Microsoft Word - Rehabilitation ethics COVID19 Bangladesh Journal of Bioethics 2021; 12 (1): 49-53 49 COVID-19 Pandemic: Ethical and Medical issues arising for people with disability in Bangladesh Taslim Uddin1, Hassan Tasdeed Mohammad2, Naima Siddiquee3 1. Professor and Chairman, Department of Physical Medicine and Rehabilitation, Bangabandhu Sheikh Mujib Medical University, Dhaka. Bangladesh. Email: taslimpmr@gmail.com (Corresponding Author) 2.Asstt Surgeon, Colonel Malek Medical College Hospital, Manikgonj. Dhaka. Bangladesh. Email:drtasdeed@gmail.com 3. Department of Physical Medicine and Rehabilitation, United Hospital, Dhaka. Bangladesh. Email: drnaima_2008@yahoo.com DOI: https://doi.org/10.3329/bioethics.v12i1.51901 Abstract: The disability viewpoint is the fundamental for understanding social justice in a given population. Disability rights need to be obeyed in the inclusive preparedness and response to all the disasters or during the crisis period including COVID-19 pandemic. COVID-19 pandemic jeopardized the health and rehabilitation services globally. The impact is much more in low resource developing countries like Bangladesh. In general, people with disability (PWD) suffer from multiple medical and rehabilitation complications and they need frequent rehabilitation consultations or hospital admissions in comparison to people without disability. As a developing country, Bangladesh has poor ratios of doctors, nurses and technologists of 1:0.4:0.24 (WHO: 1:3:5) to face the COVID-19 challenge. Rehabilitation services have been disrupted in almost two-thirds (63%) of countries of the world. Even though rehabilitation is the key to recovery following severe illness from COVID-19. There are many concerns and debates about the preparedness, response and mitigation the process of COVID-19 on the part of the national government. According to recent study reports, the lives of about 100% of PWD have been impacted by the COVID-19 pandemic. COVID-19 National Technical Advisory Committee is working for strategic planning, response and mitigation process but omission of a representative of PWD or a rehabilitation physician in the committee has created much dissatisfaction. The difficult COVID-19 testing process due to country wide shutdown of rehabilitation essential services and central pulling of rehabilitation physicians have side lined the PWD inclusiveness. It is expected that the rehabilitation preparedness, response and mitigation of the pandemic should be based on an ethics driven process. Key words: COVID-19, Bangladesh, Ethical issues, Medical issues, people with disability, Introduction: During March 11, 2020 the World Health Organization (WHO) declared the outbreak of the novel coronavirus disease (COVID-19) to be a pandemic1. In Bangladesh first case of COVID-19 was detected on 08th March 2020, it reached 100 cases on April 9th and exceeded 200 cases (Case Doubling Time) within next two days. As of October12, 2020, there were 379,738 confirmed cases including 5,555 deaths with the case fatality rate (CFR) 1.85% and recovery rate 77.5% respectively2. Recent survey reports show that about 100% of the people with disability lives have been changed by COVID 19 pandemic 3. It is talk of the town that the 2nd wave of COVID-19 should learned lessons from the worse 2nd wave of the 1918 Spanish Flu. During the COVID-19 Pandemic there were resource constraints at emergency e.g. central oxygen supply, rationing ventilators and intensive care beds4. Great concerns about the COVID-19 preparedness, health and rehabilitation response for people with disability (PWD) in Bangladesh Bangladesh Journal of Bioethics 2021; 12 (1): 49-53 50 were given. COVID-19 related rehabilitation challenges were highlighted and strategy to adapt during the pandemic was documented but issues in relation to people with disability were not addressed5. An attempt was made in this communication to examine the key concerns and issues affecting health care and life of PWD impacted by COVID-19 pandemic in this low resource developing country. COVID-19 preparedness: Recently, three ethical duties for health care leaders as part of COVID-19 pandemic preparedness are proposed e.g. (a) the duty to safeguard (supporting workers and protecting vulnerable populations), (b) the duty to plan (managing uncertainty), and (c) the duty to guide (contingency levels of care and crisis standards of care) 6. As a useful source of updated information, a “COVID-19 dashboard” has been developed in the webpage of the Directorate General of Health Services. “Bangladesh preparedness and response plan” (BPRP) for the coronavirus disease 