Don’t let the bedbugs bite: the Cimicidae debacle and the denial of healthcare and social justice
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- Aultman, J.M. Med Health Care and Philos (2013) 16: 417. doi:10.1007/s11019-012-9404-x
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Although bedbug infestation is not a new public health problem, it is one that is becoming more alarming among healthcare professionals, public health officials, and ethicists given the magnitude of patients who may be denied treatment, or who are unable to access treatment, especially those underserved populations living in low income housing. Efforts to quarantine and eradicate Cimicidae have been and should be made, but such efforts require costly interventions. The alternative, however, can further exacerbate the already growing problems of injustice, i.e., unfair treatment of patients, inaccessibility of needed resources. In the following paper, I examine the ramifications of denying access to medical care, among other healthcare justice dilemmas surrounding bedbug infestations. I also explore the value of health, and how healthcare professionals and public officials often feel as though bedbugs are not a priority because they, themselves, are not diseases, regardless of the fact they cause physical and mental problems that affect a person’s health. I propose recommendations for improving the health and well-being of those vulnerable populations who are facing a difficult and growing public health problem that is currently being ignored in medical and public health ethics literature, regardless of increased media attention and unusual habitats of localized infestations, e.g., Statue of Liberty, New York City.
KeywordsPublic health ethicsSocial justiceBedbugsHealthcare deliveryCommunity
Although bedbug infestation is not a new public health problem, it has become more alarming amongst healthcare professionals, public health officials, and ethicists, especially given the magnitude of patients who may be denied, or are unable to access treatment. Vulnerable populations, including the underserved, elderly, and mentally ill with known or suspected bed bug infestations are often denied access to employment offices, healthcare clinics, libraries, and other public services (Associated Press of Now Public 2011; Associated Press of se Missourian 2011). News outlets report that care providers are unwilling to transport and care for their clients and patients, since the bugs may be transferred to the carpet and upholstery of their automobiles, clothing, and other personal items, thus jeopardizing their lives and other clients or patients (James, Associated Press of ABC News 2011).
Efforts to quarantine and eradicate Cimicidae have been and should be made, but such efforts require costly interventions. Doing nothing, however, can exacerbate the growing problems of injustice, namely, the unfair treatment of persons and unequal access to needed resources. Furthermore, while Cimicidae can affect all people, regardless of socioeconomic status, race, ethnicity, gender, and location, the poor or unkempt are typically targeted as suspects for carrying the pest, and, consequentially, are stigmatized. And, for those who have Cimicidae infestations, these individuals may not only be denied access to healthcare and other public services, but also access to proper extermination services, which may be too costly (e.g., thermal treatments versus pesticide).
In the following paper, I examine the complex ethical issues associated with this public health problem, particularly drawing on examples from the United States, and supporting four central claims: (1) Bed bug infestations have become a global public health issue, reaching epidemic proportions in some areas of the world; (2) Treating infestations is emotionally and financially costly, disproportionately falling on the underserved, elderly, and mentally ill; (3) Such disparities represent a significant social injustice as infection leads people to be unable to fulfill basic capabilities, and (4) The capabilities approach to justice can help address the physical and mental health and stigmatization of affected individuals, as well as the need for community support and involvement. Through this normative framework, which recognizes caring relationships, I make recommendations for improving the health and well-being of those persons and communities who are facing a difficult and growing public health problem.1
What are bedbugs?
Bedbugs are Hemiptera order insects of the Cimicidae family. Genus Cimex lectularius (bed bugs in temperate zones), and Cimex hemipterus, (bed bugs in both tropical areas and temperate zones), are the two commonly identifiable types of bed bugs. These hematophagous arthropods are small, reddish-brown and flat, and generally active at night, although they can be detected during the day. “Hiding places are usually within 1–2 m of suitable hosts and include seams in mattresses, crevices in box springs, backsides of headboards, spaces under baseboards or loose wall-paper, and even behind hanging pictures” (Goddard and deShazo 2009, p. 1360). Live bugs, along with their eggs, excrement, blood and molts, can be visibly detected. They can also be detected by smell, as they emit an offensive, sweet, musty odor (similar to the smell of almonds) caused by a glandular secretion. A female can lay 200–500 eggs in her lifetime of 6–24 months. There are 6 life cycles following the egg stage, including five nymph stages and one adult stage.
