived intravitreal injectionin ophthalmology practice is generally in this age group[19].Thesepatientswerealsointheriskygroupintermsof mortality and morbidity in this pandemic due to thefrequencyofaccompanyingothersystemicdiseases.

For patientswith retinal disease during the COVID-19pandemic, the plan should be aimed atminimizing risks.Duringthepandemic,ithasbeenreportedthattheriskofexposuretoCOVID-19diseaseshouldbereducedforboththehealthcareworkersandthepatient,andactionshouldbetakeninconsiderationoftherisksofirreversiblevisionloss for the patient. It has been reported that it isappropriate to avoid regimens requiring frequent follow-up for those who receive treatment. The necessity ofdetermining strict safetypracticesand the treatment thatrequires urgent care and setting priorities are alsoreported[20].

In the study of Yang et al., consistent with previousstudies, they showed that disruptions in treatment can

EubiosJournalofAsianandInternationalBioethics31(1)(January2021)58cause a remarkable deterioration in visual acuity. It hasbeen stated that visual acuity results may changedepending on the length of treatment interruption. Theeffects of the treatment interruption should beinvestigated in long-term studies. In addition, moredetailed guidance of global medical retina specialists isneeded in the difIicult conditions during the COVID-19pandemic[21-23].

Thepatientswere advised to continue their treatmentin order to avoid vision loss. With the arrangement ofexamination and operation rooms in away to reduce therisk of contamination, the treatment of the patients wascarriedout.Someof thepatientsdidnotwanttocometothe hospital of their own accord and disrupted theirtreatment and therefore suffered vision loss. It isimportant to plan the treatment and follow-up of thepatientsinawaythatminimizestheriskofcontaminationasmuchaspossibleandatthesametimeconsideringthesituationsthatrequireemergencytreatment.

InTurkey,thenumberofpatientsineyeclinicshasbeenreduced,disinfectionoftheequipmentintheexaminationroom,wideningofthewaitingrooms,determinationofthenumberofpatientsaccordingtothecapacityofthewaitingroom,keepingpatients'relativesinthegardenratherthanin theclinic, triageat thehospitalentrance,screening thepatientstobeoperated,toarrangetheoperatingrooms,touse full laminar Ilow theaters for the operating room, touse mobile ventilation devices that clean the room fromextra viral load, to take a 30-45 minute break betweenoperations and to perform extra disinfectionmeasures inthe room to reduce the aerosol load during eye surgery.Measures such as the use of sterile medical drapescovering thepatient'sheadwithanoperatingmicroscopehavebeenimplemented.Eachpatienttobetakenintotheoperatingroomwasscreened,althoughitvariedaccordingto the practice of the health institution. In someinstitutions,allpatientswereaskedforlungX-rayscanningand, if necessary lung CT scanning, blood tests andevaluationofthesetestsbytheinternalmedicinedoctor,ifnecessary, COVID-19 tests in suspected cases. Somemedical centers stipulated more strict criteria such asdirectCOVID-19antigentestforallpatientstobeoperated.During these screenings, some patients who have noknown typical symptomatic disease, were diagnosed asCOVID-19, andwere quarantined. The treatment of thesepatientswerearrangedaccordingly,basedonthedegreeoftheurgency.

The procedures applied in ophthalmology practice inthe pandemic have also been the cause of a separatediscussion.Beforethepandemic,inespeciallyhighvolumeophthalmology clinics in our country, due to the highnumber of patients and the demand for eye care, therewere toomanypeople in the appointment list and itwasvery crowded in thewaiting roomsof the ophthalmologydepartments and the ability to allocate very little time topatients. Ironically,becausethepatientswereallocatedatregularintervalswithlongertimesinthepandemicperiod,new arrangements with less number of patients waiting

for eye examination in the ophthalmology departmentsduring thepandemic is actually thought tobemustbe innormal eye care practice. An eye care service where thephysician can spend better time for the patient in areducednumberofpatientsmaybemoreethicalandevenmoreeffectiveorcost-effectiveinthemanagementofsomeeye pathologies. This model could be experienced in ourcountry or possibly in similar countries due to thepandemic.SolutionmustbefoundformorepatientIlowtoservemorepatientsinthenewnormalafterthepandemic.

ExpectationsafterthePandemicPeriodItishighlylikelythatchangesinpandemicophthalmologypracticewill have an impact on future ophthalmic healthdeliverypractices.Afterthepandemicperiod,therewillbean hard work Ilow due to patient density and delayedsurgeries.Inadditiontotheimportanceofinnovationsthatwill help in the remote diagnosis and decision-makingprocesswithartiIicial intelligence,theimportanceofeachcountry having guidelines based on ethical rules andregulationsisunderstood.Itisexpectedtodeveloppoliciescompatible with the solidarity in the Iield of healthbetween countries. Patient management with remotetelemedicine is expected to become a model in someapplications in the future. Research that has beenpostponed due to the pandemicwill continue to increaseafter the pandemic. In ophthalmology education, theshortcomings in practical application will be tried to becompleted.

Possible Ethical Situations inOphthalmology PracticeDuringthePandemicPeriod

TheCOVID-19pandemichas raised the issueof ethicsinophthalmologyhealthcare,asinallmedicalpractices.IntheCOVID-19pandemic,itisimportanthowtoimplementthehealthservicethatwillbeofferedasrestrictedaswellasprotectionfromtransmission.Atthispoint,theissueofethicalprinciplesshouldbediscussed.Asamatteroffact,itshouldbedeterminedhow,andtowhom,healthserviceswill be provided in addition to non-urgent, postponed,elective surgical interventions. Performing electivesurgeriesthatmaybedelayed,not interveninginpatientsrequiring urgent surgery, and not taking necessaryprecautions inpatients tobe examinedmay causeethicalconcerns.Therefore,guidelinesregardingethicalsituationsin medical practice during the pandemic period can beguiding.

