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Sustainable Tourism as a Driving force of the Tourism Industry in a Post-Covid-19 Scenario

• Original Research
• Published: 12 June 2021
• Volume 158 , pages 991–1011, ( 2021 )

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• Beatriz Palacios-Florencio   ORCID: orcid.org/0000-0003-2789-7914 1 ,
• Luna Santos-Roldán 2 ,
• Juan Manuel Berbel-Pineda 1 &
• Ana María Castillo-Canalejo 2  

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The tourism industry is probably one of the most affected by the crisis caused by Covid-19. It is the responsibility of politicians, tourism professionals and researchers to look for solutions to revive this important industry. This article shows how the development of Sustainable Tourism can help in the sustenance of the tourism industry, since one of the premises on which Sustainable Tourism is based is the non-overcrowding of tourist destinations (essential factor in the current context). Considering this argument and the existing regulations on lockdown rules, social distancing and meet up, it is considered that the practices in Sustainable Tourism can become a potential solution to stimulate tourist movements and help the revival of the tourism industry. Therefore, more specifically, the main objective of this article is to know tourist´s perception among about Sustainable Tourism and to determine which factors help its development. In this sense, the use of structural equation models in a research of 308 tourists has determined how factors related to the tourists’ attitude, motivation and perceived benefits provided by the development of Sustainable Tourism increase the intention to consume this type of tourism.

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1 Introduction

It is widely accepted that one of the aspects considered by Sustainable Tourism is the fight against overcrowding in certain tourist destinations and avoid damages associated (eg. Jurowski & Gursoy, 2004 ; Santana-Jiménez & Hernández, 2011 ). In fact, Sustainable Tourism has been trying (for years) to place itself as a solution to the negative aspects that involve tourism in its development and to the criticism it frequently receives (Sharpley, 2020 ). And it is now, in this context, that this perception makes more sense than ever before.

The massification of tourist destinations and the damage this causes (both in cities and to natural environments), is one of the fiercest criticisms levelled at tourism. In this sense, Sustainable Tourism is based, among other things, on promoting and developing less massified tourist destinations or Sustainable Mass Tourism as the desired impending outcome for most destinations. In relation to this, the research of Weaver ( 2012 ) highlights the concept of Sustainable Mass Tourism as an emerging tourism state—something that can be convenient reconsidered in the current situation-. According to this author, this type of tourism is perceived as a desired outcome for destinations with a focus on sustainability and indicates three convergent developmental trajectories: organic, incremental and induced.

On the other hand, we would like to point out that, among the measures being taken to combat Covid-19, restrictions on meetings and social distancing measures stand out (World Health Organization, 2020 ). And, why are these measures being referred to here? The explanation is simple, as this paper takes as the basis the fight against overcrowding in tourist destinations; relating it to the measures adopted (nearly worldwide), due to the social distancing caused by Covid-19. In fact, this measure, together with the tourist's perception of fear of travelling, are the ingredients for preventing overcrowded destinations, and therefore strenght Sutainable Tourism.

Therefore, it can be stated that tourism industry is highly sensitive to significant shocks like the Covid-19 pandemic (Chang et al., 2020 ). In other words, tourism is particularly susceptible to measures to counter pandemics due to restricted mobility and social distancing. This leads to global travel restrictions (which are unprecedented) that, together with confinement, are causing the most severe disruption to the global economy in recent decades (Gössling et al., 2020 ). According to the declarations made by the World Tourism Organization (UNWTO) on its website, on April, 96% of worldwide destinations have implemented travel restrictions. Around 40 destinations are experiencing a partial border closure, while 90 destinations have closed totally their borders. An unforeseen and, for the time being, unpredictable situation that urges survival measures for the sector.

Given this current scenario, Sustainable Tourism may find a great opportunity for its development (Higgins-Desbiolles, 2020 ; Petrizzo, 2020 ). Indeed, this article focuses primarily on determining factors focuses on the tourist's perception for promoting Sustainable Tourism.

The UNWTO defined in 2005 the concept of Sustainable Tourism as “ one whose practices and principles can be applicable to all forms of tourism in all types of destinations, including mass tourism and the various niche tourism segments ”. Sustainability principles refer to the environmental, economic, and socio-cultural aspects of tourism development, and a suitable balance must be established between these three dimensions to guarantee its long-term sustainability (UNWTO, 2005 ). In addition to international organizations, we also find many authors who have defined the concept of Sustainable Tourism (Higgins-Desbiolles et al., 2019 ; Hussain, et al., 2015 ; Mohaidin, et al., 2017 ). Conversely, despite the fact that Sustainable Tourism has been recognized in business practice in many destinations, the volume of academic research has not been as large as it deserves (Ruhanen et al., 2015 ). From the start, the development of Sustainable Tourism is based on the preservation of the environment (Ciacci et al., 2021 ), the cultural authenticity and the democratic profitability of the tourist activity in destination (Crosby, 1996 ). It is only this tourism that recognizes the priority place of social return, as an index of well-being reversed on the visited destination; and also the exclusively economic return, that is, whether the tourist activity generates sufficient income for the local population, in terms of employment, wealth and available resources (Fernández, 2018 ).

The purpose of this study is to identify the factors that help the development of Sustainable Tourism (from a tourist's perception point of view), since a greater use of this type of tourism could help the revival of the tourism industry. In this sense, and considering the guidelines of the World Health Organization (WHO), the different governments in all countries recommend avoiding large concentrations of people (which favors the development of this type of tourism).

However, in generic terms, tourism implies people concentration, and even more so in those destinations considered as “overcrowded”: large cities, charming cities, main beach locations, amusement parks, airports, etc. That is why, under the conditions exposed, it is necessary to combat the social, economic, financial and cultural consequences of a pandemic, which entails a challenge for the tourism sector, that requires a careful assessment of its impact dimensions, as well as a reconsideration of a new hitherto unknown approach. Thus, the development of tourism as it is currently known will change in the coming years, which will have serious repercussions on the profitability of tourism industry (Hancock, 2020 ).

Henceforth, this study gives an assessment of Sustainable Tourism and the variables that enable accelerated development (which becomes more necessary in this crisis context in tourism industry). The theoretical frame study analyzes the factors of perceived quality, motivation, attitude, and satisfaction as attributes with a potential influence on the intention of choosing this kind of tourism. Consequently, the study is based on literature focused on consumer behavior based on their perception. However, the main contribution of this study is not theoretical (since there is a lot of literature based on this approach). The main contribution lies in extracting all the positive aspects that sustainable tourism brings to tourism development and highlighting its value in these times of crisis that this industry is going through.

2 Theorical Background

2.1 the relation between positive impacts and the attitude towards the development of sustainable tourism, the perception of service quality and motivation.