Delaunay et al. (2011) describe two modes of spreading: active dispersal and passive dispersal. Active dispersal is when the bugs move from their resting places to their hosts. Bedbugs typically feed on their human hosts at night for approximately 5 min, and then return to their hiding places. They inject an anesthetic into their hosts, so the feeding and removal of blood is not usually felt. Persons may receive several bites throughout the night, and clusters of bites can be visibly seen on the skin. The most common clinical manifestation of bedbug bites includes small clusters of pruritic, erythematous papules, or wheals, indicating a single bedbug repeatedly fed on its host. Passive dispersal is when the bugs travel longer distances via human transportation (in clothing, luggage, and furniture). Alice Anderson (2011) explains, “The affluent American and European desire for additional novel travel destinations during the last decade, and the exorbitant incomes some citizens had to fulfill these desires, gave bedbugs new travel opportunities as well” (p. 54).
Bedbug infestations were particularly problematic in the 1940s, but with the introduction of pesticides such as DDT, the bugs were quickly eliminated. Reason for the recent resurgence of bed bug infestations is unclear, “although some reports have suggested a role for increasing world travel, reluctance to use insecticides because of concerns regarding toxicity, and insecticide resistance” (Hwang et al. 2005, p. 535). Natural pest control methods with less harmful effects to humans were introduced and replaced those pesticides that had more residual control capabilities (Anderson 2011, p. 53). This change is one possible reason for the resurgence.
Negative effects of bedbugs
It is estimated that, based on discoveries of bedbugs in ancient tombs at Tell al-Armana, Egypt, bedbugs have affected populations for at least 3550 years (Usinger 1966; In: Delaunay et al. 2011). Throughout history, bedbugs, particularly the most common type, Cimex lectularius, have caused great distress to people due to their preferred bedding and feeding habits, i.e., biting the flesh of humans as they sleep. Frank Cowan (1865), author of Curious facts in the history of insects, suggests the word ‘bug’ was applied to Cimex lectularius because they were considered ‘terrors of the night’ (McSweeney 2010).
Bedbugs have been suspected of transmitting infectious agents and over 40 microorganisms have frequently been considered strong candidates (Goddard and deShazo 2009; Delaunay et al. 2011, p. 203). However, scientific studies are limited and have yet to prove that bedbugs are infectious disease vectors. Because worldwide infestations have increased significantly and are exacerbated by social injustices, ineffective interventions, and lack of community and government support, scientific research and public health initiatives are currently being developed to combat the negative effects of bedbugs.
In this section, I describe the negative effects of bedbugs from various perspectives, arguing that this global problem is worth public attention and resolution. Besides the clinical presentation of bedbugs and their physical and mental negative effects, there are significant financial, legal, and social problems associated with bedbug infestations.
The clinical presentation: physical and mental effects
When looking specifically at the clinical presentation of the negative effects of bedbugs, these effects, or reactions, can be divided into three categories: cutaneous, systemic, and psychological. Individuals’ clinical presentations may range from no effects to significant, life-threatening effects in all three categories. Reported cutaneous reactions span from no reaction with a barely visible punctum at the location of the bite to pruritic maculopapular, erythematous lesions, pruritic wheals around central punctum, popular urticaria, diffuse urticaria, and bullous rashes. Complex cutaneous reactions can “evolve into pruritic papules or nodules that may become superinfected after scratching and persisting for weeks” (Goddard and deShazo 2009, p. 1363) There is also the possibility of a secondary infection, which may result in folliculitis, cellulitis, or eczematoid dermatitis in the case of pre-existing eczema. Treatment may include topical application of over the counter or prescription agents such as paroxysme or corticosteroids. If bites become superinfected, patients should receive topical mupirocin or system antibiotics.
Reported systemic reactions include asthma, generalized urticarial, and anaphylaxis. “Systemic reactions to bites are treated as insect-induced anaphylaxis with intramuscular epinephrine, antihistamines, and corticosteroids” (Goddard and deShazo 2009, p. 1363). Goddard et al. explain, “Treatment options for cutaneous and systemic reactions from bed bug bites have not been evaluated in clinical trials and there is no evidence that outcomes differ significantly from those receiving no treatment”. “Evidence for disease transmission by bed bugs is lacking, although severe bed bug infestations can initiate iron-deficiency anemia due to significant blood loss” (Eddy and Jones 2011, p. 9).
In addition to cutaneous and systemic reactions, bedbug bites can cause significant psychological distress. Doggett and Russell (2009) report, “This is a very real health problem and should not be ignored. There is an apparent stigma associated with bed bugs that relates the insect with poor housekeeping and hygiene, even though five star hotels do not escape infestations” (p. 882). Patients may feel bites and insects crawling on them even if the bedbugs have been eliminated for some time. Furthermore, the authors explain, “As bed bugs often bite on the face and neck, the resulting bite marks can affect an individual’s self-esteem and possibly interfere with employment performance or prospects” (Doggett and Russell 2009, p. 883). The financial cost, time and effort of bedbug eradication can also cause mental anguish, especially when significant resources are required to detect, eliminate, and monitor bedbug infestations.