Guidelines prepared by the Ministry of Health andprofessional organizations in different countries can helpin this regard. There are four basic principles ofmedicalethics.Theautonomyof thepatient, theprincipleofnon-harm, the principle of beneIicience and justice are thesefour basic principles. In one article, ethical issues arediscussed in case studies related to patients inophthalmology practice during the COVID-19 pandemic.Medical ethics experts have recommended that decisionsbe made regarding these situations, following four basicprinciples. Of course, each patient will be evaluated

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 59 individually. Detailed information about the patient'sillness, the principle of autonomy, the principle of notharmingthepatient,theprincipleofbeneIicencebasedonthebeneIitofthepatient,aswellastheprincipleofjustice,whichexpressesjusticeamongindividualsforpatientcare,summarizes these principles. It is autonomous in patientdecisions. It should also respect the principle of justice.Thephysicianshouldrespectthepatient'sautonomy,takeintoaccountthebeneIit-harmsituationforthepatientandwatchovertheprincipleofjustice.Inanarticlediscussingethicaldilemmasregardingophthalmologicalcare,thecasescenarios asked to the ethics experts and the ethicalsituationsrelated toCOVID-19wereasked.Ethicsexpertsseekanswersto fourquestionsthatneedtobeaddressedinanysituation.Whatistheproximityandseverityoftheexpected harm without intervention? What is theeffectiveness of the intervention under consideration?Whatarethetreatmentrisksforthepatient?Whataretherisksoftreatingthepatientforthehealthcareteam?Itwasstated that each case needs an individual risk beneIitanalysis. As in the teachings in medicine, there is nodisease,justlikethesayingthereisapatient,eachpatientisevaluatedintheirownway.Adetailedinformedconsentinterviewwiththepatientisrequired.Differentresponsesmay be obtained for similar situations among patients.Althoughthereisnoobjectivescoringtoolfortheprocessoftreatingpatientsinophthalmology,theapproachshouldbethesame[24].

Among the restricted appointment schedules, it wasevaluatedhowaphysiciancouldmakeriskstratiIicationina limited information environment (such as the patient'sretinal status, estimated risk of infection). In this case, itwasstatedthatasamoralresponsibility, triageshouldbeperformed for each patient whose appointment will bedelayed, according to the proximity and severity of theharm.AlthoughitisdifIicultandtimeconsumingintermsoflogistics,itisstatedthatthisistheethicallyappropriatesituation.

During this pandemic, risk stratiIication is requiredbased on what is known about the patient's ophthalmicstatus.Everyphysicianshoulddohisbest.Asstatedinthearticle, the law enacted in New York state (USA) on thetreatmentofcriticallyillpatientsininadequateconditionsduetohumanandresourcescarcity,duringtheemergency,hospital physicians and nurses, unless gross negligence,decisionandactionhasbeengrantedexemptionfromlegalandcriminalliability[24].Thispandemicperiodremindedeveryone thatwehave responsibilities for both ourselvesandothers.Asapublicdisclosure,thesecuritymeasurestobe followed regarding COVID-19 were presented in bothpublic spaces and private sector.Warningmessageswerepublished in the form of public service announcementsfrom the media. An effort was made to raise publicawareness. Thenumberof patientswas reduced in orderto avoid density in hospitals. During this period, ithappenedinpatientswhodidnotwanttotaketheriskofvisionlossandcometotreatment.

ConclusionWiththeCOVID-19epidemicthataffectsthewholeworld,patients with diseases other than COVID 19 are greatlyaffected by this situation. Throughout the pandemic, wemust act by minimizing the risks so that patients,healthcareprofessionals andourenvironment canescapefrom this situation with as less harm as possible. Asophthalmologists, whilemanaging the acute pandemic inthisdifIicultperiod,wemusttakethenecessaryprotectivemeasurestoprotectourselves,whiletreatingourpatients'ophthalmological conditions that threaten their vision,independence and even their quality of life. While doingthese practices, we must deliver health services byadheringtotheprinciplesofprofessionalethics.

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EJAIBEditor:Darryl Macer (Chair, Accredited Universities ofSovereignNations)AssociateEditor:Nader Ghotbi (Ritsumeikan Asia PaciIic University,APU))Editorial Board: Akira Akabayashi (Japan), SahinAksoy (Turkey), Martha Marcela Rodriguez-Alanis(Mexico), Angeles Tan Alora (Philippines), AtsushiAsai (Japan), Alireza Bagheri (Iran), Gerhold Becker(Germany), Rhyddhi Chakraborty (India/UK),Shamima Lasker (Bangladesh), Minakshi Bhardwaj(UK), Christian Byk (IALES; France), Ken Daniels(New Zea l and) , O l e Doer ing (Ge rmany) ,AmarbayasgalanDorjderem(Mongolia),HasanErbay(Turkey), Soraj Hongladarom (Thailand), Dena Hsin(Taiwan), Rihito Kimura (Japan), Abby Lippman(Canada), Umar Jenie (Indonesia), Nobuko YasuharaMacer (Japan), Masahiro Morioka (Japan), AnwarNasim(Pakistan),Jing-BaoNie(China,NewZealand),Pinit Ratanakul (Thailand), Qiu Ren Zong (China),Hyakudai Sakamoto (Japan), Sang-yong Song(Republic of Korea), Takao Takahashi (Japan),N o r i t o s h i T a n i d a ( J a p a n ) , A n a n y aTritipthumrongchok (Thailand), Yanguang Wang(China), Daniel Wikler (USA), Jeong Ro Yoon(RepublicofKorea).

Eubios Journal of Asian and International Bioethics 31(1) (January 2021) 61

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