Zeitschriftenartikel zum Thema „Assyrian Ethnic School (N.S.W.)“

School readiness is critical to academic achievement in first grade. However, often parents only focus on cognitive readiness without paying much attention to children's emotional factors and parental factors that affect school readiness. This study aims to identify the relationship between parenting skills, emotional quotient (EQ), intelligence (IQ), and children's school readiness. This study uses a correlation design that focuses on parental and internal factors. The research subjects were parents and students from 21 kindergartens in Magelang (n=165) who were selected through simple random sampling. Data collection was carried out through online questionnaires for parents, Raven Intelligence Scale, EQ Scale, and school readiness tests for children. The data obtained were analyzed through regression analysis techniques. The results of the study show that emotional intelligence has the strongest correlation with school readiness. Intelligence also correlates with children's school readiness. However, there is no significant correlation between parental skills and children's school readiness. Based on gender, there is no significant difference in school readiness between boys and girls. The findings of this study imply that school readiness needs to be improved by developing children's emotional intelligence as important as cognitive intelligence. Keywords: parenting skills, children’s EQ and IQ, school readiness References: Arnold, C., Bartlett, K., Gowani, S., & Shallwani, S. (2008). Transition to school: Reflections on readiness. Journal of Developmental Processes, 3(2), 26–38. Blankson, A. N., Miner, J., Leerkes, E. M., O’Brien, M., Calkins, S. D., & Marcovitch, S. (2017). Cognitive and Emotional Processes as Predictors of a Successful Transition into School HHS Public Access. Early Educ Dev, 28(1), 1–20. https://doi.org/10.1080/10409289.2016.1183434 Cohen, J. (2006). Social, emotional, ethical, and academic education: Creating a climate for learning, participation in democracy and well-being. Harvard Educational Review, 76(2), 201–237. Coolahan, Kathleen, Mendez, Julia, Fantuzzo, John; McDermott, P. (2020). Preschool peer interactions and readiness to learn: Relationships between classroom peer play and learning behaviors and conduct. Journal of Educational Psychology, 92(3), 458–465. https://doi.org/10.1016/j.dr.2019.01.001.The Creswell, J. W. (2015). Educational research: Planning, conducting, and evaluating quantitative and qualitative research (Fifth edition). Pearson. Crnic, Keith Lamberty, G. (1994). Reconsidering school readiness: Conceptual and applied perspectives. Early Education and Development, 5(2), 91–105. Dawson, Courtney; Huitt, W. G. (2011). Running head: Social Development. April. Edwards, C. P., Sheridan, S. M., & Lisa, K. (2008). Digital Commons @ University of Nebraska—Lincoln Parent Engagement and School Readiness: Parent- Child Relationships in Early Learning. Faculty Publications, Department of Child, Youth, and Family Studies, 60(September). Janus, M., & Offord, D. A. N. (1997). To Learn at School. 71–75. Janus, M., & Offord, D. R. (2007). Development and psychometric properties of the Early Development Instrument (EDI): A measure of children’s school readiness. Canadian Journal of Behavioural Science, 39(1), 1–22. https://doi.org/10.1037/cjbs2007001 Lucy S. King, 1 Kathryn L. Humphreys, 2 and Ian H. Gotlib1. (2020). The Neglect–Enrichment Continuum: Characterizing Variation in Early Caregiving Environments. HHS Public Asses. Lunenburg, F. C. (2011). Early Childhood Education: Implications for School Readiness. 2(1), 1–8. McLanahan, S., Haskins, R., Paxson, C., Rouse, C., & Sawhill, I. (2005). The Future of Children: School Readiness: Closing Racial and Ethnic Gaps Affairs. In The Future of Children (Vol. 15, Issue 1). Oyserman, D., Brickman, D., & Rhodes, M. (2007). School success, possible selves, and parent school involvement. Family Relations, 56(5). https://doi.org/10.1111/j.1741-3729.2007.00475.x Pagani, L. S., & Fitzpatrick, C. (2014). Children’s School Readiness: Implications for Eliminating Future Disparities in Health and Education. Health Education and Behavior, 41(1), 25–33. https://doi.org/10.1177/1090198113478818 Pagani, L. S., & Messier, S. (2012). Links between Motor Skills and Indicators of School Readiness at Kindergarten Entry in Urban Disadvantaged Children. Journal of Educational and Developmental Psychology, 2(1), 95–107. https://doi.org/10.5539/jedp.v2n1p95 Pianta, R. C., Barnett, W. S., Burchinal, M., & Thornburg, K. R. (2009). The effects of preschool education: What we know, how public policy is or is not aligned with the evidence base, and what we need to know. Psychological Science in the Public Interest, Supplement, 10(2), 49–88. https://doi.org/10.1177/1529100610381908 Raver, C., & Knitze, J. (2002). Ready to Enter: What Research Tells Policymakers About Strategies to Promote Social and Emotional School Readiness Among Three- and Four-Year-Old Children. Promoting the Emotional Well-Being of Children and Families, 3, 1–24. Sari, Y. D. L. A. (2019). Analysis of parental involvement in learning assistance in early childhood. [Analisis keterlibatan orang tua dalam pendampingan pembelajaran pada anak usia dini]. Jurnal Caksana-Pendidikan Anak Usia Dini, 2(1), 22–38. Shaari, M. F., & Ahmad, S. S. (2016). Physical Learning Environment: Impact on Children School Readiness in Malaysian Preschools. Procedia - Social and Behavioral Sciences, 222, 9–18. https://doi.org/10.1016/j.sbspro.2016.05.164 Shan, W., Zhang, Y., Zhao, J., Zhang, Y., Cheung, E. F. C., Chan, R. C. K., & Jiang, F. (2019). Association between Maltreatment, Positive Parent–Child Interaction, and Psychosocial Well-Being in Young Children. Journal of Paediatrics, 213. https://doi.org/10.1016/j.jpeds.2019.06.050 Shonkoff, J. P., & Phillips, D. A. (Eds.). (2000). From neurons to neighbourhoods: The science of early childhood development. National Academy Press. Sudarsih, W. (2011). Social Skills [Keterampilan Sosial]. Repository.Upi. Edu, 12–35. Utami, N. R., & Novitasari, K. (2020). Developing a Multirepresentation Learning Model Based on Local Wisdom to Transform Character for Students Of 5-6 Years Old. Early Childhood Education and Development Journal, 1(2), 9. https://doi.org/10.20961/ecedj.v1i2.35362 Xiao Zhang; Bi Ying Hu; Lixin Ren; Meifang. (2019). Young Chinese Children’s Academic Skill Development: Identifying Child-, Family-, and School-Level Factors: Young Chinese Children’s Academic Skill Development. New Directions for Child and Adolescent Development 2019(3), 3. Xing, X., & Wang, M. (2018). The moderating role of HPA activity in the relations between parental corporal punishment and executive function in Chinese school-aged children. Psychology of Violence, 8(4), 418–426., 8(4), 418-426.

Parental Involvement in their children's schooling has long been recognized as a critical component of good education. This study aims to find out the relationship between socioeconomic status, interpersonal communication, and school climate with parental involvement in early childhood education. Using survey and correlational research design, data collection was carried out through accumulation techniques with tests and questionnaires. The data analysis technique used statistical analysis and multiple regressions. The findings in the socio-economic context of parents show that the measure of power is an indicator in the very high category with a total score of 5, while the measures of wealth, honour and knowledge are included in the high category with a total score of 4 in relation to parental involvement. The form of interpersonal communication, the openness of parents in responding happily to information / news received from schools about children is a finding of a significant relationship with parental involvement in early childhood education. The school climate describes the responsibility for their respective duties and roles, work support provided, and interpersonal communication relationships, parents at home and teachers at school. Keywords: Socio-economic Status, Interpersonal Communication, Climate School, Parental Involvement, Early Childhood Education References Amato, P. R. (2005). The Impact of Family Formation Change on the Cognitive, Social, and Emotional Well-Being of the Next Generation. The Future of Children, 15(2), 75–96. https://doi.org/10.1353/foc.2005.0012 Arnold, D. H., Zeljo, A., Doctoroff, G. L., & Ortiz, C. (2008). Parent Involvement in Preschool: Predictors and the Relation of Involvement to Preliteracy Development. School Psychology Review, 37(1), 74–90. https://doi.org/10.1080/02796015.2008.12087910 Barbato, C. A., Graham, E. E., & Perse, E. M. (1997). Interpersonal communication motives and perceptions of humor among elders. Communication Research Reports, 14(1), 48–57. https://doi.org/10.1080/08824099709388644 Barbato, C. A., Graham, E. E., & Perse, E. M. (2003). Communicating in the Family: An Examination of the Relationship of Family Communication Climate and Interpersonal Communication Motives. Journal of Family Communication, 3(3), 123–148. https://doi.org/10.1207/S15327698JFC0303_01 Barnard, W. M. (2004). Parent involvement in elementary school and educational attainment. Children and Youth Services Review, 26(1), 39–62. https://doi.org/10.1016/j.childyouth.2003.11.002 Benner, A. D., Boyle, A. E., & Sadler, S. (2016). Parental Involvement and Adolescents’ Educational Success: The Roles of Prior Achievement and Socioeconomic Status. Journal of Youth and Adolescence, 45(6), 1053–1064. https://doi.org/10.1007/s10964-016-0431-4 Berkowitz, R., Astor, R. A., Pineda, D., DePedro, K. T., Weiss, E. L., & Benbenishty, R. (2021). Parental Involvement and Perceptions of School Climate in California. Urban Education, 56(3), 393–423. https://doi.org/10.1177/0042085916685764 Berkowitz, R., Moore, H., Astor, R. A., & Benbenishty, R. (2017). A Research Synthesis of the Associations Between Socioeconomic Background, Inequality, School Climate, and Academic Achievement. Review of Educational Research, 87(2), 425–469. https://doi.org/10.3102/0034654316669821 Brand, S., Felner, R. D., Seitsinger, A., Burns, A., & Bolton, N. (2008). A large-scale study of the assessment of the social environment of middle and secondary schools: The validity and utility of teachers’ ratings of school climate, cultural pluralism, and safety problems for understanding school effects and school improvement. Journal of School Psychology, 46(5), 507–535. https://doi.org/10.1016/j.jsp.2007.12.001 Brand, S., Felner, R., Shim, M., Seitsinger, A., & Dumas, T. (2003). Middle school improvement and reform: Development and validation of a school-level assessment of climate, cultural pluralism, and school safety. Journal of Educational Psychology, 95(3), 570–588. https://doi.org/10.1037/0022-0663.95.3.570 Culp, A. M., Hubbs-Tait, L., Culp, R. E., & Starost, H.-J. (2000). Maternal Parenting Characteristics and School Involvement: Predictors of Kindergarten Cognitive Competence Among Head Start Children. Journal of Research in Childhood Education, 15(1), 5–17. https://doi.org/10.1080/02568540009594772 Dearing, E., McCartney, K., Weiss, H. B., Kreider, H., & Simpkins, S. (2004). The promotive effects of family educational involvement for low-income children’s literacy. Journal of School Psychology, 42(6), 445–460. https://doi.org/10.1016/j.jsp.2004.07.002 Desforges, C., Abouchaar, A., Great Britain, & Department for Education and Skills. (2003). The impact of parental involvement, parental support and family education on pupil achievements and adjustment: A literature review. DfES. El Nokali, N. E., Bachman, H. J., & Votruba-Drzal, E. (2010). Parent Involvement and Children’s Academic and Social Development in Elementary School: Parent Involvement, Achievement, and Social Development. Child Development, 81(3), 988–1005. https://doi.org/10.1111/j.1467-8624.2010.01447.x Englund, M. M., Luckner, A. E., Whaley, G. J. L., & Egeland, B. (2004). Children’s Achievement in Early Elementary School: Longitudinal Effects of Parental Involvement, Expectations, and Quality of Assistance. Journal of Educational Psychology, 96(4), 723–730. https://doi.org/10.1037/0022-0663.96.4.723 Epstein, J. L. (Ed.). (2002). School, family, and community partnerships: Your handbook for action (2nd ed). Corwin Press. Fan, X. (2001). Parental Involvement and Students’ Academic Achievement: A Growth Modeling Analysis. The Journal of Experimental Education, 70(1), 27–61. https://doi.org/10.1080/00220970109599497 Fan, X., & Chen, M. (2001). Parental Involvement and Students’ Academic Achievement: A Meta-Analysis. Educational Psychology Review, 23. Georgiou, S. N., & Tourva, A. (2007). Parental attributions and parental involvement. 10. Gorski, P. (2008). The Myth of the Culture of Poverty. Educational Leadership, 65(7), 32–36. Hamre, B. K., & Pianta, R. C. (2005). Can Instructional and Emotional Support in the First-Grade Classroom Make a Difference for Children at Risk of School Failure? Child Development, 76(5), 949–967. https://doi.org/10.1111/j.1467-8624.2005.00889.x Hill, N. E., & Taylor, L. C. (2004). Parental School Involvement and Children’s Academic Achievement: Pragmatics and Issues. Current Directions in Psychological Science, 13(4), 161–164. https://doi.org/10.1111/j.0963-7214.2004.00298.x Hong, S., & Ho, H.-Z. (2005). Direct and Indirect Longitudinal Effects of Parental Involvement on Student Achievement: Second-Order Latent Growth Modeling Across Ethnic Groups. 11. Hornby, G., & Lafaele, R. (2011). Barriers to parental involvement in education: An explanatory model. Educational Review, 63(1), 37–52. https://doi.org/10.1080/00131911.2010.488049 Hoy, W. K., Tarter, C. J., & Hoy, A. W. (2006). Academic Optimism of Schools: A Force for Student Achievement. American Educational Research Journal, 43(3), 425–446. https://doi.org/10.3102/00028312043003425 Jeynes, W.H. (2014). Parent involvement for urban youth and student of color. In Handbook of urban education (In H. R. Milner&K. Lomotey (Eds.)). NY: Routledge. Jeynes, William H. (2005). Effects of Parental Involvement and Family Structure on the Academic Achievement of Adolescents. Marriage & Family Review, 37(3), 99–116. https://doi.org/10.1300/J002v37n03_06 Jeynes, William H. (2007). The Relationship Between Parental Involvement and Urban Secondary School Student Academic Achievement: A Meta-Analysis. Urban Education, 42(1), 82–110. https://doi.org/10.1177/0042085906293818 Kaplan, D. S., Liu, X., & Kaplan, H. B. (2010). Influence of Parents’ Self-Feelings and Expectations on Children’s Academic Performance. 12. Kuperminc, G. P., Leadbeater, B. J., & Blatt, S. J. (2001). School Social Climate and Individual Differences in Vulnerability to Psychopathology among Middle School Students. Journal of School Psychology, 39(2), 141–159. https://doi.org/10.1016/S0022-4405(01)00059-0 Kutsyuruba, B., Klinger, D. A., & Hussain, A. (2015). Relationships among school climate, school safety, and student achievement and well-being: A review of the literature. Review of Education, 3(2), 103–135. https://doi.org/10.1002/rev3.3043 Long, H., & Pang, W. (2016). Family socioeconomic status, parental expectations, and adolescents’ academic achievements: A case of China. Educational Research and Evaluation, 22(5–6), 283–304. https://doi.org/10.1080/13803611.2016.1237369 Loukas, A. (2007). High-quality school climate is advantageous for all students and may be particularly beneficial for at-risk students. 3. Mattingly, D. J., Prislin, R., McKenzie, T. L., Rodriguez, J. L., & Kayzar, B. (2002). Evaluating Evaluations: The Case of Parent Involvement Programs. Review of Educational Research, 72(4), 549–576. https://doi.org/10.3102/00346543072004549 McWayne, C., Hampton, V., Fantuzzo, J., Cohen, H. L., & Sekino, Y. (2004). A multivariate examination of parent involvement and the social and academic competencies of urban kindergarten children. Psychology in the Schools, 41(3), 363–377. https://doi.org/10.1002/pits.10163 Miedel, W. T., & Reynolds, A. J. (1999). Parent Involvement in Early Intervention for Disadvantaged Children: Does It Matter? 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Early Schooling of Children at Risk. 31. Reynolds, A. J. (1992). Comparing measures of parental involvement and their effects on academic achievement. Early Childhood Research Quarterly, 7(3), 441–462. https://doi.org/10.1016/0885-2006(92)90031-S Reynolds, A. J., Ou, S.-R., & Topitzes, J. W. (2004). Paths of Effects of Early Childhood Intervention on Educational Attainment and Delinquency: A Confirmatory Analysis of the Chicago Child-Parent Centers. Child Development,75(5), 1299–1328. https://doi.org/10.1111/j.1467-8624.2004.00742.x Reynolds, A. J., Temple, J. A., Ou, S.-R., Arteaga, I. A., & White, B. A. B. (2011). School-Based Early Childhood Education and Age-28 Well-Being: Effects by Timing, Dosage, and Subgroups. 333, 6. Shute, V. J., Hansen, E. G., Underwood, J. S., & Razzouk, R. (2011). A Review of the Relationship between Parental Involvement and Secondary School Students’ Academic Achievement. 