2019 document was published during July 2020 with the goal to prevent and control the spread of COVID-19 in order to reduce its impact on the health, to scale up its core capacities, wellbeing and economy of the country and to set out the framework to treat the infected people.7 The Health Ministry has established a high-level National Technical Advisory Committee consisting of government and independent experts to advise COVID-19 health related issues. However, there was no mentioning of the most vulnerable group of PWD. Although about 14 million people live with some form of disability in the country, omission of representation from disability and rehabilitation sector is a concern. The Government has recruited an additional 2000 doctors and 5000 nurses to start addressing this situation but no news or indication was available on escalation of members from the rehabilitation team7. COVID-19 Testing: According to the number of COVID-19 cases, Bangladesh is positioned 16th in the world. The numbers of new cases are added on regularly. The strategic recommendation of COVID-19 preparedness and response was to detect the virus with increasing the testing capacity following the health guidelines provided by WHO and endorsed by the government. However, there was a great public health concerns and criticizing of the lowest corona virus testing capacity with charging a fee for the test.8 That hampered COVID -19 responses as many of the poor or PWD had disadvantages. Most of Polymerase Chain Reaction (PCR) testing facilities were based mostly concentrated in the Capital City Dhaka that required an online PWD non-user-friendly appointment system. Another issue was test results, in some cases it was a week-long delay or in some other cases it did not at all arrived to the patient 8. Many of the patients with non-communicable diseases (NCD)s or with disabilities could not be admitted in hospitals because of the delayed COVID-19 test results. There was a delay for permitting COVID-19 serological tests in Bangladesh. According to the drafted government policy, the rapid antibody testing kit can be used for sero- surveillance, convalescent plasma therapy and research9. Bangladesh and disability & rehabilitation health Sector. Bangladesh is a small country with about 165 million populations. It is the most densely populated country in the world. The load was further burdened with the largest Pakistani and Rohinga refugees with the fear of mass infections by the corona virus agent.10 Bangladesh has poor ratios of doctors nurses and technologists of 1:0.4:0.24 (WHO: 1:3:5) 11. It is a lower-middle-income developing country (LMIC) with less than 3% of GDP is spent on health sector 10. It has poor emergency treatment facilities including hospital beds, central oxygen supply and has limited rehabilitation facilities. Bangladesh Journal of Bioethics 2021; 12 (1): 49-53 51 Quality of services at these facilities, however, is quite low due to insufficient allocation of resources, institutional limitations and absenteeism or negligence of providers. According to the WHO about 15% of Bangladesh's total population is disabled. Because of lower immune protection they are more likely prone to be infected with corona virus than others. Bangladesh had few rehabilitations works forces with mal-distribution of the therapists and rehabilitation physicians5. Article 11 of the United Nations Convention on the Rights of Persons with Disabilities (UNCRPD) requires that every state shall adopt all necessary measures to ensure the protection and safety of PWDs in situations of risk, including situations of armed conflict, humanitarian emergencies and the occurrence of natural disasters.12 In Bangladesh, according to a recent country wide survey, 28.4% of the PWD did not know anything about the coronavirus. This survey also reports that 47% of persons with disabilities are the sole earners in their families and due to COVID -19 lockdown restrictions the income of 61.6% of working persons with disabilities decreased13. The report recommended completing the disability identification (and registration process) survey of 2012 with prioritizing the women and children. Another report states that about 50% of Bangladeshi PWD did not have access to personal protective equipment (PPE) at family level and at works to protect the family members and themselves3. this papa is better suit under heading of Bangladesh and Disability & rehabilitation health sector. COVID-19 disability impact and ethical issues: PWD with major disabling events like traumatic brain injury (TBI), spinal cord injury (SCI), limb amputations, or other neuro- musculoskeletal