Most research conclude that the three basic categories of benefits and costs that affect to a community which receives tourists are economic, environmental, and social (Chi-Ming et al., 2017 ; Gee et al., 1989 ; Gunn, 1988 ; Gursoy et al., 2000 ; Gursoy et al., 2002 ; Murphy, 1985 ; Nunkoo & So, 2015 ; Palacios-Florencio et al., 2018 ; Vargas, 2007 ).

The economic benefits of tourism development are usually translated into employment opportunities (Belisle & Hoy, 1980 ; Davis et al., 1988 ; Ritchie, 1988 ; Tyrrell and Spaulding, 1984 ; Tosum, 2002 ; Var et al., 1985 ), income derivatives of the tourism sector (Davies et al., 1988 ; Lankford, 1994 ; Jurowski et al., 1997 ; Murphy, 1983 ; Tyrrel and Spaulding, 1984 ) and investment and business opportunities (Davis et al., 1988 ; Sethna & Richmond, 1978 ).

Regarding the social impact of tourism, it can be conceived as changes in the people lives residing in the communities that are part of the destination and related to tourism activity (Mathieson & Wall, 1982 ). Likewise, the social and cultural benefits (Besculides et al., 2002 ) translate into an increase in leisure activities (Keogh, 1990 ; Liu et al., 1987 ; Murphy, 1983 ; Pizam, 1978 ; Rothman, 1978 ; Sheldom and Var, 1984 ), the improvement of public services and infrastructures (Pizam, 1978 ; Sethna & Richmond, 1978 ) and the instigating effect on social change (Harrison, 1992 ). Between its benefits, tourism increases cultural identity and pride, the cohesion and the exchange of ideas, improves knowledge of the area culture (Esman, 1984 ), creates opportunities for cultural exchange, revitalizes local traditions, increases the quality of life and improves the image of the community (Besculides et al., 2002 ).

Similarly, in the environmental field, tourism may be the reason to protect natural resources and conserve homogeneous urban designs (Díaz & Gutiérrez, 2010 ), so that it can be possible to promote an ordered tourist development based on a model integrated in the environment. Miller et al., ( 2014 ) refer to the concept of pro-environmental behaviour, understood as the actions for protecting the environment, while tourists´ pro-environmental behaviour were connected to nature-based tourism and ecotourism. Ciacci et al., ( 2021 ) adds to the environmental factor, logistical and infrastructural dimension. While it is true that environmental quality can be composed by objective and subjective components, it has been widely accepted that a good link between environmental protection, logistic and infrastructural development is seen as fundamental for a successful Sustainable Tourism development strategy.

The notion of sustainable development is a relatively recent concept, first defined in 1987 in the Brundtland report by the UN. This report, also called “Our Common Future”, declares that sustainable development tries to “meet the needs of the present generation without the ability of future generations to meet their own needs” (CMMAD, 1992 : 67).

Following the arrival of the concept of sustainable development in 1987 with the aforementioned Brundtland report, it was applied to the tourism field.

This type of tourism weights the importance of stakeholders and, although the key role of residents is recognized (Gursoy et al., 2018 ; Stylidis et al., 2014 ), it is also interesting to analyze the perspective of the tourists themselves. Indeed, knowing the attitudes of tourists towards the development of Sustainable Tourism and raising culture, environment and economy awareness of the communities visited are vital factors to protect tourist destinations and reduce negative impacts (Othman et al., 2010 ).

On the other hand, most studies report a positive relation between the attitude towards Sustainable Tourism development and the perception of its positive impacts (Andereck & Vogt, 2000 ; Byrd et al., 2009 ; Chi-Ming et al., 2017 ; Ekanayake & Long, 2012 ; Hussain, et al., 2015 ; Pavlić et al., 2017 ; Su & Chang, 2017 ). The provision of high quality and environmentally friendly services has been identified as an important factor for the success of a tourist destination (Miller et al., 2014 ).

Service quality is defined as the level of satisfaction an event or experience produces according to individual needs or expectations (Michael, 2013 ). Mukhles ( 2013 ) proposes five main components to analyze the quality of the tourist service: attractions and neighborhoods, facilities and services, accessibility, destination image, and pricing. The attractions and neighborhoods of the destination are elements that largely determine the choice of tourists and motivate the visit to this destination, include both natural and artificial attractions. The facilities and services include accommodation, restaurants, transportation, sports or other activities and tourist sale points. Accessibility includes elements related to transport and its infrastructure. The destination image is the subjective interpretation of reality by the tourist and, the fifth component, the price enables to measure the quality of the different services. On the other hand, Mohaidin et al. ( 2017 ) considers other attributes that should be taken into account: the environment safety and harmony and the ability to perform the promised service in a reliable and accurate way. Hence, the following model hypotheses are raised:

Tourism motivation is a driving force that motivates people to go on holiday or visit destinations. Beerli and Martin ( 2004 ) describe the motivation to travel as an internal need that drives an individual to act in a certain way to achieve his desired satisfaction. Yoon and Uysal ( 2005 ) found that motivation is the most important factor that increases satisfaction together with the services and the loyalty to a destination. In addition to being the most important factor in predicting tourism behavior, motivation to travel also significantly influences the understanding of the intentions of tourist visits (Li et al., 2010 ; Mohaidin, et al., 2017 ).

The motivation to travel to a destination will be higher whether the tourist is aware of the positive impacts that Sustainable Tourism can have on there (Crouch & Ritchie, 1999 ). From this information, the following hypothesis of this study is proposed:

2.2 The Relation Between the Attitude Towards the Development of Sustainable Tourism and the Intention to Choose a Sustainable Tourist Destination

Intention can be defined as a stated probability of engaging in a certain behavior (Oliver, 1997 ). Efforts to recognize and attract the right visitors are crucial in ensuring Sustainable Tourism. Behavioral intentions represent a vital issue in the field of tourism, since it is necessary to know and understand the tourist loyalty, i.e. the factors that influence positive intentions towards a destination (Mohaidin et al., 2017 ).

Ventakesh ( 2006 ) and Mohaidin, et al. ( 2017 ) point out that, among the psychological factors that affect tourists in their intention to select a sustainable tourist destination, a respectful attitude towards the environment has a positive effect. Luo and Deng ( 2008 ) verifies that people who show positive attitudes towards the environment during trips can transmit a greater desire for Sustainable Tourism experiences with nature.

Miller, et al. ( 2014 ) indicate that are several types of variables that are associated with pro-environmental behavior in the context of large mass tourism urban destinations, including individual background factors, habit, attitudes and external contextual factors. This study suggests that psychological factors such as attitudes may be more important than socio-demographic and contextual factors in determining pro-environmental behaviour in sustainable urban tourism destination.

From these statements, the following hypothesis is interpreted:

2.3 The Relation Between Motivation and Attitude Towards the Development of Sustainable Tourism

Along with satisfaction, knowing the motivations of tourists is the basis for understanding the following behavior trends (Jensen, 2015 ; Xu and Chan, 2016 ). For Wong et al. ( 2017 ), it is a two-phase process where internal and external factors converge. In this sense, the internal factors concern the desire to make the trip. Kim et al. ( 2007 ) incorporates psychological reasons such as disconnection and relaxation. For their part, external factors promote the destination choice, including cultural and unique features of the destination (Pesonen et al., 2011 ).