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The purpose of this study was to find out the information whether the whole language approach can improve the speaking ability for third-grade students’ elementary school. The subjects of this study were 22 of the third-grade students of elementary school Rawamangun, East Jakarta. The method of the study was action research conducting using model of Kemmis and Taggart. Data collection and analysis using data triangulation techniques. The results of the study show that speaking ability is one of the important skills used to communicate so it needs to be developed for grade 3 elementary school students. The result showed that the whole language approach can be applied as a method in improving students' speaking ability for third-grade elementary school. Therefore, teachers need to develop a whole language approach to language learning. So that it, can improve students' speaking ability. Keywords: Elementary student 1stgrade, Speaking ability, Whole language approach References Abu-Snoubar, T. K. (2017). On The Relationship between Listening and Speaking Grades of AL-Balqa Applied University English as a Foreign Language Students. International Education Studies, 10(12), 130. https://doi.org/10.5539/ies.v10n12p130 Bayat, S. (2016). The effectiveness of the creative writing instruction program based on speaking activities (CWIPSA). International Electronic Journal of Elementary Education, 8(4), 617–628. Buckingham, L., & Alpaslan, R. S. (2017). Promoting speaking proficiency and willingness to communicate in Turkish young learners of English through asynchronous computer-mediated practice. System, 65, 25–37. https://doi.org/10.1016/j.system.2016.12.016 Chen, L., Cheng, J., & Chou, M. (2016). Literacy Development in Preschool Children: a Whole Language Curriculum. European Journal of Language Studies, 3(1), 24–49. Goodman, K. (1986). What‟s whole in whole language. Portsmouth: NH: Heinemann. Goodman, K. (2014). What’s Whole in Language in The 21 st Century? New York: Garn Press. Harmer, J. (1991). The Practice of English Language Teaching. The 3th Edition. London and New York: Longman Inc. Herbein, E., Golle, J., Tibus, M., Schiefer, J., Trautwein, U., & Zettler, I. (2018). Fostering elementary school children’s public speaking skills: A randomized controlled trial. Learning and Instruction, 55(October), 158–168. https://doi.org/10.1016/j.learninstruc.2017.10.008 Kemmis, S., & McTaggart, R. (1988). The action research planner (3rd ed.). Geelong, Australia: Deakin University Press. Khodadady, E., & Shamsaee, S. (2012). Formulaic sequences and their relationship with speaking and listening abilities. English Language Teaching, 5(2), 39–49. https://doi.org/10.5539/elt.v5n2p39 Leong, L., & Ahmadi, S. M. (2017). An Analysis of Factors Influencing Learners ’ English Speaking Skill. International Journal of Research in English Education, 2(1), 34–41. https://doi.org/10.18869/acadpub.ijree.2.1.34 Macintyre, P. D., Clément, R., Dörnyei, Z., & Noels, K. A. (2011). Conceptualizing Willingness to Communicate in a L2: A Situational Model of L2 Confidence and Affiliation. The Modern Language Journal, 82(4), 545–562. https://doi.org/10.1111/j.1540-4781.1998.tb05543.x Marzuki, M., Prayogo, J. A., & Wahyudi, A. (2016). Improving the EFL Learners’ Speaking Ability through Interactive Storytelling. Dinamika Ilmu, 16(1), 15. https://doi.org/10.21093/di.v16i1.307 Moghadam, J. N., & Adel, S. M. R. (2011). The Importance of Whole Language Approach in Teaching English to Intermediate Iranian EFL Learners. Theory and Practice in Language Studies, 1(11), 1643–1654. https://doi.org/10.4304/tpls.1.11.1643-1654 Ngalimun, & Alfulaila. (2014). Pembelajaran Keterampilan Berbahasa Indonesia. Yogyakarta: Aswaja Pressindo. Nunan, D. (2018). Teaching Speaking to Young Learners. In The TESOL Encyclopedia of English Language Teaching (First Edit). John Wiley & Sons, Inc. https://doi.org/10.1002/9781118784235.eelt0715 Park, Hyesook & Lee, A. R. (2014). L2 learners’ anxiety. Comp. Educ., 50(1), 45–57. https://doi.org/10.1080/03050068.2013.871832 Phadung, M., Suksakulchai, S., & Kaewprapan, W. (2016). Interactive whole language e-story for early literacy development in ethnic minority children. Education and Information Technologies, 21(2), 249–263. https://doi.org/10.1007/s10639-014-9318-8 Saepudin, E., Sukaesih, S., & Rusmana, A. (2018). Peran Taman Bacaan Masyarakat (Tbm) Bagi Anak-Anak Usia Dini. Jurnal Kajian Informasi Dan Perpustakaan, 5(1), 1. https://doi.org/10.24198/jkip.v5i1.10821 Schwarzer, D. (2001). Whole language in a foreign language class: From theory to practice. Foreign Language Annals, 34(1), 52–59. https://doi.org/10.1111/j.1944-9720.2001.tb02802.x Seong, Y. (2017). Assessing L2 Academic Speaking Ability: The Need for a Scenario-Based Assessment Approach. Working Papers in Applied Linguistics & TESOL, 17(2), 36–40. Stark, H. L., Snow, P. C., Eadie, P. A., & Goldfeld, S. R. (2016). Language and reading instruction in early years’ classrooms: the knowledge and self-rated ability of Australian teachers. Annals of Dyslexia, 66(1), 28–54. https://doi.org/10.1007/s11881-015-0112-0 Tarigan, & Guntur, H. (1981). Berbicara Sebagai Suatu Keterampilan Berbahasa. Bandung: Angkasa. Tuan, N. H., & Mai, T. N. (2015). Factors Affecting Students’ Speaking Performance at Le Thanh Hien High SchoolTuan, N. H., & Mai, T. N. (2015). Factors Affecting Students’ Speaking Performance at Le Thanh Hien High School. Asian Journal of Educaitonal Research, 3(2), 8–23. Asian Journal of Educaitonal Research, 3(2), 8–23. Ur, P. (1996). A course in Language Teaching. Practice and Theory. Cambridge: Cambridge. University Press. Walter, C. (2010). 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Special needs ECE children should be prepared with early literacy and numeracy skills to strengthen their competencies during the transitional phase to primary school. To help this transitional phase, teachers can provide a variety of diverse play activities. This study aims to explore and evaluate the pedagogical strategies employed by teachers in reinforcing special needs children's literacy and numeracy, as a support to their transition process from ECE to primary year. The research applied a qualitative method with data collection techniques through interviews, observations, and documentation. The sample selection applied purposive sampling based on the criteria and objectives of this study. The sample consisted of inclusive classroom teachers from ten ECE institutions in five regions of Central Java, including Semarang City, Pekalongan City, Surakarta City, Wonosobo District, and Jepara District. The study concludes that ECE teachers still see several limitations in dealing with special needs children. Therefore, teachers should modify plans and play activities to strengthen literacy and numeracy skills for special needs children to help them embark on primary school. Teachers expect necessary support for their improvement through training and guidance in dealing with special needs children, especially in developing their literacy and numeracy. Keywords: literacy and numeracy, special needs children, ECE-primary school transition References: 1 Agustina, E., & Zayyadi, M. (2023). Kemampuan Literasi Numerasi Siswa di Sekolah Inklusi. Apotema: Jurnal Program Studi Pendidikan Matematika, 9(1), 15-20. Alberta. (2019). Literacy and Numeracy Proggression. Understanding Special Education Needs, 1-15. Atlar, H., & Uzuner, Y. (2023). Supporting Teacher Development about Early Literacy in Children with Hearing Loss: An Action Research in Turkey. 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The development of creative thinking skills in student pedagogical activities can form a personality structure, which contributes to improving their professional culture and the effectiveness of the educational process. One form of stimulant that can be given to students is to make students creative in making children's literary works. The population in this study were 4th semester studentsof PGSD study program at IKIP PGRI Wates who took children's literature courses. This study aims to determine whether there is an influence of the level of student creativity on the ability to make children's literature. The influence of student learning creativity on the achievement of learning outcomes by 23% shows the tendency of the results of making children's literary works to significantly depend on the creativity of students. From the results of the study it can be concluded that the higher the creativity of students, the higher the ability to make children's literature is achieved. Keywords: Creativity, Students, Children's Literature REFERENCES Borodina, T., Sibgatullina, A., & Gizatullina, A. (2019). Developing Creative Thinking in Future Teachers as a Topical Issue of Higher Education. Journal of Social Studies Education Research, 10(4), 226–245. Bozhkova, G. N., Shastina, E. M., Kalimullina, O. V., & Shatunova, O. . (2019). Study of literary images of gifted characters in optional activities as a means to develop capable and talented youth. Space and Culture, 7(1), 264–273. https://doi.org/10.20896/saci.v7i1.463 Byrge, C., & Tang, C. (2015). Embodied creativity training: Effects on creative self-efficacy and creative production. Journal Thinking Skills and Creativity, 16(1), 51–61. https://doi.org/10.1016/j.tsc.2015.01.002 Djuanda, D. (2014). Pembelajaran sastra di SD dalam gamitan Kurikulum 2013. Mimbar Sekolah Dasar, 1(2), 191–200. https://doi.org/https://doi.org/10.53400/mimbar-sd.v1i2.882 Faidah, C. N. (2018). Dekonstruksi sastra anak: mengubah paradigma kekerasan dan seksualitas pada karya sastra anak Indonesia. KREDO: Jurnal Ilmiah Bahasa Dan Sastra, 2(1), 126–139. https://doi.org/10.24176/kredo.v2i1.2458 Hidayatullah, A. (2018). Tema dan gaya bahasa puisi siswa SMP: kajian struktural. Journal of Language Learning and Research (JOLLAR), 2(2), 1–11. Kacan, S. D., & Sahin, F. (2015). An Inquiry Concerning the Characterıstics of the Creative Person. Journal of Education and Practice, 6(27), 86–89. Kotluk, N., & Kocakaya, S. (2018). Culturally Relevant/Responsive Education: What do teachers think in Turkey. Journal of Ethnic and Cultural Studies, 5(2), 98–117. https://doi.org/10.29333/ejecs/123 Perry, A., & Karpova, E. (2017). Efficacy of teaching creative thinking skills: A comparison of multiple creativity assessments. Journal Thinking Skills and Creativity, 24(1), 118–126. https://doi.org/10.1016/j.tsc.2017.02.017 Prastiwi, K., & Sudigdo, A. S. (2022). 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The education system in the 21st century needs some transformation, particularly in terms of enhancing thinking skills. Traditional games that are well-designed can be an effective strategy for stimulating higher order thinking Skills (HOTS). This research aims to develop active and creative learning models by utilizing traditional games to stimulate HOTS in early childhood. The current study is included in the descriptive-qualitative research. Data was collected using offline and face-to-face interview techniques. 20 teachers took part in this research. The finding illustrates that HOTS can be stimulated from an early age with several conditions, including developing play and learning activities that are well managed, fun, and consider the interests of early childhood. Games that effectively stimulate HOTS such as Dolanan Gatheng, Bekel Ball, Tuk Tuk Geni, Gotah Games, Gundu, and Congklak. Children also need to carry out simple and fun science activities, so they are trained to think and act scientifically and systematically. There are several suggestions regarding opportunities for future research applications. This research only includes traditional games to stimulate HOTS. Other researchers may also consider other innovative methods or other kinds of games that are also effective for increasing HOTS in early childhood. Keywords: higher-order thinking skills, early childhood education, traditional games, active learning References: Adi, B. S., Irianto, D. P., & Sukarmin, Y. (2021). Teachers’ perspectives on motor learning with traditional game approach among early children. Jurnal Cakrawala Pendidikan, 41(1). https://doi.org/10.21831/cp.v41i1.3684 Alizadeh, F., Hashim, M. N., & Amini, R. (2014). 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Indonesia as a multicultural country has a variety of racial, ethnic, cultural, and other diversity. Indigenous faiths is one of the diversity of religions or beliefs that need to be recognized. After the Constitutional Court Decision Number 97/PUU-XIV/2016, believers feel that their rights have been recognized by the state. However, in terms of education there is still discrimination such as the portion of learning for their beliefs as indigenous faiths. This research focuses on two things, namely the implementation of Law Number 20 of 2003 concerning the National Education System and school policies related to discrimination against Sapta Darma, Subud, and Kapribaden believers in Jepara Regency. The method used in this research is socio-legal by analyzing and examining the effectiveness of laws and regulations in community interaction. An understanding of several studies and theories provides two discussion results. First, the Office of Education of Jepara Regency still pays less attention to the rights of indigenous faith students in terms of the learning portion. Second, school policies are not sufficient in suppressing the potential for discrimination against students of indigenous faiths. Based on the results of the discussion, it can be concluded that with the existence of state protection for indigenous faiths, the government is obliged to protect their constitutional rights. The need for policies from the Office of Education of Jepara Regency in the field of education to fulfill constitutional rights that are able to suppress the potential for discrimination for students of indigenous faiths. ___ Referensi Buku dengan penulis: Purwanda, S. (2018). Pendidikan Pancasila (Cetakan Kedua). Parepare: Sampan Institute. Artikel jurnal: Alfansyur, A., & Mariyani, M. (2020). Seni Mengelola Data: Penerapan Triangulasi Teknik, Sumber dan Waktu pada Penelitian Pendidikan Sosial. 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One way to reduce textile waste and emissions is by utilizing natural materials as textile dyes. This study aims to see the effect of tunjung mordan on dyeing cotton materials using onion peel and mangosteen fruit peel. This type of research is an experiment, where the object of research is cotton from tunjung dyeing. Data were collected using questionnaires distributed and arranged with Likert scales, processed using the Friedman K-related Sample test. The results showed that dyeing with tunjung mordan resulted in Chocolate Brown #524123, light dark colors in the less light category and evenness of flat category colors. Test the hypothesis for dark light colors stating 0.00 < 0.05 then H₀ is rejected, which means that there is an influence of mordan on dark light colors. In color flatness, the value of 0.00 < 0.05 H₀ is rejected, meaning that there is an influence of tunjung mordan on the evenness of the color in onion peel extract and mangosteen peel.Keywords: onion, mangosteen, dyes, tunjung. AbstrakSalah satu cara untuk mengurangi limbah dan emisi tekstil yaitu dengan memanfaatkan bahan alam sebagai pewarna tekstil. Penelitian ini bertujuan untuk melihat pengaruh mordan tunjung terhadap pencelupan bahan katun menggunakan kulit bawang merah dan kulit buah manggis. Jenis penelitian ini adalah eksperimen, dimana objek penelitiannya adalah kain katun hasil pencelupan tunjung. Data dikumpulkan menggunakan kuesioner yang disebar dan disusun dengan skala likert, dianalisis dengan uji Friedman K-related Sample. Penelitian ini menunjukkan bahwa pewarnaan dengan mordan tunjung menciptakan warna Chocolate Brown #524123, gelap terang warna pada nilai kurang terang dan kerataan warna kategori rata. Uji hipotesis untuk gelap terang warna menyatakan 0,00<0,05 maka H₀ ditolak, yang berarti adanya pengaruh mordan terhadap gelap terang warna. Pada kerataan warna memperoleh nilai 0,00<0,05 H₀ ditolak, artinya adanya pengaruh mordan tunjung pada kerataan warna pada ekstrak kulit bawang merah dan kulit buah manggis.Kata Kunci: bawang merah, manggis, pencelupan, tunjung. Authors:Nana Dwi Cahya : Universitas Negeri PadangSri Zulfia Novrita : Universitas Negeri Padang References:Adriani, A., & Atmajayanti, C. (2023). Pengaruh Mordan Tunjung Dan Kapur Sirih Terhadap Hasil Ecoprint Daun Iler (Coleus Scutellarioides Linn. Benth). Gorga: Jurnal Seni Rupa, 12(1), 230-236.Andriani, R., Adriani, A., & Novrita, S. Z. (2016). Perbedaan Mordan Asam Jawa (Tamarindus Indica Linn) Dan Jeruk Purut (Citrus Histrix) Terhadap Hasil Pencelupan Ekstrak Buah Senduduk (Melastoma Candidium D. Don) Pada Bahan Sutra. Journal of Home Economics and Tourism, 12(2).Angendari, M. D. (2015). Pemanfaatan kulit bawang merah sebagai pewarna kain dengan teknik jumputan menggunakan mordan tawas, kapur, dan tunjung. Jurnal Pendidikan Teknologi dan Kejuruan, 12(1), 25-32.Azis, A. C. K., Lubis, S. K., Kartono, G., & Daulay, M. A. J. (2023). Digitalisation of Teaching Materials for Toba Batak Ethnic Decorative Variety with Procreate Media Based on p-Books and e-Books. Jurnal Kependidikan: Jurnal Hasil Penelitian dan Kajian Kepustakaan di Bidang Pendidikan, Pengajaran dan Pembelajaran, 9(3), 782-793.Ernawati, I., & Nelmira, W. (2008). Pengetahuan Tata Busana. Padang: UNP PRESS.Fatihaturahmi, F., & Novrita, S. Z. (2019). Pengaruh perbedaan mordan tawas dan kapur sirih terhadap hasil pencelupan ekstrak daun sawo menggunakan bahan sutera. Gorga: Jurnal Seni Rupa, 8(1), 237-242.Hasanah, U., Adriani, A., & Novrita, S. Z. (2021). Pengaruh Mordan Air Tapai Ketan Hitam dan Air Tapai Singkong terhadap Hasil Pencelupan pada Bahan Sutera Menggunakan Ekstrak Kulit Buah Manggis (Garcinia Mangostana L). Journal of Home Economics and Tourism, 15(2).Hendrika, A. D. (2020). Pengaruh Ekstrak Kulit Buah Nipah (Nypha Fructicans) dengan Kulit Bawang Merah (Allium Ascalonium L) Menggunakan Mordan Tunjung, Tawas dan Kapur Sirih Terhadap Hasil Pencelupan Pada Bahan Katun. (Doctoral dissertation, Universitas Negeri Padang).Masyitoh, F., & Ernawati, E. (2019). Pengaruh mordan tawas dan cuka terhadap hasil pewarnaan eco print bahan katun menggunakan daun jati (Tectona Grandis). Gorga: Jurnal Seni Rupa, 8(2), 387-391.Noor, F. (2007). Teknik Eksplorasi Zat Pewarna Alam dari Tanaman di Sekitar Kita Untuk Pencelupan Tekstil. Jurnal PKK UNY.Purnomo, E., Aisyah, S., Hadjarati, H., Azis, ACK, Suardika, IK, Jermaina, N., ... & Gumilar, A. (2024). The Coach's Role in Understanding the Athletes' Condition: Maximizing Communication Functions. Retos, 55, 543-551.Putri, L. A., Adriani, A., & Novrita, S. Z. (2015). Perbedaan Mordanting terhadap Hasil Pencelupan Zat Warna Alam Air Limbah Penirisan Getah Gambir pada Sutera Menggunakan Mordan Tunjung (Feso4). Journal of Home Economics and Tourism, 9(2).Revianti, M. M., & Novrita, S. Z. (2019). Pengaruh Mordan Terhadap Pencelupan ekstrak Daun Puring (Codiaeum Variegatum) pada Bahan Katun. Gorga: Jurnal Seni Rupa, 8(2), 403-408.Rizky, A. F., & Fatimah, S. (2020). Belimbing Wuluh (Averhoa belimbi L.) sebagai Mordan pada Sintesis Zat Warna Alami dari Kulit Bawang Merah (Allium ascalonium L.) dengan Metode Ekstraksi Ultrasonik. Reka Buana: Jurnal Ilmiah Teknik Sipil dan Teknik Kimia, 5(2): 104-111.Saputri, A., & Novrita, S. Z. (2021). Perbedaan Berat Mordan Tunjung, Tawas dan Kapur Sirih terhadap Hasil Pencelupan Kulit Buah Alpukat Pada Bahan Katun. Jurnal Pendidikan, Busana, Seni dan Teknologi, 3(2), 80-90.Setya, W. P. (2020). Pengaruh Mordan Kapur Sirih Dan Tunjung Terhadap Hasil Pencelupan Ekstrak Batang Pisang Ambon Pada Bahan Katun. (Doctoral dissertation, Universitas Negeri Padang).Siregar, N. H., Azis, A. C. K., Mesra, M., & Mirwa, T.(2020). Analisis Gambar Bentuk Bunga Anggrek dengan Teknik Pointilis Berwarna di SMP Al-Fityan School Medan. Gorga: Jurnal Seni Rupa, 9(1), 94-99.Yuled, U. R., & Adriani, A. (2021). Perbedaan Mordan Tunjung Dan Baking Soda Terhadap Hasil Pencelupan Pada Bahan Katun Dengan Menggunakan Ekstrak Kunyit (Curcuma Longa). Jurnal Pendidikan, Busana, Seni dan Teknologi, 3(2), 97-103.