disorders including stroke have need more health and rehabilitation care and require frequent hospitalization and rehabilitation team care14. The problem was further intensified when rehabilitation health care professionals were pulled in to the centrally administered COVID-19 emergency duty roster then the rehabilitation OPDs were shutdown5. No record available for reference about the number of PWD affected by COVID-19, but the sufferings including child hood disabilities are much more than it was thought15. The entire health system including rehabilitation services were jeopardized by COVID-19 which raises challenging bioethical dilemmas16. Understanding of disability rights is central in an all-inclusive COVID-19 preparedness; which was not obeyed by the policy makers. This has created significant disruptions and additional risks to their autonomy, health and daily living activities. Limited and selective rehabilitation therapies were available to PWD resulted to gross reduction of previously attained functional capabilities of the neuro-musculo-skeletal and cardiorespiratory system.17. Health care workers had to work hard under lot of anxiety and agony during the pandemic; still there were arguments about their prioritization at the work places18. PWD are not always patients and service seekers; it requires a recognition that doctors and nurses serving PWD have been working at the frontline in this pandemic19. PWD in Bangladesh are regularly subjected to discrimination and they suffer greatly during the COVID-19 crisis period. Many of them could not get reliefs provided by the different public and private agencies because they could not stand in queues or compete with crowds13. Maintenance of social distancing and using masks remain as a barrier for blind and deaf person. “Social distancing” is not a better term for PWD, it may be replaced with “physical distancing” 20. There was a threat on patient- rehabilitation health care worker (RHCW) relationship during the COVID- 19 crisis period. Unlike acute and short-term illnesses and disease, this relationship is long term bondage of trust based on moral rules and Bangladesh Journal of Bioethics 2021; 12 (1): 49-53 52 principles. While examining the COVID-19 related prevailing ethical issues following recommendation are provided in the box 1. Conclusion: There was limited application of existing frameworks of emergency planning for PWD in the COVID-19 pandemic. COVID-19 rehabilitation preparedness, response and mitigation should be based on ethics driven process. The right of vulnerable populations in the areas of equality of access to health care and supports should not be forgotten during the crisis periods or at peace. Access to COVID-19 information system and a special response inclusive plan for PWD is of paramount importance. Box: 1 Recommendations for PWD inclusive COVID-19 preparedness and response 1. Inclusion of representatives of Rehabilitation team members and PWD in the National Technical Advisory Committee (NTAC). 2. NTAC working groups should explicitly recruit physiatrist, PWD and chronic illnesses in rehabilitation response strategies. 3. Increase rehabilitation capacity building with empowerment of PWD21. 4. Improved information for PWD and establishing mandatory sign language in all crisis information. 5. Establishing special dedicated high level control cell 24 hours services for PWD. 6. To follow the WHO’s advice for disability- inclusive COVID-19 considerations to mitigate the barriers for PWD22. 7. Providing accommodations to PWD who work in a distant place. 8. More online job market should be created for PWD so as to they can work staying at home. References: 1. World Health Organization. https://www.who.int/docs/default- source/searo/bangladesh/covid-19-who- bangladesh-situation-reports/who-ban-covid-19- sitrep-10.pdf?sfvrsn=c0aac0b8_4. (Accessed October15, 2020.) 2. World Health Organization, Bangladesh. https://www.who.int/docs/default- source/searo/bangladesh/covid-19-who- bangladesh-situation-reports/who-covid-19- update-33-20201012.pdf?sfvrsn=8e5f58c7_2 accessed October 14, 2020 3. http://www.edf-feph.org/sites/default/files/i2i- covid19-survey-accessible.pdf. (Accessed October15, 2020.) 