The tourist motivation has positive effects on their visit intention, as the commitment to the environment, nature care and conservation in the case of Sustainable Tourism development (Hunter, 2000 ). Huang and Liu ( 2017 ) apply these constructs to ecotourism to confirm that greater environment sensitivity of tourists is related to the motivation and the intention to repeat the visit. Similarly, Zhang and Lei ( 2012 ) argue that environmental knowledge and concern are directly related to the motivation and intention of a tourist visit.

2.4 The Relation Between the Perception of Service Quality and Satisfactory Experience

Understanding what factors influence tourist satisfaction is one of the most relevant research topics in the tourism sector, due to the impact it has on the success of any tourism product or service. The perceived quality is a measure that represents the quality obtained from product or service attributes and is related to the satisfaction of the customer’s needs and the product or service availability (ACSI, 2016 ).

It is widely recognized in the literature that the service quality perceived by the customer directly influences the tourist experience satisfaction (Castillo Canalejo & Jimber del Río, 2018 ; Hui et al., 2007; Mohaidin et al., 2017 ; Wu et al., 2016 ). Therefore, the following model hypothesis is formulated:

2.5 The Relation Between the Attitude Towards the Development of Sustainable Tourism and Satisfactory Experience

Experimental satisfaction goes beyond the concept of service satisfaction, taking into account it focuses on customers’ evaluations regarding their experiences once such service has been consumed (Wu et al., 2016 ). If this is applied to sustainable development in the aforementioned Brutland Report, the concept of satisfaction becomes vitally relevant. The development of Sustainable Tourism must satisfy the needs of tourists and residents at the same time that economic, socio-cultural and environmental need (UNWTO, 2005 ).

In the scientific literature, some authors (Chang & Fong, 2010 ; Kao et al., 2008 ; Wu et al., 2016 ) allude to green experiential satisfaction to refer to the clients’ general evaluations regarding their experience with respectful aspects of the environment and its expectations on the sustainable development of tourist destinations or services. From the study of these authors, the following hypothesis is based:

2.6 The Relation Between Satisfactory Experience and Intention to Choose a Sustainable Tourist Destination

Another widely recognized factor in the scientific literature that influences the intention to visit a place is satisfaction. According to Oliver ( 1980 ), it is considered as the balance of expectations and perceptions before and after the visit to a destination, whose importance lies in the ability to influence future behavior (Ohn & Supinit, 2016 ; Choo et al., 2016 ). In tourism studies, the satisfaction produced by the experience of tourist activities is especially important, as these are the most memorable and are conceived as a differentiating element from other visits (Walls et al., 2011 ).

There are numerous studies that prove the relation between tourist satisfaction and the intention of returning (Baker & Crompton, 2000 ; Beecho and Prentice 1997 ; Castillo Canalejo & Jimber del Río, 2018 ; Caneed, 2003 ; Dimitriades, 2006 ; Hallowell, 1996 ; Pizam, 1994 ; Sung, et al., 2016 ). Other authors, such as Jurdana and Frleta ( 2012 ) or Chin et al. ( 2018 ), focus on a specific type of tourism: rural tourism. From the reading of these authors, the following hypothesis is proposed:

2.7 The Relation Between Motivation and Intention to Choose a Sustainable Tourist Destination

Motivation is an individual internal factor that can affect the tourist behavior by influencing their trip valuation. This construct can be considered as a key factor in the process of selecting tourist destinations and the intention to visit (Chang et al., 2014 ; Hsu and Huang 2009 ).

In the bibliography, we find several examples of authors that demonstrate that motivation and satisfaction influence the tourist’s decision when choosing a destination (Chiu et al., 2016 ; Yoon & Uysal, 2005 ). In this sense, the study of Malaysia of Mohaidin et al. ( 2017 ) confirms that motivation positively influences the intention to choose a sustainable tourist destination, in line with the results offered by Beerli and Martin ( 2004 ), and Prebensen ( 2006 ). Based on this, the last hypothesis is proposed:

In summary, hereunder the conceptual model to be studied is shown in Fig.  1

Conceptual mode. Source Own elaboration

3 Data and Methodology

The data was collected from tourists who visited the city of Córdoba (Spain) between the months of October and November 2019. Córdoba (a World Heritage city) is one of the main cities receiving tourism (both national and international). This means that one of the main challenges that it faces is massification and the problems associated (Weaver, 2012 ). The sample included a total of 308 tourists, who received the questionnaires personally and on-site in the monumental area of the city. The questionnaires were handed out randomly to people visiting the monumental area, after requesting their collaboration and verifying that they were tourists and not simple passers-by. Despite its possible limitations, we considered this procedure to be the most appropriate for the objectives of this research. So, we have used a non-probabilistic sampling.

In relation to the instruments used, the original versions of the scales were translated with special attention into the linguistic characteristics of the population. All variables were measured on a Likert scale from 1 to 5. Where 1 = totally disagree and 5 = totally agree. The items in the questionnaire were translated and adapted for the different constructs. The items of positive socio-cultural, economic and environmental impacts were extracted and adapted from Pavlić et al. ( 2017 ), the items related to experiential satisfaction were obtained from the research carried out by Wu & Li ( 2015 ), the items of Sustainable Tourism Development Attitude were adapted from the study of Wei-San Su et al. ( 2017 ), and the constructs of “perceived service quality, intention to select sustainable tourist destination and motivation” were extracted and adapted from Mohaidin et al. ( 2017 ).

Table 1 shows the main aspects related to the respondents’ profile. It has to be emphasized that a relative equality is observed regarding the origin of the tourists surveyed. In general, these are tourists who come on holiday, own financing and, in a high percentage of cases, basing on their own decision. More than 60% of the travelers are 35 years old or more, have a stable partner (married and living as a couple), live in households based on 2 or more people and earn a monthly income of between 1000 and 2000 euros. Although the majority of the respondents stated that they were visiting this city for the first time (62.7%), a high percentage (close to 40%) repeated their destination. On average, the tourists who participated in the study stayed in the city for 2–3 days.

For the analysis of relations between the variables of the proposed model, structural equation modeling has been used, more specifically the Partial Least Squares (PLS) technique, based on variance (Roldán and Sánchez-Franco, 2012 ). We have specifically chosen this technique for the following reasons (Cepeda-Carrion and Roldan, 2004 ): (a) the better suitability of the technique for research in the social sciences (economics, business organization, marketing, etc.); (b) the absence of strict requirements on the distribution of the data; and (c) the possibility of using composite variables. The measurement model used in this study is composite and reflective (Mode A). This makes the use of traditional PLS viable (Sarstedt et al., 2016 ). We have used PLS SmartPLS 3.2.8 software (Ringle et al., 2015 ).