This study aimed to examine the implementation pattern of the constructivist theory in limited face-to-face learning (PTMT). The method used was descriptive qualitative with the subject of teachers in the Malang City area. Data was collected by using a survey distributed online through Google Forms. The results showed that the implementation pattern ofconstructivist theory in limited face-to-face learning (PTMT) was carried out through 5 (five) base of learning implementation, namely the application of problem-based learning, the application of project-based learning, the use of digital-based teaching materials and media, the application of psychosocial learning and contextuallearning. Teachers carried out limited face-to-face learning by applying constructivist theory massively and gradually, starting from planning, the process of learning activities, and learning evaluation. In addition to the use of media and 5M learning models in this study, the application of constructivist theory in PTMT learning aimed to help students become more active and teachers as moderators be more innovative. Learning process carried out at the elementary school level was only 50 percent attendance at the maximum. The implementation of student-centered learning showed 45% was very good, 50% was good, 2.5% was good, 2.5% was not good. The results showed that the inhibiting factor for student-centered implementation was the limited duration of time in learning. On the other hand, there were also restrictions on interactions carried out in the classroom so that teachers experienced a decline in exploring the learning process. Keywords: constructivism theory. limited face-to-face learning, elementary school. References: Adiyono, A. 2021. Implementasi Pembelajaran: Peluang dan Tantangan Pembelajaran Tatap Muka Bagi Siswa Sekolah Dasar di Muara Komam. 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Traditional arts that have high artistic value must always be preserved from extinction. In order to maintain the popularity of traditional art in Indonesia, it is necessary that artists, teachers, and society understand it deeply. Every fine arts artist, teacher, and community must have a sense of nationalism towards traditional art in order to be able to maintain and become a stronghold of traditional art itself. This study aims to rediscover the values of traditional culture that are spread in several regions in Indonesia with the hope that it can be absorbed into modern art so that the value of traditional art is not completely eroded. This research uses Spradley's qualitative research method or ethnographic qualitative research with the aim of systematically describing deeper cultural characteristics. This research produces a description of the characteristics of traditional culture contained in several traditional arts and crafts spread across Indonesia, each region has cultural characteristics that are different from other regions which are influenced by several diverse factors. The characteristics of each artistic value are maintained and absorbed into modern art for maintained and taught in the world of education so that art saviors are born who are able to transform traditional arts into modern artistic values. As art saviors, artists need awareness of a sense of "nationalism" in each of them which is obtained through an understanding of these traditional arts.Keywords: high art, education, culture, nationalism. AbstrakKesenian tradisional yang memiliki nilai seni tinggi harus selalu dilestarikan dari kepunahan. Untuk mempertahankan popularitas seni tradisional di Indonesia, diperlukan seniman, guru, dan masyarakat yang memahaminya secara mendalam. Setiap seniman seni rupa, guru dan masyarakat harus memiliki rasa nasionalisme terhadap seni tradisional agar mampu menjaga dan menjadi benteng kesenian tradisional itu sendiri. Penelitian ini bertujuan untuk menemukan kembali nilai nilai kebudayaan tradisional yang tersebar di dibeberapa daerah di Indonesia dengan harapan dapat dilakukan penyerapan kedalam seni modern agar nilai dari kesenian tradisional tidak terkikis sepenuhnya. Penelitian ini menggunakan metode penelitian kualitatif Spradley atau penelitian kualitatif etnografi dengan tujuan mendeskripsikan karakteristik kultural lebih mendalam secara sistematis. Penelitian ini menghasilkan deskripsi karakteristik kebudayaan tardisional yang terkandung dari beberapa kerajinan seni tradisional yang tersebar di wilayah Indonesia, setiap daerah memiliki karakterstik kebudayaan yang berbeda dari daerah lain yang dipengaruhi oleh beberapa factor yang beragam, Karakteristik dari setiap nilai kesenian dipertahankan dan diserap kedalam kesenian modern untuk dipertahankan dan diajarkan dalam dunia Pendidikan agar terlahir penyelamat kesenian yang mampu melakukan transformasi seni tradisional menjadi nilai seni modern. Sebagai penyelamat seni, seniman membutuhkan kesadaran akan rasa “Nasionalisme” pada diri masing-masing yang diperoleh melalu pemahaman akan kesenian tradisional tersebut.Kata Kunci: seni tinggi, pendidikan, budaya, nasionalisme. Authors:Budiwirman : Universitas Negeri PadangSyeilendra : Universitas Negeri PadangAry Ramadhan : Universitas Negeri PadangSyafei : Universitas Negeri Padang References:Yoeti, O. K. 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Timeliness of financial reporting is a qualitative characteristics that enhance the usefulness of information and significant to users of financial statements. This study examines that board diversity (GENDERCHAIR), CEO age (CEOAGE) have impact on audit report timeliness. The sample of this study comprises of 100 companies listed on Vietnamese Stock Exchange in the period 2012 - 2014. Ordinary Least Square (OLS) regression analysis are performed to test the audit report timeliness determinants . Using quantitative research methods, findings found that there is a significant positive relationship between board diversity on timeliness of financial reporting while proxy variables of the CEO age have a significant negative relationship with timeliness of financial reporting. . This paper extends prior research by addressing the potential effects of female executives on timeliness of financial reporting. Keywords Chief executive officer, timeliness of financial reporting, listed firms, Vietnam References Abdullah, S. N., “Board composition, audit committee and timeliness of corporate financial reports in Malaysia”, Corporate Ownership & Control, 4 (2006) 4, 33-45.Al-Ajmi, J., “Audit and reporting delays: Evidence from an emerging market”, Advances in Accounting, 24 (2008) 2, 217-226Al-Akra, M., Eddie, I. A., & Ali, M. J., “The influence of the introduction of accounting disclosure regulation on mandatory disclosure compliance: Evidence from Jordan”, The British Accounting Review, 42 (2010) 3, 170-186.Alkhatib, K., & Marji, Q., “Audit reports timeliness: Empirical evidence from Jordan”, Procedia-Social and Behavioral Sciences 62 (2012), 1342-1349.AL-Shwiyat, Z. M. M., “Affecting factors on the timing of the issuance of annual financial reports: empirical study on the jordanian public shareholding companies”, European Scientific Journal, 9 (2013) 22, 407-423.Ashton, R. H., Graul, P. 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Apolipoprotein C3 (APOC3) plays an important role in regulating lipid levels. This study aimed to assess whether the polymorphism APOC3-rs2854116 is associated with lipid profiles in primary school children in Hanoi. A case-control study was designed including 161 cases with dyslipidemia and 406 controls without dyslipidemia. Genotype for APOC3-rs2854116 polymorphism was determined by the polymerase chain reaction and restriction fragment length polymorphism method (PCR-RFLP). The results showed that there were differences in the effect of APOC3-rs2854116 polymorphism to lipid profiles among children with dyslipidemia. In comparison with A/G and A/A carriers, the G/G carriers had the higher concentration of serum TC, TG, and LDL-C (P < 0.05). APOC3-rs2854116 polymorphism was related to hypercholesterolemia in children with the most appropriate genetic model being additive model. Increasing each of the G alleles increased the risk of hypercholesterolemia by 2.2 times (P = 0.005) after adjustment for age and sex. This relationship was almost unchanged after adjustment for obesity-related traits. The study suggested that the APOC3-rs2854116 polymorphism significantly associated with hypercholesterolemia in primary school children in Hanoi independent of obesity-related traits. Keywords APOC3, rs2854116, hypercholesterolemia, primary school children. References [1] A. Kawakami, M. Yoshida, Apolipoprotein CIII links dyslipidemia with atherosclerosis, Journal of atherosclerosis and thrombosis 16(1) (2009) 6-11. https://doi.org/10.5551/jat.e607.[2] D. Gaudet, D. Brisson, K. Tremblay, V.J. Alexander, W. Singleton, S.G. Hughes, J.L. Witztum, Targeting APOC3 in the familial Chylomicronemia syndrome, New England Journal of Medicine 371(23) (2014) 2200-2206. https://doi.org/10.1056/NEJMoa1400284.[3] P. Libby, Triglycerides on the rise: should we swap seats on the seesaw?, European heart journal 36 (2015) 774-776. https://doi.org/10.1093/eurheartj/ehu500.[4] W.W. Li, M.M. Dammerman, J.D. Smith, S. Metzger, J.L. Breslow, T. Leff, Common genetic variation in the promoter of the human apoC-III gene abolishes regulation by insulin and may contribute to hypertriglyceridemia, Journal of Clinical Investigation 96(6) (1995) 2601-2605. https://doi.org/10.1172/JCI118324.[5] C. Couillard, M.C. Vohl, J.C. Engert, I. Lemieux, A. Houde, N. Alméras, J. Bergeron, Effect of apoC-III gene polymorphisms on the lipoprotein-lipid profile of viscerally obese men, Journal of lipid research 44(5) (2003) 986-993. https://doi.org/10.1194/jlr.M300043-JLR200.[6] J. Dallongeville, A. Meirhaeghe, D. Cottel, J.C. Fruchart, P. Amouyel, N. Helbecque, Gender related association between genetic variations of APOC-III gene and lipid and lipoprotein variables in northern France, Atherosclerosis 150(1) (2000) 149-157. https://doi.org/10.1016/s0021-9150(99)00362-7.[7] C.A. Rocco, D. Mecikovsky, P. Aulicino., R. Bologna, L. Sen, A. Mangano, Hypercholesterolemia Is Associated with the Apolipoprotein C-III (APOC3) Genotype in Children Receiving HAART: An Eight-Year Retrospective Study, PLos One 7(7) (2012) e39678. https://doi.org/10.1371/journal.pone.0039678.[8] S. Li, Y. Yang, X. Ouyang, J. Shen, M. Zhou, Y.Y. Song, Associations of the APOC3 rs2854116 and rs2854117 polymorphisms with plasma APOC3 and lipid levels: a meta-analysis, Int J Clin Exp Med 9(8) (2016) 15972. http://www.ijcem.com/files/ijcem0025065.pdf[9] N.C. Khan, L.B. Mai, D.T.P. Ha, N.D. Minh, L.D. Tuyen, H.H Tue, Overweight, obesity and related association in adults aged 25-54 years, Nutrition status and intervention strategy in Vietnam (2007) 49-72. (in Vietnamese).[10] T.T. Mai, L.T. Hop, N.T. Lam, N.T. Xuan, Overweight, obesity and dyslipidemia in children aged 4-9 years in some primary schools of Hoan Kiem District, Hanoi. Journal of Food and Nutrition 9(3) (2013) 9-18. (in Vietnamese).[11] P.O. Kwiterovich, Recognition and management of dyslipidemia in children and adolescents, The Journal of clinical endocrinology and metabolism 93(11) (2008) 4200-4209. https://doi.org/10.1210/jc.2008-1270.[12] National Cholesterol Education Program, Report of the Expert Panel on Blood Cholesterol Levels in Children and Adolescents, Pediatrics 89(S) (1992) 525-584. https://pediatrics.aappublications.org/content/pediatrics/89/3/495.full.pdf.[13] T.G. Lohman, A.F. Roche, R. Martorell, Anthropometric standardization reference manual, Champaign, IL: Human Kinetics Book, UK (1988).[14] N.T.H. Hanh, P.T. Phuong, T.Q. Binh, APOC3 rs2854116 single nucleotide polymorphism in Hanoi primary school children, The 2nd National Scientific Conference on Biological Research and Teaching in Vietnam, Vietnam National University Publishing House (2016) 287-294.[15] X. Solé, E. Guinó, J. Valls, R. Iniesta, V. Monero, SNPStats: a web tool for the analysis of association studies, Bioinformatics 22(15) (2006) 1928-1929. https://doi.org/10.1093/bioinformatics/btl268.[16] R.L. Pollex, M.R. Ban, T.K. Young, P. Bjerregaard, S.S. Anand, S. Yusuf, M.W. Huff, Association between the-455T>C promoter polymorphism of the APOC3 gene and the metabolic syndrome in a multi-ethnic sample, BMC medical genetics 8(1) (2007) 80-87. https://dx.doi.org/10.1186%2F1471-2350-8-80.[17] N.T.H. Hanh, B.T. Nhung, L.T. Hop, T.Q. Binh, Association of nutritional status, family and neonatal characteristics with hypertriglycemia in primary school children in Hanoi. VNU Journal of Science: Natural Sciences and Technology 31(4S) (2015) 94-101 (in Vietnamese).[18] N.T.H. Hạnh, B.T. Nhung, T.Q. Binh, L.T. Hop, Optimal model on association of some environmental factors with Hyperalphalipoproteinemia in primary school children in Hanoi. Second National Conference on study and education of biology in Vietnam VNU publishing house (2016) 295-303 (in Vietnamese).[19] N.T.H. Hanh, B.T. Nhung, L.T. Hop, T.Q. Binh, Relationship between some environmental factors and hyperbetalipoproteinemia in 6 - 11 year-old children in Hanoi, Journal of Science, Hanoi National University of Education 61(9) (2016) 185-192. https://doi.org/10.18173/2354-1059.2016-0072.[20] M. Larsson, E. Vorrsjö, P. Talmud, A. Lookene, G. Olivecrona, Apolipoproteins CI and C-III inhibit lipoprotein lipase activity by displacement of the enzyme from lipid droplets, Journal of Biological Chemistry 288(47) (2013) 33997-34008. https://doi.org/10.1074/jbc.M113.495366.[21] M. Miller, J. Rhyne, H. Chen, V. Beach, R. Ericson, K. Luthra, A. Misra, APOC3 promoter polymorphisms C-482T and T-455C are associated with the metabolic syndrome, Archives of medical research 38(4) (2007) 444-451. https://doi.org/10.1016/j.arcmed.2006.10.013.[22] E.D. França, J.G.B. Alves, M.H. Hutz, APOA1/C3/A4 gene cluster variability and lipid levels in Brazilian children, Brazilian journal of medical and biological research 38(4) (2005) 535-541. http://dx.doi.org/10.1590/S0100-879X2005000400006.[23] F. Sentinelli, S. Romeo, C. Maglio, M. Incani, M.A. Burza, F. Scano, M.G. Baroni, Lack of effect of apolipoprotein C3 polymorphisms on indices of liver steatosis, lipid profile and insulin resistance in obese Southern Europeans, Lipids in health and disease 10(1) (2011). http://doi.org/10.1186/1476-511X-10-9.