4. White DB, Lo B. A Framework for Rationing Ventilators and Critical Care Beds During the COVID-19 Pandemic. JAMA 2020. DOI: 10.1212/WNL.0000000000009936 5. Uddin T, Siddiq AB, Islam MT Strategies to Adapt COVID-19 Impacted Low Resource Rehabilitation Services. Int J Phys Med Rehabil 202 ; 8:558. DOI: 10.35248/2329-9096.20.08.558 6. Berlinger N, Wynia M, Powell T, Hester DM, Milliken A, Fabi R, et al. Ethical Framework for Health Care Institutions & Guidelines for Institutional Ethics Services Responding to the Coronavirus Pandemic: Managing Uncertainty, Safeguarding Communities, Guiding Practice The Hastings Center 16 March 2020 Available from: https://www.thehastingscenter.org/ethicalframew orkcovid19/ (Accesses on September 30,2020) 7. Bangladesh Preparedness and Response Plan for COVID-19. Government of the People’s Republic of Bangladesh. July 2020. file:///C:/Users/User/Downloads/COVID%20Sin gle%20Plan_Approved.pdf (Accessed October16, 2020) 8. Sophie Cousins. Bangladesh’s COVID-19 testing criticized. The Lancet, World Report. August 29, 2020. 396(10251): 591.DOI:https://doi.org/10.1016/S0140- 6736(20)31819-5 9. Government of Bangladesh. https://mofa.portal.gov.bd/sites/default/files/files /mofa.portal.gov.bd/page/836e2514_cd8d_48d1_ b4c3_ff51cd37ebd0/Bangladesh%20Finalises%2 0Antibody%20Test%20Policy.pdf. (Accessed October15, 2020) 10. Uddin T, Rahman MA. COVID 19: Importance of Physical Rehabilitation Medicine Capacity Building. Mymensingh Med J. 2020;29(3):496- 497. PMID- 32844784. Bangladesh Journal of Bioethics 2021; 12 (1): 49-53 53 https://pubmed.ncbi.nlm.nih.gov/32844784/ (Accesses on September15,2020) 11. http://www.searo.who.int/entity/asia_pacific_obs ervatory/publications/hits/hits_ban_0_executive_ summary.pdf?ua=1. (Accessed October15, 2020) 12. United Nations. Convention on the Rights of Persons with Disabilities. Vienna: United Nations; 2006. https://treaties.un.org/pages/ViewDetails.aspx?sr c=TREATY&mtdsg_no=IV- 15&chapter=4&clang=_en (Accessed on September 13,2020) 13. Swarna Moye Sarker. How Covid-19 is affecting persons with disabilities. 12 June 2020. https://tbsnews.net/thoughts/how-covid-19- affecting-persons-disabilities-92416. Accessed October15, 2020. https://tbsnews.net/thoughts/how-covid-19- affecting-persons-disabilities-92416 (Accessed on September 13,2020) 14. Kibria G, Islam T, Miah S, Ahmed S, Hossain A. Barriers to healthcare services for persons with disabilities in Bangladesh amid the COVID-19 pandemic. Public Health in Practice. 2020; 1:100027. DOI:10.1016/j.puhip.2020.100027 15. UNICEF Data: Monitoring the situation of children and women. Child hood disability and COVID-19. April 2020 https://data.unicef.org/topic/child- disability/covid-19/ (Accessed October 21,2020) 16. Maya Sabatello, Teresa Blankmeyer Burke, Katherine E. McDonald, Paul S. Appelbaum, “Disability, Ethics, and Health Care in the COVID-19 Pandemic”, American Journal of Public Health 110, no. 10 (October 1, 2020): pp. 1523-1527. DOI:10.2105/AJPH.2020.305837 17. Uddin T, Islam M T, Rahim R H, et al. Rehabilitation Perspectives of COVID-19 Pandemic in Bangladesh. Journal of Bangladesh College of Physicians and Surgeons 2020; 38 76- 81. https://doi.org/10.3329/jbcps.v38i0.47345 (Accessed October15, 2020). 18. Mark P. Aulisio & Thomas May. Why Healthcare Workers Ought to Be Prioritized in ASMR During the SARS-CoV-2 Pandemic? The American Journal of Bioethics 2020, 20:7, 125- 128, DOI: 10.1080/15265161.2020.1779411 19. Newz Hook. Disabled healthcare professionals stand shoulder to shoulder in the fight against coronavirus March 2020. Available from: https://newzhookcom/story/doctors-disa bilities- disabled-healthcare-professiona ls-coronavirus/ (Accessed October 20,2020.) 20. Singh S. Disability ethics in the coronavirus crisis. J Family Med Prim Care. 2020;9(5):2167- 2171. Published 2020 May 31. DOI:10.4103/jfmpc.jfmpc_588_20 21. Uddin T, Rahman MA. COVID 19: Importance of Physical Rehabilitation Medicine Capacity Building. Mymensingh Med J. 2020;29(3):496- 497. PMID- 32844784. https://pubmed.ncbi.nlm.nih.gov/32844784/ (Access on September 10,2020) 22. World Health Organization. Disability considerations during the COVID-19 outbreak, 26 March 2020. World Health Organization; 2020. Available from: https://wwwwhoint/who- documents-det ail/disability-considerations-durin g-the-covid-19-outbreak. (Accessed October21,2020.) Author contribution: 1st author Taslim Uddin conceived the idea, designed of the manuscript, performed the literature search, wrote the initial draft, checked the manuscript meticulously and gave final approval of the manuscript for submission. 2nd author Hassan Tasdeed Mohammad did the critical revision of the article, performed the literature search and gave the final approval of the manuscript for submission. 3rd author Naima Siddiquee performed the literature search, revised the article critically and checked the manuscript meticulously and gave final approval of the manuscript for submission. Conflict of interests: No conflict of interest in this study to declare.