The use of a single questionnaire in a self-report format to obtain the data of the latent variables made it necessary to verify the existence of common variance between them. All the experts’ suggestions (Huber and Power, 1985 ; Podsakoff et al., 2003 ) on the procedural steps regarding the design of questionnaires have been followed. The different measures used were separated and, on the other hand, the anonymity of the respondents was guaranteed. The Harman test (1967) has been used to detect the existence of common influence in the responses. The results of the exploratory factor analysis show that the 40 elements of the questionnaire are grouped into a total of 12 factors, where the largest of them explains 17% of the variance. This allows us to confirm the absence of a common factor of influence between these items (Podsakoff and Organ, 1986).

The latent model perspective (MacKenzie & Royle, 2005 ; Real et al., 2006 ) was used when analyzing the relations between the different constructs of the model and its factors. And, as in any model of structural equations, both the measurement model and the structural model were validated (See table A in the appendix that includes the correlation matrix between the items of the model).

4 Results and Discussion

4.1 measurement model.

Table 2 collects both the mean and standard deviation of each element and the data necessary to begin with the validation of the measurement model: determine the reliability of the individual items. We have measured all latent variables (constructs) in mode A (reflective). It is observed that the factor loads of most of the items exceed the minimum criterion of 0.707 (Carmines and Zeller, 1979), only two elements with lower values have been maintained, although very close (0.68). These items have been taking into account after checking their level of significance via bootstrapping (5000 subsamples) and according to the suggestions made by Hair et al. ( 2017 ). 25 items of a total of 40 were removed from the original questionnaire.

The reliability of the constructs was evaluated using the composite reliability index (ρ c ) (Werts et al., 1974 ). In all cases, we observe the fulfillment of the minimum requirement: a composite reliability greater than 0.7 (Nunnally, 1978 ). Regarding convergent validity, as Table 1 illustrates, all latent variables exceed the minimum level of 0.5 (Fornell and Larcker, 1981 ) in the AVE.

The analysis of the discriminant validity of the various constructs (latent variables) has been performed based on the Fornell-Larcker criterion. The data is collected in Table 3 . The Fornell-Larcker criterion is strictly followed in all cases. This allows us to affirm the discriminant validity between the latent variables and their way of measuring them.

After validating the measurement model, the structural model can be validated.

4.2 Structural Model

Following the indications of Roldán and Cepeda ( 2018 ), the study of the structural model must begin with the analysis of the sign, size and significance of the path coefficients, the R 2 values and the Q 2 test. According to Hair et al. ( 2017 ), we have used the bootstrapping technique with 5000 samples, to determine the t statistics and the confidence intervals and, in this way, obtain the significance of the relations. Table 4 offers the direct effects (path coefficients), the value of the t statistic, the corresponding confidence intervals and the verification of proposed hypotheses validity, along with the values of R 2 and Q 2 .

Not all direct effects are significant and positive and, therefore, the data do not indicate a widespread validity for the hypotheses proposed. 2 relations of a total of 3 are significant, but with an opposite sign to proposed one: the effect of the attitude towards the development of Sustainable Tourism on the intention to choose is negative, the same as the positive impact on the tourist motivation. Another invalid hypothesis regarding the effect of the attitude towards Sustainable Tourism on the tourist motivation is also contrary to the proposed one; although, in this case, it has no statistical significance.

The R 2 values only offer an appropriate predictive level for the variable attitude towards Sustainable Tourism development and a moderate level for the perceived service quality. The final variable intention to choose a sustainable tourist destination does not reach significant predictive levels. Besides, the Q 2 values indicate a certain level of predictive relevance of the model, since they all are greater than 0, although some of them are quite low.

In our model, we have also intended to verify whether there are mediation relations concerning the various endogenous variables included in the model. The results on mediation appear in Table 5 , where the values of all the indirect effects presented in the model are collected. The results indicate the presence of significant and positive indirect effects in total only in the case of the following relations: between the effect of the attitude towards the development of Sustainable Tourism and the intention to select a sustainable tourist destination, and between global positive impacts and the attitude towards the development of Sustainable Tourism. The model and its results are presented graphically in Fig.  2 .

Structural model: results and relations. Source Own elaboration

Once the reliability of the different items and the validity of the proposed models have been verified, we observe an absence of unanimity in the confirmation of the hypotheses proposed. Thus, in this case, the results do not match with the statements provided by some authors such as Crouch and Ritchie ( 1999 ), Lit et al. (2010) or Mohaidin et al. ( 2017 ), who confirm that the positive impacts provided by Sustainable Tourism could be a motivation for the destination. Similarly, nor does the study confirm that favorable attitudes towards the development of Sustainable Tourism positively influence on the intention to select sustainable tourist destinations, as authors such as Ventakesh ( 2006 ) or Mohaidin et al. ( 2017 ) concluded in their studys. On the other hand, although numerous studies consider the tourist motivation as a driver of their future behavior and as a positive effect trigger on the intention of visiting certain destinations, in addition to as a favorable attitude related to development of Sustainable Tourism (e.g. Huang & Liu, 2017 ), these theories are not also confirmed in this case.

The rest of the hypotheses raised in this study, related to perceived service quality, satisfaction or intention to choose sustainable tourist destinations, provide results that confirm previous studies on this topic and the relations proposed in this study.

5 Conclusions, Limitations and Future Research

5.1 conclusions.

Sustainable Tourism can become a solution to the crisis caused by COVID-19. This type of tourism promotes “greener” destinations, conceiving this term not only as ecological, but also as healthy. Therefore, the current mass many of the main tourist destinations face up today seems to stop happening soon or have to evolute to a sustainable mass tourism that combines the emergence of sustainability as a societal norm with the entrenched norm of support for growth (Weaver, 2012 ).

The different governments on spaces for coexistence not because of a greater environmental awareness instilled in tourists, but because of the obligations impose this fact and, on the other hand, because of the new requirements in terms of security tourists will impose on themselves when traveling and choosing a destination. Curiously, this crisis is going to force a change in Sustainable Tourism this summer 2020 in Spain. Once the confinement is finished, only internal tourism will be able to be developed. This adaptation will help overcome old problems: the exclusivity of “sun and sand” tourism will be faced to the fear of crowds, so that the occupation of inland destinations will increase, revitalizing unpopulated areas.

Therefore, the COVID-19 crisis should indirectly boost the long-awaited Sustainable Tourism, so necessary for environmental conservation and recovery. This type of tourism will finally have the long-expected opportunity (Petrizzo, 2020 ). This is the perfect time of the positioning of a sustainable Spanish tourism brand focused on its pre-existing competitive advantages. Furthermore, although the intention of many previous studies was demonstrating the importance of Sustainable Tourism (e. g. Chi-Ming et al., 2017 ; Ekanayake & Long, 2012 ; Fernández, 2018 ; Hussain, et al., 2015 ; Mohaidin et al., 2017 ; Vargas, 2007 ; Pavlić et al., 2017 ; Su & Chang, 2017 ), it does not succeed in establishing firmly in the tourist motivation, as this study reflects. However, the study confirms that tourists consider the Sustainable Tourism positive factors as important and manifest a favorable attitude towards its develop, particularly in the intention of selecting this destination type.