Previous studies contend that Philippines is still a ‘collectivist’ society (Cf. Hofstede Center; Cukur et al. 2004:613-634). In this collectivist or community-oriented society, individualism is not something that is highly valued. Being ‘individualistic’ is often associated to being narcissistic, loner, asocial, selfish, etc. However, one may ask whether the youth in the Philippines are not spared from this insidious culture of individualism, notwithstanding the seemingly dominant collective and communitarian character of the society. Although the overwhelming poverty is still the main problem in the Philippines, where according to Wostyn (2010:26) “only the wonderland of movies gives some respite to their consciousness of suffering and oppression”, the Filipino youth of today are also exposed to the consumeristic values of the ‘city’ and are not spared from the contradictions and insecurities posed by the pluralistic society. They are citizens of an increasing social and cultural pluralism characteristic of many liberal societies. Is it possible that individualism may also exist within this culture, especially among the younger generation? Is individualism slowly creeping in as caused by their exposure and easy access to modern technology, to higher education, mobility, interactions with other cultures, etc. Would this individualistic tendency have any influence on their religious beliefs, especially their belief on salvation? What would be the implications and challenges of these findings to the families in the Philippines? These are the questions we wish to answer in this study. 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Photo by Nathan Dumlao on Unsplash ABSTRACT The demographic of physicians in the United States has failed to include a proportionate population of Latinos in the United States. In what follows, I shall argue that the medical school admission process places an undue burden on low-income Latino applicants. Hence, the underrepresentation of Latinos in medical schools is an injustice. This injustice relates to the poor community health of the Latino community. Health disparities such as diabetes, HIV infection, and cancer mortality are higher amongst the Latino community. The current representation of Latino medical students is not representative of those in the United States. INTRODUCTION The demographic of physicians in the United States has failed to include a proportionate number of Latinos, meaning people of Latin American origin. Medical schools serve as the gatekeepers to the medical field, and they can alter the profession based on whom they admit. With over 60 million Latinos in the United States, people of Latin American origin comprise the largest minority group in the nation.[1] In 2020-2021, only 6.7 percent of total US medical school enrollees and only 4 percent of medical school leadership identified as Latino.[2] Latino physicians can connect to a historically marginalized community that faces barriers including language, customs, income, socioeconomic status, and health literacy. I argue that the medical school admissions process places an undue burden on low-income Latino applicants. This paper explores the underrepresentation of Latinos in medical schools as an injustice. A further injustice occurs as the barriers to medical education result in fewer Latino doctors to effectively deliver health care and preventive health advice to their communities in a culturally competent way. I. Latino Community Health Data The terms Latino and Hispanic have largely been considered interchangeable. US government departments, such as the US Census Bureau and the Centers for Disease Control and Prevention (CDC), define Hispanic people as those with originating familial ties to native Spanish-speaking countries, most of whom are from Latin America. The term Latino is more inclusive because it refers to all of those with strong originating ties to countries in Latin America, including those coming from countries such as Brazil and Belize who are not native Spanish speakers. Throughout this work, I refer to the term Latino because it is more inclusive, although the data retrieved from US government departments may refer to the population as Hispanic. “Low-income” refers to the qualifying economic criteria for the AAMC’s Fee Assistance Program Poverty Guidelines.[3] The AAMC Fee Assistance Program is designed to help individuals who do not have the financial means to pay the total costs of applying to medical school. For this paper, low-income refers to those who qualify for this program. The US government gathers data about Latino community health and its health risks. The Latino community has a higher poverty rate than the non-Hispanic white community.[4] Latino community health has long trailed that of white people collectively. For example, the Latino community experiences higher levels of preventable diseases, including hypertension, diabetes, and hepatitis, than the non-Hispanic white community does.[5] The CDC collects data about Latino community health and provides statistics to the public. Latinos in the United States trail only non-Hispanic blacks in prevalence of obesity. The Latino adult obesity rates are 45.7 percent for males and 43.7 percent for females.[6] Of the 1.2 million people infected with HIV in the United States, 294,200 are Latino.[7] The infection rate of chlamydia is 392.6 per 100,000 ― 1.9 times the rate in the non-Hispanic white population.[8] The tuberculosis incidence rate is eight times higher than that of non-Hispanic white people at 4.4 per 100,000.[9] Furthermore, Latinos have the third highest death rate for hepatitis C among all races and ethnic groups.[10] The prevalence of total diabetes, diagnosed and undiagnosed, among adults aged 18 and older also remains higher than that of non-Hispanic whites at 14.7 percent compared to 11.9 percent.[11] The high disease rate evidences the poor health of the community. Furthermore, 19 percent of Latinos in the United States remain uninsured.[12] Almost a quarter of the Latino population in the United States lives in poverty.[13] The high incidence of disease, lack of insurance, and high poverty rate create a frail health status for the Latino community in the United States. The medical conditions seen are largely preventable, and the incident rates can be lowered with greater investments in Latino community health. Considering the health disparities between Latino and non-Hispanic White people, there is an ethical imperative to provide better medical care and guidance to the Latino community. II. Ethical and Practical Importance of Increasing the Number of Latino Physicians Minorities respond more positively to patient-physician interactions and are more willing to undergo preventative healthcare when matched with a physician of their racial or ethnic background.[14] Latino medical doctors may lead to an improvement in overall community health through improved communication and trusting relationships. Patient-physician racial concordance leads to greater patient satisfaction with their physicians.[15] Identifying with the ethnicity of a physician may lead to greater confidence in the physician-patient relationship, resulting in more engagement on the patient’s behalf. A randomized study regarding African American men and the race of their attending physician found an increase in requests for preventative care when assigned to a black doctor.[16] Although the subjects were African American men, the study has implications applicable to other minority racial and ethnic groups. The application process is unjust for low-income Latinos. The low matriculation of Latinos in medical schools represents a missed opportunity to alleviate the poor community health of the Latino population in the United States. Medical school also would create an opportunity to address health issues that plague the Latino community. Becoming a physician allows low-income Latinos to climb the social ladder and enter the spaces in health care that have traditionally been closed off to them. Nonwhite physicians significantly serve underserved communities.[17] Increasing the number of Latino doctors can boost their presence, potentially improving care for underserved individuals. Teaching physicians cultural competence is not enough to address the health disparities the Latino community faces. Latino physicians are best equipped to understand the healthcare needs of low-income Latinos. I contend that reforming the application process represents the most straightforward method to augment the number of Latino physicians who wish to work in predominantly Latino or diverse communities, thereby improving healthcare for the Latino community. III. Cultural Tenets Affecting Healthcare Interactions “Poor cultural competence can lead to decreased patient satisfaction, which may cause the patient not to attend future appointments or seek further care.”[18] Latino community health is negatively affected when medical professionals misinterpret cultural beliefs. Cultural tenets like a reservation towards medication, a deep sense of respect for the physician, and an obligation to support the family financially and through advocacy affect how Latinos seek and use the healthcare system.[19] First, the Latino population's negative cultural beliefs about medication add a barrier to patient compliance. It is highlighted that fear of dependence upon medicine leads to trouble with medication regimens.[20] The fear stems from the negative perception of addiction in the Latino community. Taking as little medication as possible avoids the chance of addiction occurring, which is why many take the prescribed medicine only until they feel healthier, regardless of the prescribing regimen. Some would rather not take any medication because of the deep-rooted fear. Physicians must address this concern by communicating the importance of patient compliance to remedy the health issue. Explaining that proper use of the medication as prescribed will ensure the best route to alleviate the condition and minimize the occurrence of dependence. Extra time spent addressing concerns and checking for comprehension may combat the negative perception of medication. Second, the theme of respeto, or respect, seems completely harmless to most people. After all, how can being respectful lead to bad health? This occurs when respect is understood as paternalism. Some patients may relinquish their decision-making to the physician. The physician might not act with beneficence, in this instance, because of the cultural dissonance in the physician-patient relationship that may lead to medical misinterpretation. A well-meaning physician might not realize that the patient is unlikely to speak up about their goals of care and will follow the physician’s recommendations without challenging them. That proves costly because a key aspect of the medical usefulness of a patient’s family history is obtaining it through dialogue. The Latino patient may refrain from relaying health concerns because of the misconceived belief that it’s the doctor’s job to know what to ask. Asking the physician questions may be considered a sign of disrespect, even if it applies to signs, symptoms, feelings, or medical procedures the patient may not understand.[21] Respeto is dangerous because it restricts the patients from playing an active role in their health. Physicians cannot derive what medical information may be relevant to the patient without their cooperation. And physicians without adequate cultural competency may not know they need to ask more specific questions. Cultural competency may help, but a like-minded physician raised similarly would be a more natural fit. “A key component of physician-patient communication is the ability of patients to articulate concerns, reservations, and lack of understanding through questions.”[22] As a patient, engaging with a physician of one’s cultural background fortifies a strong physician-patient relationship. Latino physicians are in the position to explain to the patients that respeto is not lost during a physician-patient dialogue. In turn, the physician can express that out of their value of respeto, and the profession compels them to place the patient’s best interest above all. This entails physicians advocating on behalf of the patients to ask questions and check for comprehension, as is required to obtain informed consent. Latino physicians may not have a cultural barrier and may already organically understand this aspect of their patient’s traditional relationship with physicians. The common ground of respeto can be used to improve the health of the Latino community just as it can serve as a barrier for someone from a different background. Third, in some Latino cultures, there is an expectation to contribute to the family financially or in other ways and, above all, advocate on the family’s behalf. Familial obligations entail more than simply translating or accompanying family members to their appointments. They include actively advocating for just treatment in terms of services. Navigating institutions, such as hospitals, in a foreign landscape proves difficult for underrepresented minorities like Latinos who are new to the United States. These difficulties can sometimes lead to them being taken advantage of, as they might not fully understand their rights, the available resources, or the standard procedures within these institutions. The language barrier and unfamiliar institutional policies may misinterpret patients’ needs or requests. Furthermore, acting outside of said institution’s policy norms may be erroneously interpreted as actions of an uncooperative patient leading to negative interactions between the medical staff and the Latino patient. The expectation of familial contribution is later revisited as it serves as a constraint to the low-income Latino medical school applicant. Time is factored out to meet these expectations, and a moral dilemma to financially contribute to the family dynamic rather than delay the contribution to pursue medical school discourages Latinos from applying. IV. How the Medical School Admission Process is Creating an Undue Burden for Low-Income Latino Applicants Applying a bioethics framework to the application process highlights its flaws. Justice is a central bioethical tenet relevant to the analysis of the MD admissions process. The year-long medical school application process begins with the primary application. The student enters information about the courses taken, completes short answer questions and essays, and uploads information about recommenders. Secondary applications are awarded to some medical students depending on the institutions’ policies. Some schools ask all applicants for secondary applications, while others select which applicants to send secondary requests. Finally, interviews are conducted after a review of both primary and secondary applications. This is the last step before receiving an admissions decision. The medical school application process creates undue restrictions against underserved communities. It is understood that matriculating into medical school and becoming a doctor should be difficult. The responsibilities of a physician are immense, and the consequences of actions or inactions may put the patients’ lives in jeopardy. Medical schools should hold high standards because of the responsibility and expertise required to provide optimal healthcare. However, I argue that the application process places an undue burden on low-income Latino applicants that is not beneficial to optimal health care. The burden placed on low-income Latino applicants through the application process is excessive and not necessary to forge qualified medical students. The financial aspect of the medical school application has made the profession virtually inaccessible to the working class. The medical school application proves costly because of the various expenses, including primary applications, secondary applications, and interview logistics. There is financial aid for applications, but navigating some aid to undertake test prep, the Medical College Admission Test (MCAT), and the travel for interviews proves more difficult. Although not mandatory, prep courses give people a competitive edge.[23] The MCAT is one of the key elements of an application, and many medical schools will not consider applications that do not reach their score threshold. This practically makes the preparatory courses mandatory for a competitive score. The preparatory courses themselves cost in the thousands of dollars. There has been talk about adjusting the standardized test score requirements for applicants from medically underserved backgrounds. I believe the practice of holding strict cutoffs for MCAT scores is detrimental to low-income Latino applicants, especially considering the average MCAT scores for Latinos trail that of white people. The American Association of Medical Colleges’ recent data for the matriculating class of 2021 illustrates the wide gap in MCAT scores: Latino applicants average 500.2, and Latino matriculants average 506.6, compared to white applicants, who average 507.5 and white matriculants, who average 512.7.[24] This discrepancy suggests that considerations beyond scores do play some role in medical school matriculation. However, the MCAT scores remain a predominant factor, and there is room to value other factors more and limit the weight given to scores. The practice of screening out applicants based solely on MCAT scores impedes low-income Latino applicants from matriculating into medical school. Valuing the MCAT above all other admissions criteria limits the opportunities for those from underserved communities, who tend to score lower on the exam. One indicator of a potentially great physician may be overcoming obstacles or engaging in scientific or clinical experiences. There are aspects of the application where the applicant can expand on their experiences, and the personal statement allows them to showcase their passion for medicine. These should hold as much weight as the MCAT. The final indicator of a good candidate should not solely rest on standardized tests. There is a cost per medical school that is sent to the primary application. The average medical school matriculant applies to about 16 universities, which drives up the cost of sending the applications.[25] According to the American Association of Medical Colleges, the application fee for the first school is $170, and each additional school is an additional $42. Sending secondary applications after the initial application is an additional cost that ranges by university. The American Medical College Application Service (AMCAS), the primary application portal for Medical Doctorate schools in the United States and Canada, offers the Fee Assistance Program (FAP) to aid low-income medical school applicants. The program reduces the cost of the MCAT from $325 to $130, includes a complimentary Medical School Admission Requirements (MSAR) subscription, and fee waivers for one AMCAS application covering up to 20 schools.[26] The program is an important aid for low-income Latino students who would otherwise not be able to afford to send multiple applications. Although the aid is a great resource, there are other expenses of the application process that the program cannot cover. For a low-income applicant, the burden of the application cost is felt intensely. A study analyzing the American Medical College Application Service (AMCAS) data for applicants and matriculants from 2014 to 2019 revealed an association between income and acceptance into medical school. They state, “Combining all years, the likelihood of acceptance into an MD program increased stepwise by income. The adjusted rate of acceptance was 24.32 percent for applicants with income less than $50 000, 27.57 percent for $50 000 - $74 999, 29.90 percent for $75 000 - $124 999, 33.27 percent for $125 000 - $199 999, and 36.91 percent for $200,000 or greater.”[27] It becomes a discouraging factor when it is difficult to obtain the necessary funds. The interview process for medical schools may prove costly because of travel, lodging, and time. In-person interviews may require applicants to travel from their residence to other cities or states. The applicant must find their own transportation and housing during the interview process, ranging from a single day to multiple days. Being granted multiple interviews becomes bittersweet for low-income applicants because they are morally distraught, knowing the universities are interested yet understanding the high financial cost of the interviews. The expense of multiple interviews can impede an applicant from progressing in the application process. Medical schools do not typically cover travel expenses for the interview process. Only 4 percent of medical school faculty identify as Latino.[28] The medical school admission board members reviewing the application lack Latino representation.[29] Because of this, it is extremely difficult for a low-income Latino applicant to portray hardships that the board members would understand. Furthermore, the section to discuss any hardships only allows for 200 words. This limited space makes it extremely difficult to explain the nuances of navigating higher education as a low-income Latino. Explaining those difficulties is then restricted to the interview process. However, that comes late in the application process when most applicants have been filtered out of consideration. The lack of diversity among the board members, combined with the minimal space to explain hardships or burdens, impedes a connection to be formed between the Latino applicants and the board members. It is not equitable that this population cannot relate to their admissions reviewers because of cultural barriers. Gatekeeping clinical experience inadvertently favors higher socioeconomic status applicants. Most medical schools require physician shadowing or clinical work, which can be difficult to obtain with no personal connections to the field. Using clinical experience on the application is another way that Latinos are disadvantaged compared to people who have more professional connections or doctors in the family and social circles. The already competitive market for clinical care opportunities is reduced by nepotism, which does not work in favor of Latino applicants. Yet some programs are designed to help low-income students find opportunities, such as Johns Hopkins’ Careers in Science and Medicine Summer Internship Program, which provides clinical experience and health professions mentoring.[30] Without social and professional ties to health care professionals, they are forced to enter a competitive job and volunteer market in clinical care and apply to these tailored programs not offered at all academic institutions. While it is not unique to Latinos, the time commitment of the application process is especially harsh on low-income students because they have financial burdens that can determine their survival. Some students help their families pay for food, rent, and utilities, making devoting time to the application process more problematic. As noted earlier, Latino applicants may also have to set aside time to advocate for their families. Because the applicants tend to be more in tune with the dominant American culture, they are often assigned the family advocate role. They must actively advocate for their family members' well-being. The role of a family advocate, with both its financial and other supportive roles ascribed to low-income Latino applicants, is an added strain that complicates the medical school application. As a member of a historically marginalized community, one must be proactive to ensure that ethical treatment is received. Ordinary tasks such as attending a doctor's appointment or meeting with a bank account manager may require diligent oversight. Applicants must ensure the standard of service is applied uniformly to their family as it is to the rest of the population. This applies to business services and healthcare. It can be discouraging to approach a field that does not have many people from your background. The lack of representation emphasizes the applicant's isolation going through the process. There is not a large group of Latinos in medicine to look to for guidance.[31] The group cohesiveness that many communities experience through a rigorous process is not established among low-income Latino applicants. They may feel like outsiders to the profession. Encountering medical professionals of similar backgrounds gives people the confidence to pursue the medical profession. V. Medical School Admission Data This section will rely on the most recent MD medical school students, the 2020-2021 class. The data includes demographic information such as income and ethnicity. The statistics used in this section were retrieved from scholarly peer-reviewed articles and the Medical School Admission Requirement (MSAR) database. Both sources of data are discussed in more detail throughout the section. The data reveals that only 6.7 percent of medical students for the 2020-2021 school year identify as Latino.[32] The number of Latino students in medical school is not proportional to the Latino community in the United States. While Latinos comprise almost 20 percent of the US population (62.1 million), they comprise only 6.7 percent of the medical student population.[33] Below are three case studies of medical schools in cities with a high Latino population. VI. Medical School Application Process Case Studies a) New York University Grossman School of Medicine is situated in Manhattan, where a diverse population of Latinos reside. The population of the borough of Manhattan is approximately 1,629,153, with 26 percent of the population identifying as Latino.[34] As many medical schools do, Grossman School of Medicine advertises an MD Student Diversity Recruitment program. The program, entitled Prospective MD Student Liaison Program, is aimed such that “students from backgrounds that are underrepresented in medicine are welcomed and supported throughout their academic careers.”[35] The program intervenes with underrepresented students during the interview process of the medical school application. All students invited to interviews can participate in the Prospective MD Student Liaison Program. They just need to ask to be part of it. That entails being matched with a current medical student in either the Black and Latinx Student Association (BALSA) or LGBTQMed who will share their experiences navigating medical school. Apart from the liaison program, NYU participates in the Science Technology Entry Program (STEP), which provides academic guidance to middle and high school students who are underrepresented minorities.