Social, legal, and economic effects of infestation
Because bed bugs have not yet been proven to be vectors of disease, local jurisdictions are hesitant to respond to complaints of bed bugs, “while simultaneously considering their manpower shortages and lack of regulatory authority,” even though bedbugs can cause significant physical and mental health problems among their victims (Eddy and Jones 2011, p. 8). Besides limited financial resources and manpower, there is an overwhelming reluctance among governments to fulfill responsibilities in ensuring the safety of individuals and communities for developing policies and procedures to guide appropriate resource distribution and access to care; and to prevent abuses and unlawful actions against vulnerable persons and groups.
As a result, some people have taken matters into their own hands to remove the pests, often causing more harm than good. In the United States, state and local governments are overwhelmed with complaints, and are receiving reports of widespread misuse of pesticides in the prevention and control of bedbugs. Citizens are damaging their homes and are potentially placing themselves and their pets at risk when using “bug bombs,” other available pesticides, and heat treatments. For example, a two-family home in Cincinnati, Ohio burned to the ground as the carpeting near one of the propane gas tanks used in a heat treatment caught fire (Associated Press of ABC News 2011).
Since the bedbug does not transmit infectious disease, no records of bedbug populations are recorded by world health organization (WHO), the US centers for disease control and prevention (CDC 2010), or other health organizations. Therefore, official government action was not seen as necessary until upscale hotels began identifying bedbug infestations and patrons began filing related lawsuits (p. 53)
The public demand to eradicate bedbug infestations was not so much based on public health concerns, but on the substantial loss of national and international economic revenue (Anderson 2011, p. 54). As Lois Rossi (2010) describes, “[T]he economic losses from health care, lost wages, and lost productivity can be substantial. The cost of bed bug eradication may be significantly more than that of other pests since bed bug control usual requires multiple visits by a licensed pest control operator. The cost of treating multi-unit dwellings is exponentially more than treating single-family units” (Rossi 2010, p. 34).
Furthermore, many community leaders have indicated a diffusion of responsibility among businesses, landlords and tenants, partly because there is no clear guidance as to who is responsible for eliminating the bedbugs. Control in multi-family dwellings can be particularly problematic as individual tenants and owners may take necessary precautions or eliminate personal dwelling infestations, but neighbors or landlords may not eradicate infestations. Communities are ignoring joint moral and social responsibility, representing a community problem as an individual one. Such feelings and lack of responsibility stem, in part, from associated stigmas (e.g., carriers are poor and unkempt), and victims of bedbug infestations are led to believe it is their fault.
Who do bedbugs affect?
Bedbug infestations have become a global epidemic with reports on every continent. For example, Germany disclosed five reported cases in 1992, which rose to 76 cases in 2004. Bencheton et al. (2011) report, “France has the same experience regarding the resurgence of bed bugs as several European countries, USA, Canada and Australia. Southern France is particularly concerned as suggested in our observations, what can be explained by increase trades and travels. This new health problem can be attributed to the ignorance of population, difficulties to treat due to resistance to insecticides and absence of legislations for treatment, and the increase in proliferation of bed bugs in blocks of flats” (p. 602). In Australia, bed bug cases increased 400% to a government public agency in 2001–2004 compared to 1997–2000. Reports have revealed infestations in Australia have risen by 4500% between 2000 and 2006. Pest control operators in Toronto reported treating bed bug infestations at 847 locations in 2003, most commonly single-family dwellings (70%), apartments (18%), and shelters (8%). Bed bug infestations were reported in Toronto at 20 of 65 homeless shelters. Hwang et al. (2005) write, “The Toronto experience indicates that these calls place a substantial time demand on public health personnel, who in many cities are already struggling with limited resources” (p. 536).
Von Drehle and Reiss (2010) reveal that all 50 states have bed bug infestations with New York City being one of the hardest cities hit. Bedbugs have been identified in the Empire State Building, United Nations, Statue of Liberty, Time Warner Center, and in many upscale shops and hotels. In 2004, there were 84 infestations reported in NYC in multi-family residences. By 2009, the number rose to 4,088 reported and confirmed cases. For the past 5 years, infestations have increased by 800% in Alaska and the number of reported cases in San Francisco has doubled between 2004 and 2006 (May 2007; In: Goddard and deShazo 2009). Another severely impacted area is central and southwestern Ohio. For example, 1 in 5.5 residents in Cincinnati, Ohio have experienced bedbugs (University of Ohio Institute for Policy Research 2011).