Based on the structural model proposed in this article and the results provided by its analysis, we see how the intention to select sustainable touristic destinations is supported by motivation (H9) and by the tourists’ satisfaction of developing favorable attitudes towards Sustainable Tourism (H8). Likewise, a positive and significant relationship of the tourist’s attitude towards the development of Sustainable Tourism is observed, fostered by the generic positive impact that it entails (H1). Respect to the tourist’ satisfaction experienced when consuming Sustainable Tourism, this is generated by the tourist’ attitude to develop Sustainable Tourism (H7) and by the service quality perceived on it (H6). This perceived service quality is caused by the generic positive impacts resulting from the development of Sustainable Tourism (H2). The rest of the relations established in the model (H3, H4 and H5) do not find statistical support in the results obtained.

Delving into the current approach of the Spanish tourism industry, the prospects noticed are dramatic, since this industry has a vital importance in the country, becoming the main axis of the national economic strength. Therefore, tourism experts and academics have the duty of find solutions to the crisis caused by the coronavirus. For this reason, we consider that promoting less crowded destinations and, ultimately, fostering Sustainable Tourism may be one of the solutions to this unprecedented crisis.

In summary, Sustainable Tourism can build on the momentum provided by this context of health crisis to increase a favorable attitude towards Sustainable Tourism development. Achieving this attitude will allow an increase in the tourist´s awareness, translated as the tourist´s perception of the positive impact and the satisfaction experienced with the consumption of this tourism type. The contributions that this work provides are several. In general, it highlights the convenience for Sustainable Tourism at present. It summarizes the constructs involved in the tourist's perception of Sustainable Tourism, contrary to other research focused on certain types of Sustainable Tourism. Specifically, our research model covers a total of 9 hypothesis with a new combination of constructs, in comparison to other publications with the same topic.

Public Institutions, in addition to managing the restrictions in the different territories, should also have the responsibility of developing policies for saving the tourism sector from the current crisis. Since Sustainable Tourism (as analyzed here) can help to promote tourist movements, it is the responsibility of Public Institutions to promote them. Therefore, it is important to determine the factors motivating tourists to engage in Sustainable Tourism, so that Public Institutions can also encourage its development, carrying out policies focused on the promotion and encouragement of this type of tourism.

The main contribution of this study is not theoretical (since there is a lot of literature based on this approach). The main contribution lies in extracting all the positive aspects that sustainable tourism brings to tourism development and highlighting its value in these times of crisis that this industry is going through.

5.2 Limitations

However, the main limitation we find in the present study is that the study was carried out prior to the crisis caused by COVID-19, therefore, aspects such as changes in attitudes, motivations and perceptions related to and caused by this new situation were not considered at any time. However, the study focused on analyzing the importance of Sustainable Tourism from a tourist perception approach. Without doubt, this relevance will be driven by this new situation. The second limitation derives from the non-probabilistic character of the sample, as the results obtained cannot be generalized; they do not guarantee a representation of the whole population, so that, it can be accepted a level of subjectivity.

In short, it is necessary to find formulas that boost the tourism industry. The development of Sustainable Tourism can help to mitigate the tourists’ perceived fear of visiting destinations with a large concentration of people. Therefore, can this crisis be the last great opportunity for the development of Sustainable Tourism?

5.3 Future Research

It would be very convenient to replicate this study in the future, when total mobility within the national territory begins to be allowed and the circulation of tourists is allowed internationally. Thus, for example, an aspect that was not supported in the present study is the importance of positive impacts a destination could have did not suppose a motivation for its choice. Thanks to the different government campaigns that are being recently launched with the aim of achieving positive impacts from visiting certain destinations, we think that this aspect could change due to the increased sensitivity perceived by the tourist.

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Palacios-Florencio, B., Santos-Roldán, L., Berbel-Pineda, J.M. et al. Sustainable Tourism as a Driving force of the Tourism Industry in a Post-Covid-19 Scenario. Soc Indic Res 158 , 991–1011 (2021). https://doi.org/10.1007/s11205-021-02735-2

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Impact of COVID-19 on the travel and tourism industry

Marinko Škare.

a Juraj Dobrila University of Pula, Faculty of Economics and Tourism “Dr. Mijo Mirković”, Croatia

Domingo Riberio Soriano

b University of Valencia, Spain

Małgorzata Porada-Rochoń

c Faculty of Economics, Finance and Management, University of Szczecin, Poland

Our paper is among the first to measure the potential effects of the COVID-19 pandemic on the tourism industry. Using panel structural vector auto-regression (PSVAR) (Pedroni, 2013) on data from 1995 to 2019 in 185 countries and system dynamic modeling (real-time data parameters connected to COVID-19), we estimate the impact of the pandemic crisis on the tourism industry worldwide. Past pandemic crises operated mostly through idiosyncratic shocks' channels, exposing domestic tourism sectors to large adverse shocks. Once domestic shocks perished (zero infection cases), inbound arrivals revived immediately. The COVID-19 pandemic, however, is different; and recovery of the tourism industry worldwide will take more time than the average expected recovery period of 10 months. Private and public policy support must be coordinated to assure capacity building and operational sustainability of the travel tourism sector during 2020–2021. COVID-19 proves that pandemic outbreaks have a much larger destructive impact on the travel and tourism industry than previous studies indicate. Tourism managers must carefully assess the effects of epidemics on business and develop new risk management methods to deal with the crisis. Furthermore, during 2020–2021, private and public policy support must be coordinated to sustain pre-COVID-19 operational levels of the tourism and travel sector.

1. Introduction

From the start of the COVID-19 crisis in China, the impact of the pandemic on the travel tourism industry was significantly underestimated. Even now, policymakers and tourism practitioners do not have a full understanding of the scenarios and effects of the crisis, which will have an unprecedented impact on the tourism industry. Empirical studies on the impact of pandemic outbreaks on the tourism industry are widely missing in the literature. Our paper is among the first to measure the potential impact of the COVID-19 pandemic in the short and long term, both worldwide and on a geographical level. The study attempts to explore what is expected to be a negative impact on the world and the geographical travel and tourism industry. It also plans to investigate the nature of the impact. Understanding the level of potential impact and the global channels of transmission  will help us predict the extent of current and future epidemic effects on the travel and tourism industry. It will help policymakers and practitioners design policies aimed at capacity building and operational sustainability of the travel tourism sector during 2020–2021 as a policy response to the COVID-19 crisis. Health care quality innovation will play an important role in fighting this pandemic crisis ( Zsifkovits et al., 2016 ).