[36] With the set programs in place, one would expect to find a significantly larger proportion of Latino medical students in the university. The Medical School Admission Requirement (MSAR) database compiled extensive data about participants in the medical school; the data range from tuition to student body demographics. Of the admitted medical students in 2021, only 16 out of 108 identified as Latino, despite the much larger Latino population of New York.[37] Furthermore, only 4 percent of the admitted students classify themselves as being from a disadvantaged status.[38] The current efforts to increase medical school diversity are not producing adequate results at NYU. Although the Latino representation in this medical school may be higher than that in others, it does not reflect the number of Latinos in Manhattan. The Prospective MD Student Liaison Program intervenes at a late stage of the medical school application process. It would be more beneficial for a program to cover the entire application process. The lack of Latino medical students makes it difficult for prospective students to seek advice from Latino students. Introducing low-income Latino applicants to enrolled Latino medical students would serve as a guiding tool throughout the application process. An early introduction could encourage the applicants to apply and provide a resourceful ally in the application process when, in many circumstances, there would be none. Latino medical students can share their experiences of overcoming cultural and social barriers to enter medical school. b) The Latino population in Philadelphia is over 250,000, constituting about 15 percent of the 1.6 million inhabitants.[39] According to MSAR, the cohort of students starting at Drexel University College of Medicine, located in Philadelphia, in 2021 was only 7.6 percent Latino.[40] 18 percent of matriculated students identify as having disadvantaged status, while 21 percent identify as coming from a medically underserved community.[41] Drexel University College of Medicine claims that “Students who attend racially and ethnically diverse medical schools are better prepared to care for patients in a diverse society.”[42] They promote diversity with various student organizations within the college, including the following: Student National Medical Association (SNMA), Latino Medical Student Association (LMSA), Drexel Black Doctors Network, LGBT Medical Student Group, and Drexel Mentoring and Pipeline Program (DMAPP). The Student Center for Diversity and Inclusion of the College of Medicine offers support groups for underrepresented medical students. The support offered at Drexel occurs at the point of matriculation, not for prospective students. The one program that does seem to be a guide for prospective students is the Drexel Pathway to Medical School program. Drexel Pathway to Medical School is a one-year master’s program with early assurance into the College of Medicine and may serve as a gateway for prospective Latino Students.[43] The graduate program is tailored for students who are considered medically underserved or socioeconomically disadvantaged and have done well in the traditional pre-medical school coursework. It is a competitive program that receives between 500 and 700 applicants for the 65 available seats. The assurance of entry into medical school makes the Drexel Pathway to Medical School a beneficial program in aiding Latino representation in medicine. Drexel sets forth minimum requirements for the program that show the school is willing to consider students without the elite scores and grades required of many schools. MCAT scores must be in the 25th percentile or higher, and the overall or science GPA must be at least 2.9.[44] The appealing factor of this program is its mission to attract medically underserved students. This is a tool to increase diversity in medical school. Prospective low-income Latino students can view this as a graduate program tailored to communities like theirs. However, this one-year program is not tuition-free. It may be tempting to assume that patients prefer doctors with exceptional academic records. There's an argument against admitting individuals with lower test scores into medical schools, rooted in the belief that this approach does not necessarily serve the best interests of health care. The argument asserts that the immense responsibility of practicing medicine should be entrusted to the most qualified candidates. Programs like the Drexel Pathway to Medical School are designed to address the lower academic achievements often seen in underrepresented communities. Their purpose is not to admit underqualified individuals into medical school but to bridge the educational gap, helping these individuals take the necessary steps to become qualified physicians. c) The University of California San Francisco School of Medicine reports that 23 percent of its first-year class identifies as Latino, while 34 percent consider themselves disadvantaged.[45] The Office of Diversity and Outreach is concerned with increasing the number of matriculants from underserved communities. UCSF has instilled moral commitments and conducts pipeline and outreach programs to increase the diversity of its medical school student body. The Differences Matter Initiative that the university has undertaken is a complex years-long restructuring of the medical school aimed at making the medical system equitable, diverse, and inclusive.[46] The five-phase commitment includes restructuring the leadership of the medical school, establishing anti-oppression and anti-racism competencies, and critically analyzing the role race, ethnicity, gender, and sexual orientation play in medicine. UCSF offers a post-baccalaureate program specifically tailored to disadvantaged and underserved students. The program’s curriculum includes MCAT preparation, skills workshops, science courses, and medical school application workshops.[47] The MCAT preparation and medical school application workshops serve as a great tool for prospective Latino applicants. UCSF seems to do better than most medical schools regarding Latino medical students. San Francisco has a population of 873,965, of which 15.2 percent are Latino.[48] The large population of Latino medical students indicates that the school’s efforts to increase diversity are working. The 23 percent Latino matriculating class of 2021 better represents the number of Latinos in the United States, which makes up about a fifth of the population. With this current data, it is important to closely dissect the efforts UCSF has taken to increase diversity in its medical school. Their Differences Matter initiative instills a commitment to diversifying their medical school. As mentioned, the school's leadership has been restructuring to include a diverse administrative body. This allows low-income Latino applicants to relate to the admissions committee reviewing their application. With a hopeful outlook, the high percentage of Latino applicants may reflect comprehension of the application process and the anticipated medical school atmosphere and rigor among Latino applicants and demonstrate that the admissions committee understands the applicants. However, there are still uncertainties about the demographics of the Latino student population in the medical school. Although it is a relatively high percentage, it is necessary to decipher which proportion of those students are low-income Latino Americans. UCSF School of Medicine can serve as a model to uplift the Latino community in a historically unattainable profession. VII. Proposed Reform for Current Medical School Application One reform would be toward the reviewing admissions committee, which has the power to change the class composition. By increasing the diversity of the admissions committee itself, schools can give minority applicants a greater opportunity to connect to someone with a similar background through their application. It would address low-income Latino applicants feeling they cannot “get personal” in their application. These actions are necessary because it is not just to have a representative administration for only a portion of the public. Of the three medical schools examined, the University of California San Francisco has the highest percentage of Latino applicants in their entering class. They express an initiative to increase diversity within their medical school leadership via the Differences Matter initiative. This active role in increasing diversity within the medical school leadership may play a role in UCSF’s high percentage of Latino matriculants. That serves as an important step in creating an equitable application process for Latino applicants. An important consideration is whether the medical school administration at UCSF mirrors the Latino population in the United States. The importance of whether the medical school administration at UCSF mirrors the Latino population in the United States lies in its potential to foster diversity, inclusivity, and cultural competence in medical education, as well as to positively impact the healthcare outcomes and experiences of the Latino community. A diverse administration can serve as role models for students and aspiring professionals from underrepresented backgrounds. It can inspire individuals who might otherwise feel excluded or underrepresented in their career pursuits, including aspiring Latino medical students. Furthermore, a diverse leadership can help develop curricula, policies, and practices that are culturally sensitive and relevant, which is essential for addressing health disparities and providing equitable healthcare. It is also important to have transparency so the public knows the number of low-income Latino individuals in medical school. The Latino statistics from the medical school generally include international students. That speaks to diversity but misses the important aspect of uplifting the low-income Latino population of the United States. Passing off wealthy international students from Latin America to claim a culturally diverse class is misleading as it does not reflect income diversity. Doing so gives the incorrect perception that the medical school is accurately representing the Latino population of the United States. There must be a change in how the application process introduces interviews. It needs to be introduced earlier so the admissions committee can form early, well-rounded inferences about an applicant. The interview allows for personal connections with committee members that otherwise would not be established through the primary application. The current framework has the interviews as one of the last aspects of the application process before admissions decisions are reached. At this point in the application process, many low-income Latinos may have been screened out. I understand this is not an easy feat to accomplish. This will lead to an increase in interviews to be managed by the admissions committee. The burden can be strategically minimized by first conducting video interviews with applicants the admission committee is interested in moving forward and those that they are unsure about because of a weakness in a certain area of the application. The video interview provides a more formal connection between the applicants and admission committee reviewers. It allows the applicant to provide a narrative through spoken words and can come off as a more intimate window into their characteristics. It would also allow for an opportunity to explain hardships and what is unique. From this larger pool of video-interviewed applicants, the admission committee can narrow down to traditional in-person interviews. A form of these video interviews may be already in place in some medical school application process. I believe making this practice widespread throughout medical schools will provide an opportunity to increase the diversity of medical school students. There must be an increase in the number of programs dedicated to serving as a gateway to clinical experience for low-income Latino applicants. These programs provide the necessary networking environment needed to get clinical experience. It is important to consider that networking with clinical professionals is an admissions factor that detrimentally affects the low-income Latino population. One of the organizations that aids underserved communities, not limited to Latinos, in clinical exposure is the Summer Clinical Oncology Research Experience (SCORE) program.[49] The SCORE program, conducted by Memorial Sloan Kettering Cancer Center, provides its participants with mentorship opportunities in medicine and science. In doing so, strong connections are made in clinical environments. Low-income Latinos seek these opportunities as they have limited exposure to such an environment. I argue that it is in the medical school’s best interest to develop programs of this nature to construct a more diverse applicant pool. These programs are in the best interest of medical schools because they are culturing a well-prepared applicant pool. It should not be left to the goodwill of a handful of organizations to cultivate clinically experienced individuals from minority communities. Medical schools have an ethical obligation to produce well-suited physicians from all backgrounds. Justice is not upheld when low-income Latinos are disproportionally represented in medical schools. Programs tailored for low-income Latinos supplement the networking this population lacks, which is fundamental to obtaining clinical experience. These programs help alleviate the burden of an applicant’s low socioeconomic status in attaining clinical exposure. VIII. Additional Considerations Affecting the Medical School Application Process and Latino Community Health A commitment to practicing medicine in low-income Latino communities can be established to improve Latino community health.[50] Programs, such as the National Health Service Corps, encourage clinicians to practice in underserved areas by forgiving academic loans for years of work.[51] Increasing the number of clinicians in underserved communities can lead to a positive correlation with better health. It would be ideal to have programs for low-income Latino medical students that incentivize practicing in areas with a high population of underserved Latinos. This would provide the Latino community with physicians of a similar cultural background to attend to them, creating a deeper physician-patient relationship that has been missing in this community. Outreach for prospective Latino applicants by Latino medical students and physicians could encourage an increased applicant turnout. This effort can guide low-income Latinos who do not see much representation in the medical field. It would serve as a motivating factor and an opportunity to network within the medical field. Since there are few Latino physicians and medical students, a large effort must be made to make their presence known. IX. Further Investigation Required It is important to investigate the causes of medical school rejections of low-income Latinos. Understanding this piece of information would provide insight into the specific difficulties this population has with the medical school application. From there, the requirements can be subjected to bioethical analysis to determine whether those unfulfilled requirements serve as undue restrictions. The aspect of legacy students, children of former alumni, proves to be a difficult subject to find data on and merits further research. Legacy students are often given preferred admission into universities.[52] It is necessary to understand how this affects the medical school admissions process and whether it comes at a cost to students that are not legacy. It does not seem like these preferences are something universities are willing to disclose. The aspect of legacy preferences in admissions decisions could be detrimental to low-income Latino applicants if their parents are not college-educated in the United States, which often is the case. It would be beneficial to note how many Latinos in medical school are low-income. The MSAR report denotes the number of Latino-identified students per medical school class at an institution and the number of students who identify as coming from low resources. They do not specify which of the Latino students come from low-income families. This information would be useful to decipher how many people from the low-income Latino community are matriculating into medical schools. CONCLUSION It is an injustice that low-income Latinos are grossly underrepresented in medical school. It would remain an injustice even if the health of the Latino community in the United States were good. The current operation of medical school admission is based on a guild-like mentality, which perpetuates through barriers to admissions. It remains an exclusive club with processes that favor the wealthy over those who cannot devote money and time to the prerequisites such as test preparation courses and clinical internships. This has come at the expense of the Latino community in the United States in the form of both fewer Latino doctors and fewer current medical students. It is reasonable to hope that addressing the injustice of the underrepresentation of low-income Latinos in the medical field would improve Latino community health. With such a large demographic, the lack of representation in the medical field is astonishing. The Latino population faces cultural barriers when seeking healthcare, and the best way to combat that is with a familiar face. An increase in Latino medical students would lead to more physicians that not only can culturally relate to the Latino community, but that are a part of it. This opens the door for a comprehensive understanding between the patient and physician. As described in my thesis, Latino physicians can bridge cultural gaps that have proven detrimental to that patient population. That may help patients make informed decisions, exercising their full autonomy. The lack of representation of low-income Latinos in medicine is a long-known issue. Here, I have connected how the physician-patient relationship can be positively improved with an increase in low-income Latino physicians through various reforms in the admissions process. My hope is to have analyzed the problem of under-representation in a way that points toward further research and thoughtful reforms that can truly contribute to the process of remedying this issue. - [1] Passel, J. S., Lopez, M. H., & Cohn, D. (2022, February 3). U.S. Hispanic population continued its geographic spread in the 2010s. Pew Research Center. https://www.pewresearch.org/fact-tank/2022/02/03/u-s-hispanic-population-continued-its-geographic-spread-in-the-2010s/ [2] Ramirez, A. G., Lepe, R., & Cigarroa, F. (2021). Uplifting the Latino Population From Obscurity to the Forefront of Health Care, Public Health Intervention, and Societal Presence. JAMA, 326(7), 597–598. https://doi.org/10.1001/jama.2021.11997 [3] Association of American Medical Colleges. (2023). Who is eligible to participate in the fee assistance program? https://students-residents.aamc.org/fee-assistance-program/who-eligble-participate-fee-assistance-mprogram [4] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [5] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm; Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf; Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [6] Prevalence of Obesity and Severe Obesity Among Adults: United States, 2017–2018. (2020). Center for Disease Control and Prevention. https://www.cdc.gov/nchs/products/databriefs/db360.htm [7] Center for Disease Control and Prevention. (2021, October). Estimated HIV incidence and prevalence in the United States 2015–2019. https://www.cdc.gov/hiv/pdf/group/racialethnic/hispanic-latino/cdc-hiv-group-hispanic-latino-factsheet.pdf [8] Hispanics / Latinos | Health Disparities | CDC. (2020, September 14). Health Disparities in HIV, Viral Hepatitis, STDs, and TB. https://www.cdc.gov/nchhstp/healthdisparities/hispanics.html [9] CDC. (2020). [10] CDC. (2020). [11] Center for Disease Control and Prevention. (2019). National Diabetes Statistic Report. https://www.cdc.gov/diabetes/pdfs/data/statistics/national-diabetes-statistics-report.pdf [12] Office of the Assistant Secretary for Planning and Evaluation. (2021, October). Issue Brief No. HP-2021-2. Health Insurance Coverage and Access to Care Among Latinos: Recent Trends and Key Challenges. U.S. Department of Health and Human Services. https://aspe.hhs.gov/reports/health-insurance-coverage-access-care-among-latinos [13] U.S. Department of Health and Human Services Office of Minority Health. (2021). Profile: Hispanic/Latino Americans. https://minorityhealth.hhs.gov/omh/browse.aspx?lvl=3&lvlid=64 [14] Alsan, M., Garrick, O., & Graziani, G. (2019). Does Diversity Matter for Health? Experimental Evidence from Oakland. American Economic Review, 109(12), 4071–4111. https://doi.org/10.1257/aer.20181446 [15] Takeshita, J., Wang, S., Loren, A. W., Mitra, N., Shults, J., Shin, D. B., & Sawinski, D. L. (2020). Association of Racial/Ethnic and Gender Concordance Between Patients and Physicians With Patient Experience Ratings. JAMA Network Open, 3(11). https://doi.org/10.1001/jamanetworkopen.2020.24583 [16] Alsan, et. al. (2019). [17] Marrast, L., Zallman, L., Woolhandler, S., Bor, D. H., & McCormick, D. (2014). Minority physicians’ role in the care of underserved patients. JAMA Internal Medicine, 174(2), 289. https://doi.org/10.1001/jamainternmed.2013.12756 (“Nonwhite physicians cared for 53.5% of minority and 70.4% of non-English speaking patients.” Increasing the number of Latino doctors could lead to more nonwhite physicians to care for the underserved populations as they serve those populations at disproportionate rates. This may lead to better care for the patients.) [18] Cersosimo, E., & Musi, N. (2011). Improving Treatment in Hispanic/Latino Patients. The American Journal of Medicine, 124(10), S16–S21. https://doi.org/10.1016/j.amjmed.2011.07.019 [19] Flores, G. (2000). Culture and the patient-physician relationship: Achieving cultural competency in health care. The Journal of Pediatrics, 136(1), 14–23. https://doi.org/10.1016/s0022-3476(00)90043-x [20] Cersosimo & Musi. (2011). [21] Flores. (2000). [22] Torres, D. (2019). Knowing How to Ask Good Questions: Comparing Latinos and Non-Latino Whites Enrolled in a Cardiovascular Disease Prevention Study. The Permanente Journal. https://doi.org/10.7812/tpp/18-258 [23] The Princeton Review. (n.d.). Score 513+ on the MCAT, Guaranteed! | The Princeton Review. [24] 2021 FACTS: Applicants and Matriculants Data. (2022). AAMC. https://www.aamc.org/data-reports/students-residents/interactive-data/2021-facts-applicants-and-matriculants-data [25] The Princeton Review. (n.d.). How Many Med Schools Should You Apply To? https://www.princetonreview.com/med-school-advice/how-many-med-schools-should-you-apply-to [26] Association of American Medical Colleges. (n.d.). Fee Assistance Program (FAP). AAMC. https://students-residents.aamc.org/fee-assistance-program/fee-assistance-program-fap [27] Nguyen, M., Desai, M. M., Fancher, T. L., Chaudhry, S. I., Mason, H. R. C., & Boatright, D. (2023). Temporal trends in childhood household income among applicants and matriculants to medical school and the likelihood of acceptance by income, 2014-2019. JAMA. https://doi.org/10.1001/jama.2023.5654 [28] Ramirez, et al. (2021). [29] Ko, M. J., Henderson, M. C., Fancher, T. L., London, M., Simon, M., & Hardeman, R. R. (2023). US medical school admissions leaders’ experiences with barriers to and advancements in diversity, equity, and inclusion. JAMA Network Open, 6(2), e2254928. https://doi.org/10.1001/jamanetworkopen.2022.54928 [30] Johns Hopkins University School of Medicine. (n.d.). JHU CSM SIP. Johns Hopkins Initiative for Careers in Science and Medicine - the Summer Internship Program. https://csmsip.cellbio.jhmi.edu/ [31] Figure 18. Percentage of all active physicians by race/ethnicity, 2018 | AAMC. (2018). AAMC. https://www.aamc.org/data-reports/workforce/data/figure-18-percentage-all-active-physicians-race/ethnicity-2018 [32] Ramirez, et al. (2021). [33] Passel, et al. (2022). [34] Census Reporter. (n.d.). Census profile: Manhattan borough, New York County, NY. https://censusreporter.org/profiles/06000US3606144919-manhattan-borough-new-york-county-ny/ [35] MD Student Diversity Recruitment. (2022). NYU Langone Health. https://med.nyu.edu/our-community/why-nyu-grossman-school-medicine/diversity-inclusion/recruiting-diversity/md-student-diversity-recruitment [36] NYU. (n.d.). STEP Pre-College Program. New York University. https://www.nyu.edu/admissions/undergraduate-admissions/how-to-apply/all-freshmen-applicants/opportunity-programs/pre-college-programs.html [37] Association of American Medical Colleges. (2022). NYU Grossman School of Medicine. Medical School Admission Requirements (MSAR). https://mec.aamc.org/msar-ui/#/medSchoolDetails/152 [38] Association of American Medical Colleges. (2022). [39] U.S. Census Bureau. (2021). U.S. Census Bureau QuickFacts: Philadelphia County, Pennsylvania. Census Bureau QuickFacts. https://www.census.gov/quickfacts/philadelphiacountypennsylvania [40] Association of American Medical Colleges. (2022). Drexel University College of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/833 [41] Association of American Medical Colleges. (2022). [42] Drexel University College of Medicine. (n.d.). Diversity, Equity & Inclusion For Students. https://drexel.edu/medicine/about/diversity/diversity-for-students/ [43] Drexel University College of Medicine. (n.d.-b). Drexel Pathway to Medical School. https://drexel.edu/medicine/academics/graduate-school/drexel-pathway-to-medical-school/ [44] Drexel University College of Medicine. Drexel Pathway to Medical School. [45] Association of American Medical Colleges. (2022). University of California, San Francisco, School of Medicine. Medical School Admission Requirements. https://mec.aamc.org/msar-ui/#/medSchoolDetails/108 [46] The Regents of the University of California. (n.d.). Differences Matter. UCSF School of Medicine. https://medschool.ucsf.edu/differences-matter [47] The Regents of the University of California. (n.d.-b). Post Baccalaureate Program | UCSF Medical Education. UCSF Medical Education. https://meded.ucsf.edu/post-baccalaureate-program [48] United States Census Bureau. (2021). U.S. Census Bureau QuickFacts: San Francisco County, California. Census Bureau QuickFacts. https://www.census.gov/quickfacts/sanfranciscocountycalifornia [49] Memorial Sloan Kettering Cancer Center. (n.d.). Student Programs. https://www.mskcc.org/about/leadership/office-faculty-development/student-programs [50] Alsan, et al. (2021). [51] National Health Service Corps. (2021, November 2). Mission, Work, and Impact | NHSC. https://nhsc.hrsa.gov/about-us [52] Elam, C. L., & Wagoner, N. E. (2012). Legacy Admissions in Medical School. AMA Journal of Ethics, 14(12), 946–949. https://doi.org/10.1001/virtualmentor.2012.14.12.ecas3-1212