Reports of infestations at epidemic proportions begin in 2010. Anderson (2011) explains, “The recent second-round of news on the bedbug infestation in 2010 in the US was actually a continuation of bedbug infestations first identified in 2006. The US bedbug infestations followed infestation increases in Australia and other parts of the United Kingdom (U.K.), although actual government reporting was low” (p. 53). However, it can be said that US and European travelers have carried the bugs into places that have not been affected for decades. For example, in December 2007, a healthy, 30 year-old woman, carrying a bedbug nymph, visited the International Clinic at Severance Hospital in Seoul, Korea. Nine months prior to her clinical visit, she had moved from New Jersey to Korea (Lee et al. 2008). Thus, it appears as though the bedbug was introduced from abroad, since there had been no reports of bedbugs in Seoul for more than two decades.
Vulnerable populations: the underserved, mental ill, and elderly
Any one person or group can be victims of bedbug bites and infestations; however the underserved, mentally ill, and elderly are most likely to have difficulties in reporting and eliminating bedbugs. While the United States Environmental Protection Agency (2011) defines environmental justice as “Fair treatment and meaningful involvement of all people regardless of race, color, national origin or income with respect to the development, implementation, and enforcement of environmental laws, regulations and policies”, there are several inequities in the accessibility and availability of resources, including medical treatment, required to safely and effectively eliminate bedbug infestations and related health problems.
For example, Eddy and Jones (2011) write, “The escalating global bed bug resurgence leaves the divided public health community in a precarious social justice position if the lack of response to bed bug infestations disproportionately impacts underserved populations. Bed bugs are an urgent public health and environmental justice concern…” (p. 8). Research has shown that bed bug infestations are particularly difficult to eradicate in low-income communities (Wang et al. 2011). When looking at housing in these communities, Eddy and Jones (2011) explain they are typically comprised of renters who live in higher densities, have lower incomes compared to homeowners, and have less control over their living environments. For example, in Dayton, Ohio a subsidized, downtown, high-rise apartment building was “so heavily infested that all residents had to be vacated so the premises could be fumigated” (Rossi et al. 1996, p. 11).
Further social and ethical problems arise when landlords or tenants fail to disclose the truth about past and current bedbug infestations, and new tenants are exposed to the problems of bedbugs often without being able to move or lease their units to others. Dependent mentally ill and elderly populations are particularly vulnerable as caretakers and landlords may fail to disclose bedbug infestations, assuming these populations are unaware or are less likely to take action given their age and mental status (Associated Press of se Missourian 2011).
Issues of vector competence, reactions to insect bites, embarrassment, and mental anguish have been the basis for lawsuits against landlords and lodging corporations (Goddard and deShazo 2009, p. 1361; see also Goddard 2003). For example, in Ohio, while the landlord/tenant law does not address bed bugs specifically, landlords are required to maintain buildings that comply with all local health and safety codes. So while landlords may not refuse measures to control infestations, the law does not specify who is responsible for paying for the treatment. Thus, infestations often remain uncontrolled due to financial and legal disputes even when communities do view bedbugs to be a public health problem, revealing unequal distribution of infestation and control. To combat these disputes, some landlords are writing bedbug waivers into their rental agreements “declaring that the unit is currently free of infestation and that the tenant is responsible for eradication should bed bugs become introduced” (Ohio Department of Health (ODH) 2011, p. 8).
Paul Wenning of the Franklin County Board of Health in Columbus, Ohio and Franklin County, and Chair of the Central Ohio Bed Bug Task Force (COBBTF) accurately describes the challenges of bedbug eradication within the 1.2 million population of Central Ohio (Corea 2009). Besides a lack of funding, unregulated used mattress and furniture dealers, community apathy, lack of personnel, and limited availability of pest control for poor residents, he explains how a good tracking system has not yet been developed to identify the prevalence of bedbug infestations and where and who they are targeting most. To better serve the community and effectively control the bedbug epidemic, Wenning suggests making an amendment to the current United States Environmental Protections Agency policy, allowing the use of restricted pesticides. House of representatives in the State of Ohio proposed a resolution asking the administrator of the United States Environmental Protection Agency to grant an emergency exemption for the use of insecticide Propoxur to control bedbugs in Ohio.2 To date, this exemption has not yet been granted.
In addition to allowing restricted pesticides, Wenning, like many public health leaders worldwide, believe money for low-income residents and vulnerable populations would help significantly as would stronger restrictions upon sellers of used furniture and for people who sell discarded furniture. Task Forces such as COBBTF, along with community leaders and public health officials have greatly influenced the state of Ohio to develop educational policies and programs.3 However, the financial strain to vulnerable populations continues to be a national and international social and ethical problem. For example, Medicaid waiver funds, intended to provide consumers with in-home care and services as an alternate to more costly nursing home placement, are being diverted to address bed bug infestations (Ohio Department of Health (ODH) 2011). The cost of additional homemaking or chore services to prepare a home for extermination and, in some cases, the actual cost of extermination services have reduced already limited Medicaid waiver funds (Ohio Department of Health (ODH) 2011, p. 6).