The latest research report of the world travel and tourism council (WTTC) lists up to 75 million workers at immediate job risk as a result of COVID-19. Research reveals a potential Travel Tourism GDP loss in 2020 of up to US$ 2.1 trillion. WTTC also estimates the daily loss of a shocking one million jobs in the travel tourism sector for the widespread impact of the coronavirus pandemic. Pine and McKercher (2004) researched the impact of the SARS epidemic in 2002 on China's Guandong Province. Their study results show that the impact was negative, substantial, and significant. Mao et al. (2010) studied recovery patterns in Taiwan after the SARS outbreak using a catastrophe cusp model (for details see Sewell et al., 1977 ; Woodcock and Davis, 1978 ; Zeeman, 1976 ) and discovered two factors necessary for recovery from catastrophe to a normal state. The post-recovery period depends on the level of hysteresis and institutional efficiency in facing critical events. Kuo et al. (2008) found that epidemic crises affect tourism demand differently. Results of their study on SARS (2001–2004) and the widespread avian flu (2002–2006) show that SARS had an important impact on tourism demand in China, Hong Kong, Singapore, and Taiwan. The spread of avian flu, however, did not have an important negative impact on the tourism demand in Asia despite the high fatality rate. Preceding studies on pandemic impacts must be extended, however, to account for COVID-19′s new patterns and characteristics. Although in the previous widespread cases (SARS, 2002; H1N1, 2009) inbound tourist arrivals recovered almost immediately after the pandemic alerts were lifted, this will not be the case for COVID-19, and we must take that into account the new empirical models on pandemic impacts. SARS affected Asian stock market integration ( Chen et al., 2018 ) and increased hygienic measures in a limited fashion, but the COVID-19 pandemic seems to demand stricter measures ( Kostoff, 2011 ). Information and communication technologies (ICTs) will play a crucial role in fighting COVID-19 ( Gaspar et al., 2019 ).

To test the impact of COVID-19 on the travel tourism industry worldwide, we set up a dynamic model using an annual data set from 1995 to 2019. The model included 185 countries over 16 different regions and world in total. From the estimated PSVAR models, we take parameters on the empirical link between TCGD, TCEMP, SPEND, GOV, INV, and IPANDEMIC shock. Estimated parameters reflect the empirical link of past pandemic episodes from 1980 to 2019 but say little about the empirical link of the above variables with COVID-19. Demographic patterns in Europe and the rest of the world make population more vulnerable to future epidemic outbreaks ( Skirbekk et al., 2015 ).

To summarize our study results, the impact of COVID-19 on the travel tourism industry will be incomparable to the consequence of the previous pandemic episodes. Depending on the dynamics of future pandemics (from April 2020), the best-case scenario (scenario 1) shows that the travel tourism industry worldwide will drop on average from −2.93 percentage points to −7.82 in the total GDP contribution. Jobs in the travel tourism industry will decrease by −2.44 percentage points to −6.55. The estimated lost inbound tourist spending ranges from −25.0 percentage points to −35.0. Total capital investments that fall due to pandemics varies from −25.0 percentage points to −31.0. The impact is different across regions and in scenarios 1–3, which we further explain in the study.

The paper is structured as follows. After the introduction, Section 2 presents a summary of epidemic outbreaks worldwide since 1980. Section 3 describes the data sample (countries and regions in the sample) and the period used in the modeling process. Section 4 explains the methodological framework of PSVAR with a summary of the results. In Section 5 , we develop a system dynamics model that includes the empirical relationship obtained from PSVAR, extended for the new parameters (pattern and dynamic) that resulted from the COVID-19 crisis. We discuss the empirical study results in the Section 6 . Section 7 offers concluding remarks on the empirical study results and directions for further research.

2. Epidemic outbreak episodes and tourism worldwide trends since 1980

Several distinct factors determine the impact of an epidemic outbreak on tourism demand. Geographical distance to ground zero (infection epicenter) and infectious power are two of the most distinct. Other modern determinants are media attention (Internet revolution) and associated hysteria. Present worldwide socioeconomic conditions and terrorism, together with conditions of world conflict, impact tourism demand. Oil prices and environmental conditions also exhibit a substantial effect on the number of international tourists travelers. Furthermore, episodes of epidemic outbreaks have coincided with economic turmoil, both nationally and internationally, in the last 53 years (see Table 1 ). Because of tourism's seasonality character and vulnerability to exogenous factors, measuring the impact of an individual factor is a complicated task. This study aims to measure the impact of virus outbreaks on the tourism demand globally since 1980 as a prerequisite to measuring the COVID-19 impact. Several virus outbreaks globally affected worldwide tourism trends and the world economy after World War II (WWII). Table 1 shows the infections and deaths of significant virus outbreaks in the last 53 years.

Infections and deaths of significant virus outbreaks in the last 53 years.

In the past 50 years, the world has experienced several virus outbreaks with different levels of infections and mortality rates. Fig. 1 plots the virus outbreak episodes to the total number of tourist arrivals by world regions from 1950 to 2018. As expected, the impact varies by world regions depending on the source and distance to the virus outbreak source (ground zero countries).

International tourist arrivals by world regions 1950–2018.

Fig. 1 shows the that different epidemic outbreaks produce different worldwide impacts. Virus epidemic diseases, like SARS (2002) and H1N1(2009), have a large and significant impact on worldwide tourism trends and economic opportunity costs. Epidemic outbreaks with less infectious power (R naught - R 0 <1) have a lower impact on tourism trends and associated economic losses. Fig. 1 illustrates that the drop in tourist arrivals due to epidemic outbreaks varies across world regions. Table 2 displays registered (direct) drops in the number of tourist arrivals by world regions according to data from the United Nations World Tourism Organization (UNWTO)—a United Nations specialized agency—database.

Tourist arrivals and spending in a time of epidemic outbreaks by world regions, 1980–2019.

Table 2 shows that the total lost tourist arrivals worldwide from 1980 to 2019 amounted to 57 million (M) during the epidemic outbreaks. Lost tourism spending worldwide in times of epidemic outbreaks during this same period reached 95 US$ billion (bn). In relative terms, total lost tourism spending in a time of epidemic crisis was 0.23% of the world GDP (to the average world GDP value from 1980 to 2018). Epidemic outbreaks vary significantly between the type of disease outbreak and across world regions. Africa did not experience a significant impact on the tourism demand during the epidemic crisis; total losses were 2 bn US$ in tourism spent from 1980 to 2019.