A child or an adult is considered obese (wasted), when the incumbent has excess (lesser) mass-for-height. BMI (body-mass index) is, universally, employed to estimate status of obesity (wasting). The name was given by Ancel Keys (1904-2004) and co-workers, replacing the earlier name ‘Quetelet index’ (1832) after the Belgian astronomer, mathematician and statistician, Adolphe Quetelet (1796-1874). To compute BMI of an individual, one should divide the incumbent’s mass (in kg — kilograms) by square of height (in m — meters). This index has its weak as well as its strong points. It is not able to account for factors like size of body frame as well as muscularity. Further, it is based on incorrect assumptions about body fat and lean mass distribution. As the person attains mature age, a decrease in height occurs, which results in BMI reduction, although the mass is not altered. Further, BMI is not able to establish a universal threshold for conditions of overweight and underweight as well as inter- and intra-region variations in body compositions of different communities, the later one appears by the presence of different ethnic groups within the same region. For children, the BMI range, which is routinely employed for estimating statuses for adults, is not applicable. BMI tables are needed to interpret childhood obesity-and-malnutrition. Although method of calculation of BMI score is same for children and adolescents as the one for adults, the criteria used for assessment of weight are different. This is because of the fact that BMI in youngsters vary significantly with age. BMI score in children and adolescents is compared against reference charts for children matched by age and gender, in order to transform them into percentile scores (Kolimechkov & Petrov, 2020). Each individual is classified as severely thin, underweight, normal, overweight or obese based on this percentile score. Kamal et al. (2011) analyzed data of 70 family members (17 fathers, 17 mothers, 16 boys, 20 girls). Based on this analysis, the author’s group concluded that boys tend to be at a higher risk of being obese as compared to girls, when both parents are obese. Lee et al. (2022) performed a systematic review and a meta-analysis of global relationship between parent and child obesity. They concluded that childhood-obesity risk is, mainly, influenced by weight status of parents and indicated that parents could play a proactive role in preventing childhood obesity. Estimated-adult BMI was defined in 2012 to predict obesity status of children, when they reach adulthood. The name, estimated-adult BMI, was mentioned at the turn of this century by Freedman et al. (2001). However, a complete definition was given by Kamal & Jamil (2012), which is based on the current trajectory of height and mass (weight). It is computed by replacing height and mass of a child with the respective estimated-adult values and expressed in units of kg/m2. The method of computing estimated-adult BMI and determination of snapshot from the measured height and mass of a child may be summarized into the following steps — d), e) and f) explained in Kamal et al. (2011): Obtain accurate, precise and reproducible measurements of standing heights and masses (weights) of children to least counts of 0.005 cm and 0.005 kg, respectively. Boys and girls should be barefoot, bareheaded and completely undressed (with the exception of short underpants, everything needs to be taken off, which may include cap, chain, hair accessories, leggings, ornaments, scarf, shoes, socks, stockings, watch, ) to ensure proper posture, non-flexing of elbows and knees as well as complete inhaling to get maximum chest expansion and abdomen in. A standard 1-m (100-cm) scale and a standard 2-kg mass were used to calibrate height- and mass-measurement instruments daily at the beginning of each session accompanied with recording of zero errors. For measurement of standing height (stature), the stripped youngster is asked to stand touching the mounted engineering tape (vertical alignment ascertained through plumb line) and instructed to align hands with body, palms touching thighs and heels together. Stature is obtained with the child in attention position. A pencil is placed at eye level to make sure that chin of the child is parallel to floor. For recording of mass (weight), the undressed youngster is instructed to step on the beam scale (central position) in stand-at-ease position, palms on thighs and feet separated. A pencil is, then, held at eye level to make sure that the child is looking straight. Convert age of child expressed as year-month-day into decimal age (years as a whole number as well as months and days in the form of decimal entries). Evaluate percentile-of-height and percentile-of-mass (employing CDC Growth Charts and Tables, extended to include percentile range 0.01P to 99.99P — CDC stands for Centers for Disease Control and Prevention https://cdc.gov) using the mathematical-statistical technique of box interpolation. Percentile, corresponding to height (mass), of youngster is computed by first calculating heights (masses) at the given age, which are lesser and greater than the measured height (mass) employing linear interpolation (constant-percentile route; computations performed for 3 or 4 percentiles, to ensure that the required interval is not overlooked). Once the upper and the lower bounds are determined at the given age, the required percentile is obtained by another linear interpolation (constant-age route). Compute estimated-adult height and estimated-adult mass using the technique of linear interpolation employing age-20 values of height and mass read off from gender-specific growth charts. Divide estimated-adult mass of a child (in kg) by square of estimated-adult height (in m) to calculate estimated-adult Use Table-1 to classify the youngster as excessively wasted, severely wasted, wasted, normal, obese, moderately obese, severely obese or excessively obese. Table-1 WHO classification of estimated-adult BMI, applicable to pediatric population Descriptive Label BMIest-adult Values (kg/m2) Excessively Wasted. BMIest-adult < 15 Severely Wasted. 15 £ BMIest-adult < 16 Wasted. 16 £ BMIest-adult < 18.5 Normal. 18.5 £ BMIIest-adult < 25 Obese. 25 £ BMIIest-adult < 30 Moderately Obese. 30 £ BMIIest-adult < 35 Severely Obese. 35 £ BMIIest-adult < 40 Excessively Obese. BMIIest-adult ³ 40 Note: The terminologies underweight and overweight are replaced by ‘wasted’ and ‘obese’ with appropriate adjectives A snapshot of obesity on the basis of estimated-adult BMI is not enough to chart out the true state of affairs. Beyond estimated-adult BMI, the author has proposed other indicators of childhood obesity during the last decade, viz. height-percentile-based-optimal mass (2011), status, pertaining-to-mass (2011), BMI ratio (2014), algebraic status, pertaining-to-mass (2015), qualitative status, pertaining-to-mass (2015), BMI-based-optimal mass (2017), modified status, pertaining-to-mass (2018), descriptive status, pertaining-to-mass (2018), fractional status, pertaining-to-mass (2018), reference-BMI-based-optimal mass (2020), estimated-adult-specific BMI (2020), refined status, pertaining-to-mass (2021), depictive status, pertaining-to-mass (2021) and complex status, pertaining-to-mass (2021) combined with relative BMI, proposed by Poskitt (1995). All of these indicators leave the obesity researcher confused and perplexed as to which one should be used and how it should be interpreted. The author has proposed unified approaches in terms of Growth-and-Obesity Roadmaps 4.5 and 5.0 (last one used for still-growing parents) as part of solutions to childhood obesity-and-malnutrition (Kamal, 2022). These roadmaps give enhanced-nutritional status, classified into 23 categories, viz. special categories (normality, obesity, wasting, tallness, stunting), regular categories (over-nutrition, under-nutrition, energy-channelization I-II), extended categories (obesity dominated over-nutrition, tallness dominated over-nutrition, tallness dominated energy-channelization I, wasting dominated energy-channelization I, wasting dominated under-nutrition, stunting dominated under-nutrition, stunting dominated energy-channelization II, obesity dominated energy-channelization II) and limiting cases (acute malnutrition, true over-nutrition, true under-nutrition, true energy-channelization I-II, energy-channelization III, sometimes termed as puberty-induced energy-channelization). In addition, height-gain-target-achievement and mass-management-target-achievement indices, for the current checkup, are evaluated from the recommended values based on the previous checkup. For peri-pubertal children (those are just going to enter puberty), puberty rating should be performed at each checkup. It is suggested that such roadmaps should be generated for every child from the age of around 3 years (when it is possible to obtain a reliable standing height) to the end of growth (19 years for girls; 21 years for boys). Induction into the Armed Forces of any country should not be based on one measurement of height and mass (weight) but a complete growth trajectory generated from the time of pre-school entry. References Freedman, D. S., Khan, L. K., Dietz, W. H., Srinivansan, S. R. & Barenson, G. S. (2001). Relationship of childhood obesity to coronary heart disease risk factors in adulthood: the Bogalusa Heart Study. Pediatrics, 108 (3): 712-718. https://doi.org/10.1542/peds.108.3.712 Kamal, S. A. (2022). Solutions of childhood obesity-and-malnutrition. The Sky (International Journal of Physical Education and Sports Sciences), 6: i, ii (guest editorial); full text: https://www.ngds-ku.org/Papers/J68.pdf Kamal, S. A., Jamil, N. & Khan, S. A. (2011). Growth-and-Obesity Profiles of children of Karachi using box-interpolation method. International Journal of Biology and Biotechnology, 8 (1): 87-96; full text: https://www.ngds-ku.org/Papers/J29.pdf Kamal, S. A. & Jamil, S. S. (2012). A method to generate Growth-and-Obesity Profiles of children of still-growing parents. International Journal of Biology and Biotechnology, 9 (3): 233-255; full text: https://www.ngds-ku.org/Papers/J30.pdf Kolimechkov, S. & Petrov, L. (2020). The body-mass index: a systematic review. Journal of Exercise Physiology and Health, 3 (2): 21-27; full text: https://www.ngds-ku.org/Papers/J67/BMI.pdf Lee, J. S., Jin, M. H. & Lee, H. J. (2022). Global relationship between parent and child obesity: a systematic review and meta-analysis. Clinical and Experimental Pediatrics, 65 (1): 35-46. https://doi.org/10.3345/cep.2020.01620

Photo ID 158378414 © Eduard Muzhevskyi | Dreamstime.com ABSTRACT There is a debate about the ethical implications of using human embryos in stem cell research, which can be influenced by cultural, moral, and social values. This paper argues for an adaptable framework to accommodate diverse cultural and religious perspectives. By using an adaptive ethics model, research protections can reflect various populations and foster growth in stem cell research possibilities. INTRODUCTION Stem cell research combines biology, medicine, and technology, promising to alter health care and the understanding of human development. Yet, ethical contention exists because of individuals’ perceptions of using human embryos based on their various cultural, moral, and social values. While these disagreements concerning policy, use, and general acceptance have prompted the development of an international ethics policy, such a uniform approach can overlook the nuanced ethical landscapes between cultures. With diverse viewpoints in public health, a single global policy, especially one reflecting Western ethics or the ethics prevalent in high-income countries, is impractical. This paper argues for a culturally sensitive, adaptable framework for the use of embryonic stem cells. Stem cell policy should accommodate varying ethical viewpoints and promote an effective global dialogue. With an extension of an ethics model that can adapt to various cultures, we recommend localized guidelines that reflect the moral views of the people those guidelines serve. BACKGROUND Stem cells, characterized by their unique ability to differentiate into various cell types, enable the repair or replacement of damaged tissues. Two primary types of stem cells are somatic stem cells (adult stem cells) and embryonic stem cells. Adult stem cells exist in developed tissues and maintain the body’s repair processes.[1] Embryonic stem cells (ESC) are remarkably pluripotent or versatile, making them valuable in research.[2] However, the use of ESCs has sparked ethics debates. Considering the potential of embryonic stem cells, research guidelines are essential. The International Society for Stem Cell Research (ISSCR) provides international stem cell research guidelines. They call for “public conversations touching on the scientific significance as well as the societal and ethical issues raised by ESC research.”[3] The ISSCR also publishes updates about culturing human embryos 14 days post fertilization, suggesting local policies and regulations should continue to evolve as ESC research develops.[4] Like the ISSCR, which calls for local law and policy to adapt to developing stem cell research given cultural acceptance, this paper highlights the importance of local social factors such as religion and culture. I. Global Cultural Perspective of Embryonic Stem Cells Views on ESCs vary throughout the world. Some countries readily embrace stem cell research and therapies, while others have stricter regulations due to ethical concerns surrounding embryonic stem cells and when an embryo becomes entitled to moral consideration. The philosophical issue of when the “someone” begins to be a human after fertilization, in the morally relevant sense,[5] impacts when an embryo becomes not just worthy of protection but morally entitled to it. The process of creating embryonic stem cell lines involves the destruction of the embryos for research.[6] Consequently, global engagement in ESC research depends on social-cultural acceptability. a. US and Rights-Based Cultures In the United States, attitudes toward stem cell therapies are diverse. The ethics and social approaches, which value individualism,[7] trigger debates regarding the destruction of human embryos, creating a complex regulatory environment. For example, the 1996 Dickey-Wicker Amendment prohibited federal funding for the creation of embryos for research and the destruction of embryos for “more than allowed for research on fetuses in utero.”[8] Following suit, in 2001, the Bush Administration heavily restricted stem cell lines for research. However, the Stem Cell Research Enhancement Act of 2005 was proposed to help develop ESC research but was ultimately vetoed.[9] Under the Obama administration, in 2009, an executive order lifted restrictions allowing for more development in this field.[10] The flux of research capacity and funding parallels the different cultural perceptions of human dignity of the embryo and how it is socially presented within the country’s research culture.[11] b. Ubuntu and Collective Cultures African bioethics differs from Western individualism because of the different traditions and values. African traditions, as described by individuals from South Africa and supported by some studies in other African countries, including Ghana and Kenya, follow the African moral philosophies of Ubuntu or Botho and Ukama, which “advocates for a form of wholeness that comes through one’s relationship and connectedness with other people in the society,”[12] making autonomy a socially collective concept. In this context, for the community to act autonomously, individuals would come together to decide what is best for the collective. Thus, stem cell research would require examining the value of the research to society as a whole and the use of the embryos as a collective societal resource. If society views the source as part of the collective whole, and opposes using stem cells, compromising the cultural values to pursue research may cause social detachment and stunt research growth.[13] Based on local culture and moral philosophy, the permissibility of stem cell research depends on how embryo, stem cell, and cell line therapies relate to the community as a whole. Ubuntu is the expression of humanness, with the person’s identity drawn from the “’I am because we are’” value.[14] The decision in a collectivistic culture becomes one born of cultural context, and individual decisions give deference to others in the society. Consent differs in cultures where thought and moral philosophy are based on a collective paradigm. So, applying Western bioethical concepts is unrealistic. For one, Africa is a diverse continent with many countries with different belief systems, access to health care, and reliance on traditional or Western medicines. Where traditional medicine is the primary treatment, the “’restrictive focus on biomedically-related bioethics’” [is] problematic in African contexts because it neglects bioethical issues raised by traditional systems.”[15] No single approach applies in all areas or contexts. Rather than evaluating the permissibility of ESC research according to Western concepts such as the four principles approach, different ethics approaches should prevail. Another consideration is the socio-economic standing of countries. In parts of South Africa, researchers have not focused heavily on contributing to the stem cell discourse, either because it is not considered health care or a health science priority or because resources are unavailable.[16] Each country’s priorities differ given different social, political, and economic factors. In South Africa, for instance, areas such as maternal mortality, non-communicable diseases, telemedicine, and the strength of health systems need improvement and require more focus[17] Stem cell research could benefit the population, but it also could divert resources from basic medical care. Researchers in South Africa adhere to the National Health Act and Medicines Control Act in South Africa and international guidelines; however, the Act is not strictly enforced, and there is no clear legislation for research conduct or ethical guidelines.[18] Some parts of Africa condemn stem cell research. For example, 98.2 percent of the Tunisian population is Muslim.[19] Tunisia does not permit stem cell research because of moral conflict with a Fatwa. Religion heavily saturates the regulation and direction of research.[20] Stem cell use became permissible for reproductive purposes only recently, with tight restrictions preventing cells from being used in any research other than procedures concerning ART/IVF. Their use is conditioned on consent, and available only to married couples.[21] The community's receptiveness to stem cell research depends on including communitarian African ethics. c. Asia Some Asian countries also have a collective model of ethics and decision making.[22] In China, the ethics model promotes a sincere respect for life or human dignity,[23] based on protective medicine. This model, influenced by Traditional Chinese Medicine (TCM), [24] recognizes Qi as the vital energy delivered via the meridians of the body; it connects illness to body systems, the body’s entire constitution, and the universe for a holistic bond of nature, health, and quality of life.[25] Following a protective ethics model, and traditional customs of wholeness, investment in stem cell research is heavily desired for its applications in regenerative therapies, disease modeling, and protective medicines. In a survey of medical students and healthcare practitioners, 30.8 percent considered stem cell research morally unacceptable while 63.5 percent accepted medical research using human embryonic stem cells. Of these individuals, 89.9 percent supported increased funding for stem cell research.[26] The scientific community might not reflect the overall population. From 1997 to 2019, China spent a total of $576 million (USD) on stem cell research at 8,050 stem cell programs, increased published presence from 0.6 percent to 14.01 percent of total global stem cell publications as of 2014, and made significant strides in cell-based therapies for various medical conditions.[27] However, while China has made substantial investments in stem cell research and achieved notable progress in clinical applications, concerns linger regarding ethical oversight and transparency.[28] For example, the China Biosecurity Law, promoted by the National Health Commission and China Hospital Association, attempted to mitigate risks by introducing an institutional review board (IRB) in the regulatory bodies. 5800 IRBs registered with the Chinese Clinical Trial Registry since 2021.[29] However, issues still need to be addressed in implementing effective IRB review and approval procedures. The substantial government funding and focus on scientific advancement have sometimes overshadowed considerations of regional cultures, ethnic minorities, and individual perspectives, particularly evident during the one-child policy era. As government policy adapts to promote public stability, such as the change from the one-child to the two-child policy,[30] research ethics should also adapt to ensure respect for the values of its represented peoples. Japan is also relatively supportive of stem cell research and therapies. Japan has a more transparent regulatory framework, allowing for faster approval of regenerative medicine products, which has led to several advanced clinical trials and therapies.[31] South Korea is also actively engaged in stem cell research and has a history of breakthroughs in cloning and embryonic stem cells.[32] However, the field is controversial, and there are issues of scientific integrity. For example, the Korean FDA fast-tracked products for approval,[33] and in another instance, the oocyte source was unclear and possibly violated ethical standards.[34] Trust is important in research, as it builds collaborative foundations between colleagues, trial participant comfort, open-mindedness for complicated and sensitive discussions, and supports regulatory procedures for stakeholders. There is a need to respect the culture’s interest, engagement, and for research and clinical trials to be transparent and have ethical oversight to promote global research discourse and trust. d. Middle East Countries in the Middle East have varying degrees of acceptance of or restrictions to policies related to using embryonic stem cells due to cultural and religious influences. Saudi Arabia has made significant contributions to stem cell research, and conducts research based on international guidelines for ethical conduct and under strict adherence to guidelines in accordance with Islamic principles. Specifically, the Saudi government and people require ESC research to adhere to Sharia law. In addition to umbilical and placental stem cells,[35] Saudi Arabia permits the use of embryonic stem cells as long as they come from miscarriages, therapeutic abortions permissible by Sharia law, or are left over from in vitro fertilization and donated to research.[36] Laws and ethical guidelines for stem cell research allow the development of research institutions such as the King Abdullah International Medical Research Center, which has a cord blood bank and a stem cell registry with nearly 10,000 donors.[37] Such volume and acceptance are due to the ethical ‘permissibility’ of the donor sources, which do not conflict with religious pillars. However, some researchers err on the side of caution, choosing not to use embryos or fetal tissue as they feel it is unethical to do so.[38] Jordan has a positive research ethics culture.[39] However, there is a significant issue of lack of trust in researchers, with 45.23 percent (38.66 percent agreeing and 6.57 percent strongly agreeing) of Jordanians holding a low level of trust in researchers, compared to 81.34 percent of Jordanians agreeing that they feel safe to participate in a research trial.[40] Safety testifies to the feeling of confidence that adequate measures are in place to protect participants from harm, whereas trust in researchers could represent the confidence in researchers to act in the participants’ best interests, adhere to ethical guidelines, provide accurate information, and respect participants’ rights and dignity. One method to improve trust would be to address communication issues relevant to ESC. Legislation surrounding stem cell research has adopted specific language, especially concerning clarification “between ‘stem cells’ and ‘embryonic stem cells’” in translation.[41] Furthermore, legislation “mandates the creation of a national committee… laying out specific regulations for stem-cell banking in accordance with international standards.”[42] This broad regulation opens the door for future global engagement and maintains transparency. However, these regulations may also constrain the influence of research direction, pace, and accessibility of research outcomes. e. Europe In the European Union (EU), ethics is also principle-based, but the principles of autonomy, dignity, integrity, and vulnerability are interconnected.[43] As such, the opportunity for cohesion and concessions between individuals’ thoughts and ideals allows for a more adaptable ethics model due to the flexible principles that relate to the human experience The EU has put forth a framework in its Convention for the Protection of Human Rights and Dignity of the Human Being allowing member states to take different approaches. Each European state applies these principles to its specific conventions, leading to or reflecting different acceptance levels of stem cell research. [44] For example, in Germany, Lebenzusammenhang, or the coherence of life, references integrity in the unity of human culture. Namely, the personal sphere “should not be subject to external intervention.”