Such funds should not be used to address bedbug infestations given that, again, this is a community responsibility rather than the sole responsibility of individuals who are not only impoverished, but who divert their funds, often without choice, and sacrifice much needed care and services. In addition, what little personal items, mattresses, bedding, furniture, etc. the poor do possess may be destroyed in the extermination process so as to effectively remove the pest. There is great social injustice when it comes to the identification and extermination of bedbugs, the delivery of healthcare, and the costs associated with replacing damaged or removed household items.
Healthcare professionals, patients, and the clinical environment
Some mental health centers and residential facilities have spent significant funds to eradicate bed bugs, which have required the relocation of clients, purchasing of new furniture and extermination expenses. In some incidents, case managers and other residential staff have expressed concerns and fears that they would carry, or have carried, bedbugs into their private homes (p. 6).
One of the primary challenges for healthcare providers is to properly identify bedbug bites, distinguishing them from other types of dermatological conditions. Delaunay et al. (2011) report that identification is difficult due to patients’ widely varying immunological responses (p. 208). Doggett and Russell (2009) explain “Misdiagnosis often results in inappropriate medical interventions, such as the use of scabicides, biopsy of the bite site, and various blood tests, with obviously no useful result forthcoming” (p. 882). However, the responsibility of diagnosis should not lie solely with healthcare professionals; patients have a responsibility in examining their own environments even if doing so may cause unwanted embarrassment. Nonetheless, healthcare professionals and the community at large should acknowledge those individuals who may not be able to examine their environments or effectively report their symptoms, such as those with debilitating physical and mental illnesses and disorders, or other vulnerable populations (e.g., elderly).
In acknowledging the victims of bedbug infestations as persons in need, and the reasonableness of their abilities to identify, report, and eliminate bedbug infestations from their dwellings, the healthcare community can develop strategies to properly educate, diagnose, treat, and provide support to those persons affected by bedbugs.
Most of the emotional anxiety voiced by residents who have bed bugs is attributable to the current social stigma of having bed bugs, feeling powerless to do anything about an infestation, and the fear brought on by those who practice scaremongering tactics relative to bed bugs (p. 40).
When looking at this from a pragmatic ethical perspective, the therapeutic relationship and duties of both physicians and patients should be made clear. Healthcare providers have a moral and professional duty to holistically care for their patients without separating the physical distress from the mental or emotional distress, although this may be a controversial approach for some providers. Furthermore, because of their fiduciary relationship, healthcare providers should connect patients to other professionals who may have knowledge, skills, and access to needed resources (e.g., social workers, case managers, legal advisors, public health officials). When patients are able to trust their healthcare providers, seeking their guidance in social issues, their overall health improves. Furthermore, there is a greater sense of community when healthcare providers choose to address the social determinants of health and educate and guide their patients toward social, physical, and mental well-being.
However, even when healthcare providers fulfill their moral and professional duties to their patients, there may be difficult ethical challenges, especially when a patient feels as though he or she has lost autonomous control, such in the case of bedbug “quarantines.” Healthcare providers who may suspect their patients to be bedbug carriers may force them to be quarantined until any bedbugs are removed from clothing and other items, and they are showered and clothed with hospital-issue clothing (Erdogan et al. 2010). In turn, patients often feel embarrassed, angry, and humiliated, which can compromise the therapeutic relationship regardless of the beneficent intentions of the healthcare professional. Patients who are quarantined or identified as bedbug carriers may feel too embarrassed to return to that professional or clinic for further care. To circumvent such issues, clearly informing patients about bedbugs and the need for “quarantine-like” care, while showing empathy rather than fear or disdain, can alleviate patients’ negative feelings and resistance to disclosing the truth about their plight.
Public health services and healthcare facilities are becoming more aware of the problems of bedbugs and are beginning to identify core social and ethical values in developing public health programs. However, they are often ill-equipped or lack the funds to detect and eliminate bedbugs from persons’ homes, and from public places, including healthcare clinics and hospitals. Thus, these services and facilities alone cannot solve the bedbug problem. There are also several overlooked ethical issues surrounding the availability and accessibility of resources needed to treat bedbug bites and their negative physical, psychological, social, financial, and legal effects. For example, effective, high quality resources (e.g., canine detectors) are accessible for those who are able to afford them and unavailable for those who are unable to afford them, especially when repeated treatments are required. But fair distribution of resources (distributive justice) is not the only consideration for tackling the problem of bedbugs.