The SARS epidemic crisis of 2002 and H1N1 (2009) caused a striking drop in tourist arrivals by −10 million in the Americas region; in tourism spending, the loss was −21 bn US$ in the that region. The Asiatic and Pacific regions experienced a significant drop in tourist arrivals during the bird flu epidemic (1997), SARS (2002), and H1N1(2009). Lost arrivals during the bird flu crisis in that region was −1 million, and lost spending amounted to −2 bn US$ . The decline in the tourist arrivals in the region at the time of the SARS (2002) outbreaks was −12 million with a related −2 bn US$ in lost revenue. During the H1N1 (2009) crisis, the region experienced −3 million tourist arrivals decline and −6 bn US$ lost tourism spending. The European region was not significantly hit by most of the outbreaks and epidemics from 1980 to 2019 (for the distance to the virus originating region). However, in the H1N1 epidemics (2009), there was a decline of −26 million tourist arrivals and a −61 bn US$ total tourism spending loss (amounting to 0.5% of the Europe GDP at the time). In H1N1 epidemic episode, however, Europe was affected strikingly with a total decline in tourist arrivals and spending loss that surpassed the economic impact for all other world regions over the 1980–2019 period.

The Middle East region suffered travel disruptions during the H1N1 (2009) epidemic crisis, causing a −3 million decline in tourist arrivals. Tourist spending, however, did not register a decline due to a rise in the receipts per arrival. The bird flu (2013) crisis faced a −2 million decline in tourist arrivals and −1 bn US$ in international visitor spending.

We associate epidemic outbreaks with significant opportunity costs in tourism demand. Although epidemic outbreaks significantly shape and influence the tourism industry, multiple causality issues (e.g., outbreaks followed by environmental and security issues or political and economic crises) arise when it comes to measuring the opportunity costs of epidemic outbreaks. To address this issue, we use structural vector auto-regression (SVAR) models to estimate the direct and opportunity costs of COVID-19 on the tourism industry (and economy) worldwide.

3. Data and facts on pandemics' impact on travel and tourism

The travel and tourism industry in the time of services-led growth trends has become increasingly important worldwide since 1990. From 1995, the travel and tourism industry's direct contribution to the world GDP increased from 9.9% in 1995 to 10.3% in 2019. A significant impact of the travel and tourism industry is also visible on employment levels. The total contribution to world employment in 2019 was 10.4%. The SARS epidemic in 2003 and the financial crisis of 2008 had a significant negative impact on world and regional travel and tourism industries.

We use annual data for 185 countries grouped in 16 world regions: Africa, the Americas, Asia Pacific, Caribbean, Central Asia, Europe, Latin America, Middle East, Northeast Asia, North Africa, Northern America, Oceania, other Europe, South Asia, Southeast Asia, and sub-Saharan Africa. All data are in real prices (CPI US$ 2000=100 index), adjusted for the impact of inflation. We utilize two main databases: World travel and tourism council (WTTC) data gateway (wttc.org/datagateway) and UNWTO (unwto.org/data). All data are in annual frequencies from 1995 to 2019. Data series (variables) we use for modeling:

• • TCGDP = total (indirect and induced impact) of travel and tourism contribution to the national/regional GDP (in real US$ bn, WTTC 2020 )
• • TCEMP = total (indirect and induced impact) travel and tourism contribution to national/regional employment (in 000 of jobs, WTTC 2020 )
• • SPEND = total spending in the domestic economy by foreign visitors (in real US$ bn, WTTC 2020 ),
• • ARRIVALS = total tourist arrivals (in 000, UNWTO 2020 )
• • GOV = individual government expenditures on travel and tourism (in real US$ bn, WTTC 2020 )
• • INV = Investment - capital investment both private and public (in real US$ bn, WTTC 2020 )
• • PANDEMIC = dichotomous (dummy) variable, PANDEMIC = 1 when no pandemic outbreaks exist and PANDEMIC = 0 when pandemic outbreaks are present
• • IPANDEMIC = measures the impact of pandemic outbreaks SARS (2002), H1N1 (2009), MERS (2012), and H7N9 bird flu (2013)

To correctly capture the pandemic impact, we use the interaction variable (model) with ARRIVALS as a continuous variable (000 of jobs) and PANDEMIC as a dichotomous variable (dummy variable 0,1).

4. Measuring pandemics' impact on the tourism industry using PSVAR

Our goal is to analyze the impact of the new coronavirus (COVID-19) outbreak on world tourism dynamics. To our knowledge, this study is the first attempt to measure the impact of the current COVID-19 outbreak on tourism worldwide. To estimate the impact of COVID-19′s ongoing outbreak, we model the COVID-19 shocks using time series data for past coronavirus outbreaks; for SARS (2002), H1N1 (2009), and Ebola (2004); and for the past epidemic outbreaks of Hendra (1994), H5N1 bird flu (1997), Nipah (1998), MERS (2012), and H7N9 bird flu (2013). However, COVID-19 is a new type of virus, and it brings much uncertainty connected to the speed of spread, infectious power, mortality rate, and future dynamics of the virus. Therefore, we use the current state of knowledge on the COVID-19 reproduction number (R0) ( Kucharski et al., 2020 ) to calibrate our models for the SARS (2002) and H1N1(2009) variance. To study the impact of COVID-19 on tourism worldwide, we use the heterogeneous PSVAR model as developed by Pedroni (2013) . Using the PSVAR model—Ewiews code provided by Luvsannyam (2018) and Góes (2016) —we estimated how the COVID-19 shocks on tourism (arrivals, spending) propagated across world regions. We have a strong heterogeneous sample, so using PSVAR enabled us to estimate the impact of the COVID-19 shock on tourism, depending on the following factors: region-specific socioeconomic conditions, vulnerability to external shocks, health system stability, environmental conditions, tourism sector stability, and competitiveness.

Following Pedroni (2013) , we decomposed the impact of the structural shock (COVID-19) into common shock (effects of COVID-19 outbreak originating in any other region in the sample and propagating to region-specific tourism industry) and idiosyncratic shock.

Idiosyncratic shocks show the impact of COVID-19 originating in a member-specific region on the tourism industry in the same region. As in Biljanovska et al. (2017) and Pedroni (2013) , we refer to the measured COVID-19 effects on the tourism industry as a common component or spillover (common shock), and to an idiosyncratic component as country-specific (idiosyncratic shock).

We use the following estimation model for an unbalanced panel using data from 1995 to 2019 in the PSVAR bivariate form (for details see Góes (2016) ; Pedroni (2013) ; Biljanovska et al. (2017) :

where y * i,t is an s n-dimensional vector of demeaned stacked endogenous variables, and

which equals polynomial of lagged coefficients with country-specific lag lengths J i , coefficient matrix A i j , vector of stacked residuals e i,t and B i contemporaneous coefficient matrix ( Góes, 2016 ).

In this model, we allow for full heterogeneity and robust inference decomposing (using time effects) impulse response function to idiosyncratic shocks and common shocks (region-specific response). To estimate the impact of pandemic outbreaks, we use TCGDP, TCEMP, SPEND, ARRIVALS, GOV, and INV as endogenous variables, and PANDEMIC (dummy), IPANDEMIC (interaction variable), defined in Section 3 . Structural shock (white noise vector) takes the form

with ε ¯ t ′  = vector of common white noise and ε ˜ i t = vector of idiosyncratic white noise shocks.