[45] Stem cell interventions could affect this concept of bodily completeness, leading to heavy restrictions. Under the Grundgesetz, human dignity and the right to life with physical integrity are paramount.[46] The Embryo Protection Act of 1991 made producing cell lines illegal. Cell lines can be imported if approved by the Central Ethics Commission for Stem Cell Research only if they were derived before May 2007.[47] Stem cell research respects the integrity of life for the embryo with heavy specifications and intense oversight. This is vastly different in Finland, where the regulatory bodies find research more permissible in IVF excess, but only up to 14 days after fertilization.[48] Spain’s approach differs still, with a comprehensive regulatory framework.[49] Thus, research regulation can be culture-specific due to variations in applied principles. Diverse cultures call for various approaches to ethical permissibility.[50] Only an adaptive-deliberative model can address the cultural constructions of self and achieve positive, culturally sensitive stem cell research practices.[51] II. Religious Perspectives on ESC Embryonic stem cell sources are the main consideration within religious contexts. While individuals may not regard their own religious texts as authoritative or factual, religion can shape their foundations or perspectives. The Qur'an states: “And indeed We created man from a quintessence of clay. Then We placed within him a small quantity of nutfa (sperm to fertilize) in a safe place. Then We have fashioned the nutfa into an ‘alaqa (clinging clot or cell cluster), then We developed the ‘alaqa into mudgha (a lump of flesh), and We made mudgha into bones, and clothed the bones with flesh, then We brought it into being as a new creation. So Blessed is Allah, the Best of Creators.”[52] Many scholars of Islam estimate the time of soul installment, marked by the angel breathing in the soul to bring the individual into creation, as 120 days from conception.[53] Personhood begins at this point, and the value of life would prohibit research or experimentation that could harm the individual. If the fetus is more than 120 days old, the time ensoulment is interpreted to occur according to Islamic law, abortion is no longer permissible.[54] There are a few opposing opinions about early embryos in Islamic traditions. According to some Islamic theologians, there is no ensoulment of the early embryo, which is the source of stem cells for ESC research.[55] In Buddhism, the stance on stem cell research is not settled. The main tenets, the prohibition against harming or destroying others (ahimsa) and the pursuit of knowledge (prajña) and compassion (karuna), leave Buddhist scholars and communities divided.[56] Some scholars argue stem cell research is in accordance with the Buddhist tenet of seeking knowledge and ending human suffering. Others feel it violates the principle of not harming others. Finding the balance between these two points relies on the karmic burden of Buddhist morality. In trying to prevent ahimsa towards the embryo, Buddhist scholars suggest that to comply with Buddhist tenets, research cannot be done as the embryo has personhood at the moment of conception and would reincarnate immediately, harming the individual's ability to build their karmic burden.[57] On the other hand, the Bodhisattvas, those considered to be on the path to enlightenment or Nirvana, have given organs and flesh to others to help alleviate grieving and to benefit all.[58] Acceptance varies on applied beliefs and interpretations. Catholicism does not support embryonic stem cell research, as it entails creation or destruction of human embryos. This destruction conflicts with the belief in the sanctity of life. For example, in the Old Testament, Genesis describes humanity as being created in God’s image and multiplying on the Earth, referencing the sacred rights to human conception and the purpose of development and life. In the Ten Commandments, the tenet that one should not kill has numerous interpretations where killing could mean murder or shedding of the sanctity of life, demonstrating the high value of human personhood. In other books, the theological conception of when life begins is interpreted as in utero,[59] highlighting the inviolability of life and its formation in vivo to make a religious point for accepting such research as relatively limited, if at all.[60] The Vatican has released ethical directives to help apply a theological basis to modern-day conflicts. The Magisterium of the Church states that “unless there is a moral certainty of not causing harm,” experimentation on fetuses, fertilized cells, stem cells, or embryos constitutes a crime.[61] Such procedures would not respect the human person who exists at these stages, according to Catholicism. Damages to the embryo are considered gravely immoral and illicit.[62] Although the Catholic Church officially opposes abortion, surveys demonstrate that many Catholic people hold pro-choice views, whether due to the context of conception, stage of pregnancy, threat to the mother’s life, or for other reasons, demonstrating that practicing members can also accept some but not all tenets.[63] Some major Jewish denominations, such as the Reform, Conservative, and Reconstructionist movements, are open to supporting ESC use or research as long as it is for saving a life.[64] Within Judaism, the Talmud, or study, gives personhood to the child at birth and emphasizes that life does not begin at conception:[65] “If she is found pregnant, until the fortieth day it is mere fluid,”[66] Whereas most religions prioritize the status of human embryos, the Halakah (Jewish religious law) states that to save one life, most other religious laws can be ignored because it is in pursuit of preservation.[67] Stem cell research is accepted due to application of these religious laws. We recognize that all religions contain subsets and sects. The variety of environmental and cultural differences within religious groups requires further analysis to respect the flexibility of religious thoughts and practices. We make no presumptions that all cultures require notions of autonomy or morality as under the common morality theory, which asserts a set of universal moral norms that all individuals share provides moral reasoning and guides ethical decisions.[68] We only wish to show that the interaction with morality varies between cultures and countries. III. A Flexible Ethical Approach The plurality of different moral approaches described above demonstrates that there can be no universally acceptable uniform law for ESC on a global scale. Instead of developing one standard, flexible ethical applications must be continued. We recommend local guidelines that incorporate important cultural and ethical priorities. While the Declaration of Helsinki is more relevant to people in clinical trials receiving ESC products, in keeping with the tradition of protections for research subjects, consent of the donor is an ethical requirement for ESC donation in many jurisdictions including the US, Canada, and Europe.[69] The Declaration of Helsinki provides a reference point for regulatory standards and could potentially be used as a universal baseline for obtaining consent prior to gamete or embryo donation. For instance, in Columbia University’s egg donor program for stem cell research, donors followed standard screening protocols and “underwent counseling sessions that included information as to the purpose of oocyte donation for research, what the oocytes would be used for, the risks and benefits of donation, and process of oocyte stimulation” to ensure transparency for consent.[70] The program helped advance stem cell research and provided clear and safe research methods with paid participants. Though paid participation or covering costs of incidental expenses may not be socially acceptable in every culture or context,[71] and creating embryos for ESC research is illegal in many jurisdictions, Columbia’s program was effective because of the clear and honest communications with donors, IRBs, and related stakeholders. This example demonstrates that cultural acceptance of scientific research and of the idea that an egg or embryo does not have personhood is likely behind societal acceptance of donating eggs for ESC research. As noted, many countries do not permit the creation of embryos for research. Proper communication and education regarding the process and purpose of stem cell research may bolster comprehension and garner more acceptance. “Given the sensitive subject material, a complete consent process can support voluntary participation through trust, understanding, and ethical norms from the cultures and morals participants value. This can be hard for researchers entering countries of different socioeconomic stability, with different languages and different societal values.[72] An adequate moral foundation in medical ethics is derived from the cultural and religious basis that informs knowledge and actions.[73] Understanding local cultural and religious values and their impact on research could help researchers develop humility and promote inclusion. IV. Concerns Some may argue that if researchers all adhere to one ethics standard, protection will be satisfied across all borders, and the global public will trust researchers. However, defining what needs to be protected and how to define such research standards is very specific to the people to which standards are applied. We suggest that applying one uniform guide cannot accurately protect each individual because we all possess our own perceptions and interpretations of social values.[74] Therefore, the issue of not adjusting to the moral pluralism between peoples in applying one standard of ethics can be resolved by building out ethics models that can be adapted to different cultures and religions. Other concerns include medical tourism, which may promote health inequities.[75] Some countries may develop and approve products derived from ESC research before others, compromising research ethics or drug approval processes. There are also concerns about the sale of unauthorized stem cell treatments, for example, those without FDA approval in the United States. Countries with robust research infrastructures may be tempted to attract medical tourists, and some customers will have false hopes based on aggressive publicity of unproven treatments.[76] For example, in China, stem cell clinics can market to foreign clients who are not protected under the regulatory regimes. Companies employ a marketing strategy of “ethically friendly” therapies. Specifically, in the case of Beike, China’s leading stem cell tourism company and sprouting network, ethical oversight of administrators or health bureaus at one site has “the unintended consequence of shifting questionable activities to another node in Beike's diffuse network.”[77] In contrast, Jordan is aware of stem cell research’s potential abuse and its own status as a “health-care hub.” Jordan’s expanded regulations include preserving the interests of individuals in clinical trials and banning private companies from ESC research to preserve transparency and the integrity of research practices.[78] The social priorities of the community are also a concern. The ISSCR explicitly states that guidelines “should be periodically revised to accommodate scientific advances, new challenges, and evolving social priorities.”[79] The adaptable ethics model extends this consideration further by addressing whether research is warranted given the varying degrees of socioeconomic conditions, political stability, and healthcare accessibilities and limitations. An ethical approach would require discussion about resource allocation and appropriate distribution of funds.[80] CONCLUSION While some religions emphasize the sanctity of life from conception, which may lead to public opposition to ESC research, others encourage ESC research due to its potential for healing and alleviating human pain. Many countries have special regulations that balance local views on embryonic personhood, the benefits of research as individual or societal goods, and the protection of human research subjects. To foster understanding and constructive dialogue, global policy frameworks should prioritize the protection of universal human rights, transparency, and informed consent. In addition to these foundational global policies, we recommend tailoring local guidelines to reflect the diverse cultural and religious perspectives of the populations they govern. Ethics models should be adapted to local populations to effectively establish research protections, growth, and possibilities of stem cell research. For example, in countries with strong beliefs in the moral sanctity of embryos or heavy religious restrictions, an adaptive model can allow for discussion instead of immediate rejection. In countries with limited individual rights and voice in science policy, an adaptive model ensures cultural, moral, and religious views are taken into consideration, thereby building social inclusion. While this ethical consideration by the government may not give a complete voice to every individual, it will help balance policies and maintain the diverse perspectives of those it affects. Embracing an adaptive ethics model of ESC research promotes open-minded dialogue and respect for the importance of human belief and tradition. By actively engaging with cultural and religious values, researchers can better handle disagreements and promote ethical research practices that benefit each society. This brief exploration of the religious and cultural differences that impact ESC research reveals the nuances of relative ethics and highlights a need for local policymakers to apply a more intense adaptive model. - [1] Poliwoda, S., Noor, N., Downs, E., Schaaf, A., Cantwell, A., Ganti, L., Kaye, A. D., Mosel, L. I., Carroll, C. B., Viswanath, O., & Urits, I. (2022). Stem cells: a comprehensive review of origins and emerging clinical roles in medical practice. 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BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6 Culturally, autonomy practices follow a relational autonomy approach based on a paternalistic deontological health care model. The adherence to strict international research policies and religious pillars within the regulatory environment is a great foundation for research ethics. However, there is a need to develop locally targeted ethics approaches for research (as called for in Alahmad, G., Aljohani, S., & Najjar, M. F. (2020). Ethical challenges regarding the use of stem cells: interviews with researchers from Saudi Arabia. BMC medical ethics, 21(1), 35. https://doi.org/10.1186/s12910-020-00482-6), this decision-making approach may help advise a research decision model. For more on the clinical cultural autonomy approaches, see: Alabdullah, Y. Y., Alzaid, E., Alsaad, S., Alamri, T., Alolayan, S. W., Bah, S., & Aljoudi, A. S. (2022). 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Understanding and attitudes of the Jordanian public about clinical research ethics. Research Ethics, 17(2), 228-241. https://doi.org/10.1177/1747016120966779 [41] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [42] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [43] The EU’s definition of autonomy relates to the capacity for creating ideas, moral insight, decisions, and actions without constraint, personal responsibility, and informed consent. However, the EU views autonomy as not completely able to protect individuals and depends on other principles, such as dignity, which “expresses the intrinsic worth and fundamental equality of all human beings.” Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [44] Council of Europe. Convention for the protection of Human Rights and Dignity of the Human Being with regard to the Application of Biology and Medicine: Convention on Human Rights and Biomedicine (ETS No. 164) https://www.coe.int/en/web/conventions/full-list?module=treaty-detail&treatynum=164 (forbidding the creation of embryos for research purposes only, and suggests embryos in vitro have protections.); Also see Drabiak-Syed B. K. (2013). New President, New Human Embryonic Stem Cell Research Policy: Comparative International Perspectives and Embryonic Stem Cell Research Laws in France. Biotechnology Law Report, 32(6), 349–356. https://doi.org/10.1089/blr.2013.9865 [45] Rendtorff, J.D., Kemp, P. (2019). Four Ethical Principles in European Bioethics and Biolaw: Autonomy, Dignity, Integrity and Vulnerability. In: Valdés, E., Lecaros, J. (eds) Biolaw and Policy in the Twenty-First Century. International Library of Ethics, Law, and the New Medicine, vol 78. Springer, Cham. https://doi.org/10.1007/978-3-030-05903-3_3 [46] Tomuschat, C., Currie, D. P., Kommers, D. P., & Kerr, R. (Trans.). (1949, May 23). Basic law for the Federal Republic of Germany. https://www.btg-bestellservice.de/pdf/80201000.pdf [47] Regulation of Stem Cell Research in Germany. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-germany [48] Regulation of Stem Cell Research in Finland. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-finland [49] Regulation of Stem Cell Research in Spain. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-spain [50] Some sources to consider regarding ethics models or regulatory oversights of other cultures not covered: Kara MA. Applicability of the principle of respect for autonomy: the perspective of Turkey. J Med Ethics. 2007 Nov;33(11):627-30. doi: 10.1136/jme.2006.017400. PMID: 17971462; PMCID: PMC2598110. Ugarte, O. N., & Acioly, M. A. (2014). The principle of autonomy in Brazil: one needs to discuss it ... Revista do Colegio Brasileiro de Cirurgioes, 41(5), 374–377. https://doi.org/10.1590/0100-69912014005013 Bharadwaj, A., & Glasner, P. E. (2012). Local cells, global science: The rise of embryonic stem cell research in India. Routledge. For further research on specific European countries regarding ethical and regulatory framework, we recommend this database: Regulation of Stem Cell Research in Europe. Eurostemcell. (2017, April 26). https://www.eurostemcell.org/regulation-stem-cell-research-europe [51] Klitzman, R. (2006). Complications of culture in obtaining informed consent. The American Journal of Bioethics, 6(1), 20–21. https://doi.org/10.1080/15265160500394671 see also: Ekmekci, P. E., & Arda, B. (2017). Interculturalism and Informed Consent: Respecting Cultural Differences without Breaching Human Rights. Cultura (Iasi, Romania), 14(2), 159–172.; For why trust is important in research, see also: Gray, B., Hilder, J., Macdonald, L., Tester, R., Dowell, A., & Stubbe, M. (2017). Are research ethics guidelines culturally competent? Research Ethics, 13(1), 23-41. https://doi.org/10.1177/1747016116650235 [52] The Qur'an (M. Khattab, Trans.). (1965). Al-Mu’minun, 23: 12-14. https://quran.com/23 [53] Lenfest, Y. (2017, December 8). Islam and the beginning of human life. Bill of Health. https://blog.petrieflom.law.harvard.edu/2017/12/08/islam-and-the-beginning-of-human-life/ [54] Aksoy, S. (2005). Making regulations and drawing up legislation in Islamic countries under conditions of uncertainty, with special reference to embryonic stem cell research. Journal of Medical Ethics, 31:399-403.; see also: Mahmoud, Azza. "Islamic Bioethics: National Regulations and Guidelines of Human Stem Cell Research in the Muslim World." Master's thesis, Chapman University, 2022. https://doi.org/10.36837/ chapman.000386 [55] Rashid, R. (2022). When does Ensoulment occur in the Human Foetus. Journal of the British Islamic Medical Association, 12(4). ISSN 2634 8071. https://www.jbima.com/wp-content/uploads/2023/01/2-Ethics-3_-Ensoulment_Rafaqat.pdf. [56] Sivaraman, M. & Noor, S. (2017). Ethics of embryonic stem cell research according to Buddhist, Hindu, Catholic, and Islamic religions: perspective from Malaysia. Asian Biomedicine,8(1) 43-52. https://doi.org/10.5372/1905-7415.0801.260 [57] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [58] Lecso, P. A. (1991). The Bodhisattva Ideal and Organ Transplantation. Journal of Religion and Health, 30(1), 35–41. http://www.jstor.org/stable/27510629; Bodhisattva, S. (n.d.). The Key of Becoming a Bodhisattva. A Guide to the Bodhisattva Way of Life. http://www.buddhism.org/Sutras/2/BodhisattvaWay.htm [59] There is no explicit religious reference to when life begins or how to conduct research that interacts with the concept of life. However, these are relevant verses pertaining to how the fetus is viewed. ((King James Bible. (1999). Oxford University Press. (original work published 1769)) Jerimiah 1: 5 “Before I formed thee in the belly I knew thee; and before thou camest forth out of the womb I sanctified thee…” In prophet Jerimiah’s insight, God set him apart as a person known before childbirth, a theme carried within the Psalm of David. Psalm 139: 13-14 “…Thou hast covered me in my mother's womb. I will praise thee; for I am fearfully and wonderfully made…” These verses demonstrate David’s respect for God as an entity that would know of all man’s thoughts and doings even before birth. [60] It should be noted that abortion is not supported as well. [61] The Vatican. (1987, February 22). Instruction on Respect for Human Life in Its Origin and on the Dignity of Procreation Replies to Certain Questions of the Day. Congregation For the Doctrine of the Faith. https://www.vatican.va/roman_curia/congregations/cfaith/documents/rc_con_cfaith_doc_19870222_respect-for-human-life_en.html [62] The Vatican. (2000, August 25). Declaration On the Production and the Scientific and Therapeutic Use of Human Embryonic Stem Cells. Pontifical Academy for Life. https://www.vatican.va/roman_curia/pontifical_academies/acdlife/documents/rc_pa_acdlife_doc_20000824_cellule-staminali_en.html; Ohara, N. (2003). Ethical Consideration of Experimentation Using Living Human Embryos: The Catholic Church’s Position on Human Embryonic Stem Cell Research and Human Cloning. Department of Obstetrics and Gynecology. Retrieved from https://article.imrpress.com/journal/CEOG/30/2-3/pii/2003018/77-81.pdf. [63] Smith, G. A. (2022, May 23). Like Americans overall, Catholics vary in their abortion views, with regular mass attenders most opposed. Pew Research Center. https://www.pewresearch.org/short-reads/2022/05/23/like-americans-overall-catholics-vary-in-their-abortion-views-with-regular-mass-attenders-most-opposed/ [64] Rosner, F., & Reichman, E. (2002). Embryonic stem cell research in Jewish law. Journal of halacha and contemporary society, (43), 49–68.; Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [65] Schenker J. G. (2008). The beginning of human life: status of embryo. Perspectives in Halakha (Jewish Religious Law). Journal of assisted reproduction and genetics, 25(6), 271–276. https://doi.org/10.1007/s10815-008-9221-6 [66] Ruttenberg, D. (2020, May 5). The Torah of Abortion Justice (annotated source sheet). Sefaria. https://www.sefaria.org/sheets/234926.7?lang=bi&with=all&lang2=en [67] Jafari, M., Elahi, F., Ozyurt, S. & Wrigley, T. (2007). 4. Religious Perspectives on Embryonic Stem Cell Research. In K. Monroe, R. Miller & J. Tobis (Ed.), Fundamentals of the Stem Cell Debate: The Scientific, Religious, Ethical, and Political Issues (pp. 79-94). Berkeley: University of California Press. https://escholarship.org/content/qt9rj0k7s3/qt9rj0k7s3_noSplash_f9aca2e02c3777c7fb76ea768ba458f0.pdf https://doi.org/10.1525/9780520940994-005 [68] Gert, B. (2007). Common morality: Deciding what to do. Oxford Univ. Press. [69] World Medical Association (2013). World Medical Association Declaration of Helsinki: ethical principles for medical research involving human subjects. JAMA, 310(20), 2191–2194. https://doi.org/10.1001/jama.2013.281053 Declaration of Helsinki – WMA – The World Medical Association.; see also: National Commission for the Protection of Human Subjects of Biomedical and Behavioral Research. (1979). The Belmont report: Ethical principles and guidelines for the protection of human subjects of research. U.S. Department of Health and Human Services. https://www.hhs.gov/ohrp/regulations-and-policy/belmont-report/read-the-belmont-report/index.html [70] Zakarin Safier, L., Gumer, A., Kline, M., Egli, D., & Sauer, M. V. (2018). Compensating human subjects providing oocytes for stem cell research: 9-year experience and outcomes. Journal of assisted reproduction and genetics, 35(7), 1219–1225. https://doi.org/10.1007/s10815-018-1171-z https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6063839/ see also: Riordan, N. H., & Paz Rodríguez, J. (2021). Addressing concerns regarding associated costs, transparency, and integrity of research in recent stem cell trial. Stem Cells Translational Medicine, 10(12), 1715–1716. https://doi.org/10.1002/sctm.21-0234 [71] Klitzman, R., & Sauer, M. V. (2009). Payment of egg donors in stem cell research in the USA. Reproductive biomedicine online, 18(5), 603–608. https://doi.org/10.1016/s1472-6483(10)60002-8 [72] Krosin, M. T., Klitzman, R., Levin, B., Cheng, J., & Ranney, M. L. (2006). Problems in comprehension of informed consent in rural and peri-urban Mali, West Africa. Clinical trials (London, England), 3(3), 306–313. https://doi.org/10.1191/1740774506cn150oa [73] Veatch, Robert M. Hippocratic, Religious, and Secular Medical Ethics: The Points of Conflict. Georgetown University Press, 2012. [74] Msoroka, M. S., & Amundsen, D. (2018). One size fits not quite all: Universal research ethics with diversity. Research Ethics, 14(3), 1-17. https://doi.org/10.1177/1747016117739939 [75] Pirzada, N. (2022). The Expansion of Turkey’s Medical Tourism Industry. Voices in Bioethics, 8. https://doi.org/10.52214/vib.v8i.9894 [76] Stem Cell Tourism: False Hope for Real Money. Harvard Stem Cell Institute (HSCI). (2023). https://hsci.harvard.edu/stem-cell-tourism, See also: Bissassar, M. (2017). Transnational Stem Cell Tourism: An ethical analysis. Voices in Bioethics, 3. https://doi.org/10.7916/vib.v3i.6027 [77]Song, P. (2011) The proliferation of stem cell therapies in post-Mao China: problematizing ethical regulation, New Genetics and Society, 30:2, 141-153, DOI: 10.1080/14636778.2011.574375 [78] Dajani, R. (2014). Jordan’s stem-cell law can guide the Middle East. Nature 510, 189. https://doi.org/10.1038/510189a [79] International Society for Stem Cell Research. (2024). Standards in stem cell research. International Society for Stem Cell Research. https://www.isscr.org/guidelines/5-standards-in-stem-cell-research [80] Benjamin, R. (2013). People’s science bodies and rights on the Stem Cell Frontier. Stanford University Press.