Given the relatively low numbers of reported annual cases comparative to other public health issues, some would argue this public health issue does not deserve domestic and global attention and resources. However, the number of unreported cases may be quite significant, and even with low numbers, the health and well-being of individuals should not be ignored. Instances of bedbug bites and infestations may not be reported because victims learn to live with the pain and discomfort of bedbugs; others are fearful of the social stigma. Many victims cannot afford to get rid of the infestations feeling their complaints do not warrant reporting. Finally, people are generally unaware and uninformed about bedbugs, and would not think to report following a bedbug sighting or a bite. Although there may be low numbers of reported cases, bedbugs should not be ignored or viewed as a lower priority compared to other public health matters, since the negative effects of bedbug bites and infestations can compromise basic human capabilities required for a just society similar to other public health matters, e.g., contaminated water.
To resolve many of these ethical issues a normative framework is needed to identify specific injustices and to guide public health decision-making on institutional and governmental levels. Arguably, Martha Nussbaum’s capabilities approach to social justice and her consideration for vulnerable populations can best serve as this framework (Nussbaum 2002). While other justice frameworks may be as useful for guiding public health policies and recommendations, by looking at the bedbug debacle through Nussbaum’s capabilities approach, it is evident that community awareness and involvement is needed in conjunction with a fair distribution of public health resources. Furthermore, this approach recognizes vulnerable populations, e.g., elderly, without distributing resources for only the least well off.
In the identification of key capabilities, Nussbaum argues that these capabilities should be equitably distributed among members of society (in a manner similar to Rawls primary goods). According to the capabilities approach, a just society guarantees each member a minimal set of opportunities or capabilities, whether an individual member chooses them, or not. Nussbaum’s list of capabilities include: life; bodily health; body integrity; senses, imagination, thought; emotions; practical reason; affiliation; relationships with other species; play; and control over one’s environment.
What is attractive about Nussbaum’s capabilities approach with respect to a public health issue such as bedbug infestation is that her justice framework asks us to look beyond economics and the resolution of problems through priority-setting and distribution of resources. This approach asks us to recognize how injustices can affect our relationships, emotions, and affiliations, thus resolving problems not merely through resource allocation, but recognition of the other, e.g., the caregiver, and what non-material and material needs may be required for human flourishing. Her approach deliberately asks us to assist those who are vulnerable, without focusing on access to resources, prioritizing principles, or balancing benefits and burdens at the expense of certain groups, e.g., mentally disabled (as in communitarian and utilitarian frameworks). The capabilities approach is concerned with outcome oriented justice (rather than Rawls’ procedural justice), and requires a just society to guarantee basic dignity to vulnerable populations, e.g., mentally disabled.
Nussbaum explains, to protect the dignity of persons and to ensure human flourishing, members of a just society must be given access to these capabilities. “…these capabilities can be agreed by reasonable citizens to be important prerequisites of reasonable conceptions of human flourishing, in connection with the political conception of the person as political animal, both needy and dignified; and thus these are good bases for an idea of basic political entitlements in a just society” (Nussbaum 2006, p. 182). Individuals and populations are victimized not just by the bedbugs themselves, but by those institutions who fail in recognizing and supporting these capabilities. Furthermore, as Nussbaum emphasizes in Frontiers of Justice (2006), we need to look at the other side of the problem- “the burdens on people who provide care for dependents” (p. 100), as well as the values of care and cooperation. So, while it is an injustice when a mentally disabled person carrying bedbugs is denied transportation by her care manager (social worker), we need to also look at the circumstance of the care manager. She may not have the financial resources to eradicate an infestation or may be genuinely fearful of transporting the bug to her other patients’ homes. Nussbaum’s framework for social justice prompts us to see and understand the vulnerability of persons, e.g., mentally disabled, but also those who provide essential care and support, and whose capabilities may be threatened simply by virtue of this caring relationship. More precisely, without public health support (material and institutional), both victim and caregiver are not provided access to the most minimal set of entitlements, such as bodily health and affiliation.
Consider some of the specific capabilities that bedbugs negatively affect. Bodily health may be compromised through mental and physical harm from bites, insecticides, and the inability to eliminate infestations from one’s habitat due to socioeconomic and environmental factors. A person with bedbugs may not be able to move freely from place to place (Bodily integrity) either by his or her own choice or the choice of another. Thus, one loses the freedom to be mentally and physically healthy. Emotions may be blighted by fear and anxiety as one continually thinks about the ‘terrors in the night’ even after successfully eradicating the infestation or simply due to the social stigma and disrespect commonly encountered by those who are victimized. Bedbug infestations, especially in apartments and close living quarters, can leave individuals and groups incapable of affiliation as victims of infestations are often humiliated or blamed for having affected others and their homes and businesses. Finally, persons and groups may not be fully capable of controlling their environments- preventing and eliminating bedbug infestations- because they are not afforded the opportunity of education or given the freedom to change their environment. Even when infestations are controlled, we often lose sight of the fact that bedding, clothing, and furnishings in one’s home are destroyed in the process, thus leaving many individuals unable to perform daily functions, losing their dignity in the process.