Photo by Jeremy Wong on Unsplash ABSTRACT In response to the threat of COVID-19, CMS issued unprecedented restrictions severely limiting the liberty of older adults residing in long-term care. Older adults are identified as at a high risk of becoming infected through exposure to SARS-Cov-2 and of suffering the most severe morbidity and mortality. While protecting the individual from disease, the restrictions also had a determinantal effect. The restrictions exacerbated social isolation and loneliness, two pervasive public health concerns within the older adult population. Legally, the restrictions pass constitutional muster. The ethical analysis presents more questions and debates. Initially, the restrictions to protect the older adult were grounded in public health ethics and bioethics principles. However, the ethical lines become blurred as the risk of harm secondary to isolation increased over the time that the restrictions remained in effect. The ethical point of view becomes more divergent considering the restrictions also preserved medical resources for the greater good of society, arguably diverting them to serve younger people. We have a moral obligation to reduce social isolation and recognize the older adult as a valuable member of society with equal worth and dignity. INTRODUCTION In response to the threat of COVID-19, CMS issued unprecedented restrictions severely limiting the liberty of older adults residing in long-term care. Older adults are identified as at a high risk of becoming infected from exposure to SARS-Cov-2 and from suffering the most severe morbidity and mortality. While protecting the individual from disease, the restrictions also had a determinantal effect. The restrictions exacerbated social isolation and loneliness, two pervasive public health concerns within the older adult population. Legally, the restrictions pass Constitutional muster. The ethical analysis presents more questions and debates. Initially, the restrictions to protect the older adult were grounded in public health ethics and bioethics principles. However, the ethical lines become blurred as the risk of harm secondary to isolation increased over the time that the restrictions remained in effect. The devastation of COVID-19 within the older adult population extends beyond the immediate risk and harm of infection. At the beginning of the COVID-19 pandemic, experts determined that older adults, especially those living in long-term care, were at a greater risk of becoming infected and depleting scarce medical resources. Two days after WHO declared the pandemic, the Centers for Medicare & Medicaid Services (CMS) followed the Centers for Disease Control (CDC) recommendations and announced mitigation measures that required long-term care facilities to (1) restrict volunteers and nonessential personnel from entering the facility; (2) cancel all group activities and communal dining; (3) screen residents and health care personnel for fever and respiratory symptoms; and (4) encourage residents to stay in their rooms. The social isolation resulting from the mitigation measures posed a credible threat to five core domains of healthy aging: (1) promoting health; preventing injury and managing chronic conditions; (2) cognitive health; (3) physical health; (4) mental health; and (5) facilitating social engagement.[1] l. Social Isolation and Loneliness COVID-19 highlighted two pervasive public health concerns confronting older adults—social isolation and loneliness. Social isolation is an objective deficit in the number of relationships and the frequency of contact with family, friends, and the community.[2] Social Isolation is a risk factor for loneliness. Loneliness is the subjective perception of a lack of meaningful relationships.[3] Loneliness has three dimensions: (1) absence of a significant person to provide emotional support and affirm one’s value as a person; (2) absence of a small group of people seen regularly, such as a card group; and (3) absence of a larger network group of people who provide support by being together as a group, for example, church services or rotary meetings.[4] COVID-19 restrictions affected all three dimensions. Social isolation can be as dangerous as smoking fifteen cigarettes per day, earning its designation as a public health priority.[5] Isolation increases the risk of cardiovascular disease, obesity, anxiety, and depression. Loneliness can lead to depression, alcoholism, and suicidal thoughts.[6] Some studies found that loneliness is also a factor in cognitive decline. For example, caregivers reported that 63 percent of older adults with cognitive impairment experienced cognitive decline during the COVID-19 pandemic.[7] In 2017, the American Association of Retired Persons (AARP) reported that social isolation accounted for $6.7 billion in additional Medicare spending although only 14 percent of older adults in the US reported being socially isolated.[8] Approximately 24 percent of community-dwelling older adults in the US are socially isolated. Forty-three percent of adults aged 60 and older report feeling lonely. Those living in long-term care report loneliness at a rate of at least double of community-dwelling older adults.[9] WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.”[10] A broad definition of health highlights the detriment of social isolation in older adults. There is a moral obligation to mitigate the effect of isolation.[11] The additional Medicare spending costs attributable to the effects of social isolation secondary to COVID-19 will be extraordinary. Providing social support will directly benefit older adults and indirectly benefit society by reducing Medicare spending associated with the effects of social isolation. Combating the pervasiveness of social isolation requires immediate collaborative community action. Many long-term care residents who depend on visits from family and friends to socialize increasingly felt lonely, abandoned, and despondent,[12] increasing the risk of feeling grief and loss, including individual and collective trauma reactions.[13] Also, normally social opportunities, medical, and legal appointments defaulted to telephone or virtual appointments. The cessation of in-person medical appointments interfered with optimal management of chronic conditions and preventive care. Some older adults lack access to the technology, are unfamiliar with technology, or cannot use technology for other reasons. At least one study supports the potential for older adults to benefit from technology and suggests that training could promote long-term benefits in older adults aged 80 years and over.[14] Focusing on technological advances specific to older adults with input from older adults should be a priority. When communal dining abruptly stopped, residents had to eat all their meals alone in their rooms. Older adults often mention the difficulty of eating meals alone, especially if recently divorced, widowed, or otherwise separated from a spouse or partner. Closure of the exercise facilities limited the ability of an older adult to stay physically active. Reduced physical activity creates long-term adverse health effects.[15] ll. Measures to Mitigate Isolation To facilitate some contact, long-term care facilities devised window visits. The resident remained safely inside the locked facility, standing or seated in front of a window. Visitors stood outside in the grass or parking lot. Any conversation took place over the telephone. To simulate physical contact, residents and visitors pressed their palms together, separated by the glass barrier. The window visits recall the prison visits depicted in movies and television. In late June 2020, CMS relaxed the restrictions and advised that long-term care facilities could resume some communal activities and permit outdoor visits. Although CMS eased the restrictions, interpersonal contact remained minimal. Outdoor visits required scheduling an appointment during limited hours of availability. The facilities limited the visits per week and the duration of each visit to thirty minutes. In addition, the staff enforced wearing personal protective equipment and maintaining physical distancing. Several impracticalities diminished the optimism of the relaxed restrictions. Residents could leave their rooms for meals but remained physically separated at a distance that prevented any meaningful interaction. Similarly, the limitations on the in-person visits presented problems. Non-resident spouses with mobility challenges found the outdoor access difficult, if not impossible. Residents or spouses with hearing and vision losses experienced challenges in communicating while sitting outside, six feet apart, and wearing masks.[16] lll. Legal Precedent for Emergency Measures The primary legal issue stems from the conflict between individual liberty and the public good or health. Jacobson v. Massachusetts provides a framework for balancing individual liberty rights and the public good during a pandemic.[17] Jacobson clarified an essential point of law - the rights and liberties secured by the US Constitution are not absolute.[18] Faced with a pandemic, a community has the right to protect members of the community.[19] Jacobson outlines four standards for imposing public health mandates during a pandemic. First, the State overreaches when it uses public health powers unnecessarily.[20] Second, the state must use the least restrictive means to prevent harm.[21] Third, the state must use reasonable means expected to prevent or ameliorate a health threat.[22] Finally, the intervention must not pose an undue risk.[23] The guidelines in Jacobson, established during the smallpox pandemic, apply to COVID-19. In response to the threat of COVID-19, public health authorities enacted mandates to protect the public, especially older adults, against the highly contagious and virulent virus. The CMS restrictions specifically addressed older adults living in long-term care facilities. While the CMS directives obstructed residents’ liberties, they also contradicted the Assisted Living Facility social model, which places autonomy and independence at the forefront. Given the gravity of harm and the uncertainties in the early phases of the pandemic, the restrictions were arguably the least restrictive means to manage the immediate threat. The effectiveness varied from facility to facility, with many deaths throughout the US in long-term care facilities. While valuable early in the pandemic, at some point the continuation of the mitigation measures increased social isolation and its associated risks. In Jew Ho v. Williamson, the Supreme Court overturned a quarantine order to contain the bubonic plague.[24] The officials enforced the order only against a targeted ethnic population which did not present an identified risk.[25] In reaching its decision, the Court determined that the quarantine order was not a reasonable regulation to prevent the spread of the bubonic plague. Rather, it was racially motivated. The Court ruled that the government cannot impose public health orders in a racially invidious manner.[26] There are similarities between Jew Ho and the CMS restrictions. Like the quarantine order in Jew Ho, the restrictions targeted a specific population. But with COVID-19 older adults were an identified high-risk population because of their susceptibility to infection and severe illness. During the early phases of the pandemic, the directives were reasonable to accomplish the purpose of preventing the spread in the identified high-risk population. They were not discriminatory according to the rule of law in Jew Ho. The argument supporting the constitutionality of the CMS restrictions wanes as the length of the safety precautions increased. lV. Ethical Analysis of the Lengthy Social Isolation The CMS restrictions require the ethical analysis of harm, proportionality, reciprocity, and transparency. As well as analysis under the principles of autonomy, beneficence, non-maleficence, and justice. a. Harm and Proportionality As previously discussed, older adult long-term care residents were more susceptible to COVID-19 and to severe physical effects requiring hospitalization. In addition, older adults are more likely to die from COVID-19. Based on a totality of the circumstances and what we knew about the virus in the early phases of the pandemic, the restrictions were the least restrictive means to protect this high-risk population. But the question of proportionality requires ongoing assessment and re-evaluation. While the initial uncertainty and chaos justified the restrictions, as the pandemic continued and the risk of harm from the restrictions increased, the pendulum began to swing. At some point, upon proof or likelihood of safety, less restrictive alternatives should have been adopted. b. Reciprocity The concept of reciprocity is a core principle of public health and requires the balancing of the benefits and burdens of the social cooperation.[27] When individuals sacrifice their liberty for the benefit of others, they should not be penalized as a result of making the sacrifice, and thus society owes a reciprocal obligation to the individuals, such as providing individuals support and not discriminating against them.[28] Residents did not have any input or choice when CMS and the administrators stripped away their autonomy and liberties. While the restrictions protected the individual resident from the direct harm of infection, the restrictions also protected society from the indirect harm of the depletion of scarce medical resources. Public health officials identified long-term care residents as most likely to require significant medical resources. One talking point repeatedly broadcast was the need to prevent the depletion of hospital beds, ventilators, medications, and supplies. Most assisted-living facilities are for-profit, and residents pay for their food, shelter, and personal needs. What does society owe these long-term care residents in return for the liberty they sacrificed for the benefit of society at large? At the very least, I suggest we owe these individuals the commitment to conduct research exploring and addressing the effects of the restrictions. c. Transparency by Government, the Media, and the Long-Term care Facilities The communications from government and public health officials about the pandemic and the restrictions were opaque, leaving unanswered questions, doubts, and speculation. Some facilities provided families with basic information communicated through robocall messaging, with words of encouragement, painting rosy pictures of the residents' sequestered daily lives. Public health officials assert the common good and protecting the public’s safety and health justify paternalism and compulsory powers.[29] One counterargument is that the compulsory interventions or restrictions push paternalism to new levels.[30] The COVID-19 pandemic and the mitigation interventions highlight this tension between libertarian and epidemiological models based on (1) shortages that triggered rationing and prioritization; and (2) measures that safeguarded public health but infringed on individual rights.[31] d. Autonomy, Beneficence, and Non-Maleficence Through a bioethical lens, we immediately see the clash between the CMS restrictions and the long-term care residents’ autonomy. However, autonomy is not absolute. There was a benefit for the individual resident: the protection from a deadly virus. Thus, I argue that the initial restrictions were beneficent. Yet I also point to the deleterious secondary physical and emotional effects of the isolation and assert that the restrictions should have been safely modified as new information on viral spread and safety came about. We can accept the beneficence of protecting the high-risk resident from a deadly disease while acknowledging the associated harm. However, at some point, we must also ask if the harm experienced due to prolonged severe restrictions reached a level that exceeded the boundaries of beneficence and became maleficent. Perceiving the long-term care resident as a passive recipient of care is paternalistic and antithetical to autonomy and a person-centered approach.[32] Instead, society must recognize older adults as essential stakeholders in policymaking. The direct and active involvement of older adults allows the individual to retain agency rather than becoming a passive recipient of care.[33] Prioritization of the older adult as an autonomous active participant counters ageism and promotes autonomy. e. Justice Justice calls for analysis of several discrepancies. First, the special protection of long-term care residents seems justifiable due to their special vulnerability. CMS treated long-term care facilities alike. Most community-dwelling older adults could decide whether to adhere to stay-at-home restrictions and were not subject to the same level of enforcement that existed within long-term care facilities. The restrictions were far more oppressive for long-term care residents. In response to the assertion that selective lockdown discriminates against older adults, the same arguments discussed above demonstrate the morally relevant justification: older adults are more likely to require hospitalization and die from COVID-19.[34] One convincing argument against restrictions on older adults echoing Kant’s categorical imperative argues that selectively restricting older adults for the good of other people amounts to treating older adults as a means to an end for others.[35] While the restrictions imposed on the individual might slow the spread of the disease within the specific long-term care facility, which protects that individual resident, they also impose on the individual resident to serve the greater good: the preservation of scarce medical resources. The second application pushes the restrictive measures closer to violating Kant’s categorical imperative by treating the older adult as a means to the end of others. That is, younger people and those living outside of long-term care would have more hospital resources available to them if long-term care residents were more severely isolated keeping them from needing hospitalization. From a Kantian perspective, the categorical imperative demands respecting the dignity of persons—Kant’s supreme (formal) principle.[36] When we consider the restrictions, I suggest that we must also consider the impact on dignity. It has been suggested that dignity is the “overarching principle of bioethics.”[37] In the context of an analysis of the socially isolating COVID-19 mitigation measures on older adults in long-term care facilities, we should consider the relational aspect of dignity, recognizing the adult as having value and equal worth. The protracted imposed isolation of older adults to preserve medical resources devalues older adults. Ongoing COVID-19 restrictions should be analyzed for their unjustified harms. A second justice concern outside the scope here is that long-term care facilities are resourced differently, and had different results due to quality of care, number of staff, infection control protocols, and previous health infraction records. CONCLUSION The myopic focus on mortality ignores the risks of morbidity secondary to the devastating effects of social isolation on the older adult’s health and quality of life. The paternalistic prevention eclipsed the resident’s autonomy. At some point, the attention and priority must shift. When formulating policies, we must figure out at what point or in which situations the negative impact of restrictions outweighs the protective benefits. Although the restrictions may have slowed the spread of COVID-19, we must not discount the negative consequences, which may be long-term. From an ethical perspective, we must acknowledge the harm that has occurred within this population and accept the responsibility to redress the harm and prevent repeating the mistakes. The prolonged restrictions stretched legal and ethical boundaries. The mixed purpose of the restrictions (protecting the individual resident and preserving healthcare resources) makes the ethical analysis more challenging. Yet doing something for someone’s own good is still paternalistic and problematic. The public health justification includes the collective. We must confront the tough questions about the efficacy of pandemic mitigation measures and the mitigation measures’ adverse consequences. Leaving the doors to long-term care facilities open during the pandemic would have exposed every resident and staff member to a contagion that presented a significant risk of morbidity and mortality. But locking the doors exacerbated social isolation and loneliness, increasing the risk of morbidity and mortality. Julian Savulescu may be correct that there was no desirable solution. We must still work to find better solutions that will reduce social isolation and recognize the older adult as a valuable member of society with equal worth and dignity. [1] Coronavirus Disease 2019 (COVID-19) Nursing Homes & Long-term care Facilities. (n.d.). Retrieved from https://www.cdc.gov/coronavirus/2019-ncov/index.html. [2]Escalante, E., Golden, R. L., & Mason, D. J. (2020). Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World. JAMA Health Forum, 1(12),e201597. https://doi.org/10.1001/jamahealthforum.2020.1597. [3] D'cruz, M., & Banerjee, D. (2020). ‘An invisible human rights crisis’: The marginalization of older adults during the COVID-19 pandemic – An advocacy review. Psychiatry Research, 292, 113369. https://doi.org/10.1016/j.psychres.2020.113369. [4] Simard, J., & Volicer, L. (2020). Loneliness and Isolation in Long-term care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), 966–967. https://doi.org/10.1016/j.jamda.2020.05.006. [5] Escalante, E., Golden, R. L., & Mason, D. J. (2020). Social Isolation and Loneliness: Imperatives for Health Care in a Post-COVID World. JAMA Health Forum, 1(12). https://doi.org/10.1001/jamahealthforum.2020.1597. [6] Simard, J., & Volicer, L. (2020). Loneliness and Isolation in Long-term care and the COVID-19 Pandemic. Journal of the American Medical Directors Association, 21(7), 966–967. https://doi.org/10.1016/j.jamda.2020.05.006. [7] Batsis, J. A., Daniel, K., Eckstrom, E., Goldlist, K., Kusz, H., Lane, D., … Friedman, S. M. (2021, January 26). Promoting Healthy Aging During COVID‐19. American Geriatrics Society. https://agsjournals.onlinelibrary.wiley.com/doi/10.1111/jgs.17035. [8] Escalante, E., Golden, R. L., & Mason, D. J. (2020). 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