More relevant to bedbug infestation and global health, Nussbaum identifies ten principles for a just global structure. Two of these principles, which can be applied both domestically and globally, are relevant to the plight of vulnerable populations. The first of these two principles, “All institutions and individuals should focus on the problems of the disadvantaged in each nation and region” is described by Nussbaum: “The situation of people (whoever they are, at any given time) whose quality of life is especially low, as measured by the capabilities list, should therefore be a persistent focus of attention for the world community as a whole” (p. 23). This principle is applicable to healthcare professionals and their obligations to recognize the problems of the disadvantaged and the needs of communities. For example, World Medical Association (2006) identifies such duties as: “A physician shall recognize his/her important role in educating their community…” and “A physician shall strive to use health care resources in the best way to benefit patients and their community.” American Medical Association (2011) specifically states in principle VII: “a physician shall recognize a responsibility to participate in activities contributing to the improvement of the community and the betterment of public health.” Therefore, it is important for healthcare professionals to report the number, frequency, and type of occurrences of bedbug problems affecting their patients to public health agencies and community support systems, and to assist in public health education so as to improve the communities in which they serve.
The second principle that follows, “care for the III, the elderly, and the disabled should be a prominent focus of the world community,” identifies the need to care for others in a condition of dependency (p. 23). While problems of bedbugs is incomparable to diseases such as HIV/AIDS, malnutrition, homelessness, and other global problems that contribute to a low quality of life, it is a global public health issue that can prevent human flourishing and one in which communities are asking for support. Nussbaum’s capabilities approach at least gives us the framework to understand the negative impact of bedbugs on individuals and domestic and global communities and to identify when certain basic capabilities are limited, either due to a lack of freedoms or resources required for human flourishing.
What public health interventions are appropriate
The resources needed for pest control
Environmental agencies and scientists continue to develop effective pesticides that are less likely to harm persons, animals and the environment. For example, the Environmental Protection Agency (EPA), which classifies bedbugs as “a pest of significant public health importance” under the Federal Insecticide Fungicide and Rodenticide Act, is currently working with global industry and research to develop new compounds or new uses of existing compounds to control bedbugs. However, pesticides alone are not enough for effective public health interventions.
According to Hwang et al. (2005), “The pest control literature emphasizes the importance of combining insecticide treatments with environmental measures such as daily laundering of bed linens, vacuuming rooms, and steam cleaning and vacuuming mattresses. Bed bugs can be destroyed by freezing or by heat treatments at temperatures >50C, but these methods are inconvenient to implement” (p. 536). However, for the steamers and rapid freezing equipment to be fully effective, multiple treatments may be needed, which can cost consumers $500–$1200 (US) for each treatment. In some places, these treatments can go up to $2000 and most citizens are unable to pay for the initial treatment or unknowingly pay for these expensive treatments without having properly identified the type of bug infestation (i.e., in some cases the suspected insect is not a bedbug). Thus, community programs that provide these services at a lower cost are greatly needed, although identification is the first step to ensuring that costs are kept low and resources are not wasted.
In suspected and persistent bedbug infestations, trained canines can be used to detect common hiding places (e.g., crevices in the walls and floors, headboards, mattresses, and bed frames). The dogs use their olfactory glands to seek out the bedbug’s sweet and musty scent, and are trained to distinguish bedbug from other insects. However, even this service can be quite costly for homeowners, tenants, and business owners (Criado et al. 2010, p. 78). Furthermore the quality of bed bug-detecting canines “depends of the efficiency of their training and what the dogs are trained to do” (Pfiester et al. 2008, p. 1389; see also Cooper 2007); false positives are not uncommon and can be caused by faulty training or misinterpretation by the handler. However, a well-trained, certified bedbug dog can be an effective tool for locating infestations, thus reducing the number of possible lawsuits from customers (e.g., hotel managers can treat infestations before customers are bitten) (1395; In Doggett and Russell 2009).
Integrated pest management: beyond resource allocation
Lois Rossi (2010) suggests the integrated pest management (IPM) approach may be one of the most effective means of controlling bedbugs. Such a program can “incorporate surveillance, modification of the environment to make it less hospitable to bed bugs (remove clutter, encase bedding, thorough cleaning of areas with evidence of bed bugs), and selective chemical or nonchemical treatments to kill bed bugs” (Rossi 2010, p. 35). In order for this approach to be effective, however, community education and support is needed. Part of the bedbug education initiative is to guide renters, homeowners, consumers, and business owners to be socially responsible (i.e., to be aware of bedbug problems, to use preventative measures, and to be responsible in eradicating infestations when present), and aware of those who are victimized by the bedbug, especially vulnerable populations that may require more assistance. Simple measures such as not buying used mattresses, bedding, or furniture that has not been appropriately cleaned, being cognizant of what bedbugs look like, reporting rashes and other unusual markings or “bites” to healthcare professionals, and inspecting hotels and other dwellings can reduce both active and passive dispersal of bedbugs.
Public health initiatives in clinical settings
There are several examples of how healthcare clinics and hospitals are trying to deliver care to patients who have been infected and are carriers of bedbugs. Rosamond Payne, an Emergency Department administrator at Kings County Hospital Center in Brooklyn describes patients who come into the ER with suspected bed bugs (Erdogan et al. 2010). A triage nurse takes the precaution of placing the bug in a specimen cup for examination. The nurse follows hospital protocols which entail the following five steps: (1) Nurse contacts environmental services staff, who call the facility’s pest control company, which responses within 30 min; (2) the affected triage area is exterminated with chemical-based solution; (3) newly arriving patients are seen in a nearby triage, uninterrupted by the extermination process; (4) triage remains open and the hospital is not put on diversion; (5) a pest control company advises that affected area is to be closed for two-hours before being serviceable (Erdogan et al. 2010, p. 101).
In Anderson, Ohio, the Mercy Hospital Emergency Department nurse, Terri Martin, explains that the staff experience bed bug problems among patients on a weekly basis (Erdogan et al. 2010). If bugs are visibly seen in the triage area, then special precautions are taken, including escorting affected patients to a decontamination room where they are undressed, washed, and kept on the outside of the building. Martin explains that the decontamination room has a separate outside entrance door. If the patient, however, is already in an examination room when a healthcare professional determines he or she is contaminated, “housekeeping staff come into clean the room after the patient leaves” and then the room is closed for 24 h (p. 101). Furthermore, if staff members have been infected, they have to change into hospital-issue scrubs and launder their personal clothes at the hospital. The focus of Mercy Hospital is to keep the environment safe for everyone. Such policies are consistent with the values of care and cooperation, and the recognition of basic capabilities.
The intended purpose of this paper is to not only to identify ethical, social, and clinical issues surrounding the growing global bedbug problem, but to educate readers—to empower you with the knowledge to identify and eradicate bedbug infestations. The bedbug debacle requires community effort and support without placing blame or full responsibility on individuals suffering from the physical, emotional, social, and environmental effects of these pests. As a public health issue, we need to recognize its value and impact on communities and to broaden our understanding of health and disease. Bedbugs are a serious public health problem and should be recognized as such because they are environmentally communicable and cause ill-health and lack of well-being.
Recommended steps for effective bedbug control include properly identifying the species of bug, educating communities about bedbug prevention and eradication, inspecting infested and adjacent areas, implementing chemical and nonchemical control measures, such as removing bedding and furniture from the dwelling, and evaluating the success of eradication. Furthermore, whether we are healthcare professionals, travellers, educators, public health officials, patients, tenants, or landlords, we must be diligent in preventing the spread of bedbugs, while lending a hand to the vulnerable victims without fear, discrimination or bias. Through such frameworks as the capabilities approach, we can begin to recognize those essential capabilities that protect the dignity of persons and ensure human flourishing, to recognize the other in relation to the self, e.g., victim and caregiver, and to understand that resource allocation alone will not solve the bedbug debacle.
Although the examples of bedbug infestations and their media attention are presented in this paper from a US-centric perspective, the negative effects of bedbugs are not localized, and the ethical framework and recommendations identified may be beneficial to individuals and populations throughout the world who are confronted with this public health problem.
Propoxur (sold as Baygon) is one commercially available chemical that is still effective in killing bedbugs. This chemical is toxic to humans if ingested. Pesticide manufacturers dropped their registration of propoxur, after recognizing that indoor use of certain pesticides would not pass the more stringent testing requirements under the Food Quality Protection Act (FQPA) of 1996.
Ohio Bill To enact sections 3701.137 and 3707.012 of the Revised Code to establish the Bed Bug Awareness, Education, and Prevention Program and to require boards of health to adopt vermin control policies under which bedbug infestations are treated in the same manner as other infestations and to make an appropriation. http://www.legislature.state.oh.us/bills.cfm?ID=129_HB_129 (accessed 13 July 2011)
I would like to thank members and attendees of the European Society for Philosophy of Medicine and Healthcare (ESPMH) for providing support and excellent commentary on this paper. A portion of this paper was presented in Zurich, Switzerland, August 2011 at the ESPMH conference.