Composite white noise errors equal

and Λ i  =  M x M diagonal matrix with loading coefficients Λ i, m  = 1,…, M ( Pedroni, 2013 ).

Composite structural white noise shock (vector ε it ) takes the form

with ε it  = composite white noise shock, ε .,t  = common shock, and ε ˜ i , t  = country-specific idiosyncratic shock ( Biljanovska et al., 2017 ).

We use long-run identifying restrictions ( Blanchard-Quah, 1989 ) to obtain structural shock estimates for composite and common shocks. Impulse responses of common and idiosyncratic shocks (rescaled) show impulse responses to unit shocks. We intend observing an impulse response to a unit shock (−100,000 tourist arrival drop) in IPANDEMIC when pandemic outbreaks are present.

Fig. 2 presents the median composite response of the total (indirect and induced impact) travel and tourism contribution to the national/regional GDP (TCGDP) in a pandemic outbreak (unit shock) for 17 regions (including world) of the sample. A large negative impact of a pandemic outbreak on the (TCGDP) GDP created by the travel and tourism industry can be observed. The initial response of the TCGDP is negative for all regions and the world in total (panel a).

Impulse (composite) response functions’ estimate of TCGDP to IPANDEMIC

Notes: Median impulse response averaging with general to specific lag length criteria selection and 95% confidence intervals.

When a pandemic outbreak occurs, for a decline of −100,000 tourist arrivals (unit shock for pandemic), the total GDP created by the travel and tourism industry drops by −0.46 (bn) US$. The negative impact is largest in the first year with −0.46 bn US$ of the GDP lost because of the pandemic outbreak. The large initial negative impact is offset in the next year, declining from −0.46 bn to just −0.01 bn US$ in the second year. Thus, policymakers and travel and tourism practitioners can expect significant losses (in terms of the GDP created by tourism) in the first year of a pandemic outbreak. If the impact is larger than a unit shock, for example, a 10-unit increase in IPANDEMIC (equal to 1 million tourist arrivals lost) will cause −4.6 bn US$ decline of the real GDP contributed by the travel and tourism industry. With a 20-unit increase in IPANDEMIC (2 million tourist arrivals lost), we can expect the associated real GDP will drop by −9.2 bn US$. Policymakers and travel and tourism practitioners must know the deep potential impact of pandemic outbreaks on the tourism and travel industry and the national economy. Although the negative impact of the pandemic is limited to the medium-term effect (see the Fig. 2 ) on the tourism and travel industry and national economy, the impact is too large and sizable to ignore. It demands an appropriate managerial and economic policy response, an immediate and direct comeback to avoid potentially catastrophic consequences. The response must be straightforward and quick, since the time of response and the extent or limit of the measures will dictate the actual level (negative peak) of the pandemic shock. Without the appropriate managerial and economic policy response, swift and directed, the pandemic shock consequences are large enough to push any economy (even the most advanced) into a deep recession. The potential impact of a pandemic is great enough to have a tsunami effect on the total travel and tourism industry, leading to large-scale bankruptcies. We can observe the double-dip pandemic shock effect since after the initial shock TCGDP in the second-year decline just by −0.01 bn US$ for −100,000 tourist arrivals lost. However, in the third year, the drop in the TCGDP amounts to −0.06 bn US$ per −100,000 tourist arrivals lost. The pandemic shock effect dies out in the fourth year after the initial shock (medium-term effect). The cumulative negative impact of a unit pandemic shock (a drop of −100,000 arrivals) to the travel and tourism industry and the national output is −0.53 bn US$ (decline) of the revenue that the industry contributed the GDP. Pandemic crises because of their total potential economic impact on the travel and tourism industry and the national economy should be classified as a super cycle event in economic literature. For example, a pandemic event resulting in −500 million tourist arrivals' drop would cause a −2.809 bn US$ drop (3.3% of the world GDP 2018) in the GDP contributed by the travel and tourism industry worldwide.

Fig. 2 illustrates the estimate (common shock) response to the impact of the pandemic effect that originates in any other region in the sample (pandemic cluster), spilling over to the region of interest (see panel b in Fig. 2 ). The impulse response to regional pandemic effect (IPANDEMIC unit shock) is less pronounced with the composite shock impact. Past pandemic outbreaks over regions in the sample show an important but limited impact on a specific region of the travel and tourism industry and national output. Pandemic outbreaks show limited (spillover) impact when compared to the composite effects of the IPANDEMIC shock.

A unit IPANDEMIC shock (−100,000 tourist arrivals) harms the GDP originated by the travel and tourism industry of −0.10 bn US$. This means that a more extensive pandemic shock (a drop of −1 million tourist arrivals) would cause a −1 bn US$ decrease in the GDP contributed by the industry. Common shocks' impact on a particular region is less pronounced regarding the composite shock (worldwide impact), and it can have significant but limited negative effects. Remember, the composite shock impact of a unit IPANDEMIC shock is −0.46 bn US$ compared to −0.10 bn US$ for the common shock, which means that not all regions will be in danger of a super cycle event triggered by the pandemic crisis. The negative impact will not be at an "economic extinction" level but will still be important to observe. It can be observed that the median impact of the pandemic outbreak reaches through during the first year the crisis appears. The impact of the crisis is statistically significant (inside 95% confidence intervals – dashed lines). It offsets the shock effects in the second year (dropping to zero) but with a double-dip negative impact as for composite shock. The negative effect reappears in the third year with a −0.03 bn US$ impact on the GDP generated in the travel and tourism industry. We can conclude that some regions show more resilience to the negative impacts of the pandemic shock. Such evidence demands more research on the factors that determine the regional vulnerability to a pandemic crisis (like the phase of the financial/business cycle, government response, micro and macroeconomic stability, institutional efficiency, public sector efficiency, and health system stability). While the pandemic crisis is potentially devastating on a worldwide level, some regions are less vulnerable than others, and the regional economic policy is an important tool in fighting pandemic shocks.

Idiosyncratic impulse responses show how vulnerable regions are to the pandemic shock originating within the same region (idiosyncratic shocks). Panel (c) in Fig. 2 explains the effects within the region pandemic event. As expected, pandemic events originating within a particular region have devastating economic impacts on the same region. The median impact reaches through during the first year, attaining −0.45 bn US$ per unit IPANDEMIC shock. Pandemic outbreak within a region has an immediate negative effect on the GDP created by the travel and tourism industry and national output. A unit shock (−100,000 arrivals) results in the decline of the GDP (GDP drop) by −0.45 bn US$. The reaction to the shock is swift and profound. During the second year, the shock effects die out, reaching −0.01 bn US$, but the double-dip effect is present (the same as for composite and common shock). After "economic reanimation" in the second year, the negative effects of the shock intensify, reaching −0.05 bn US$ of TCGDP. The total effects of the shock die out four years after the shock, with the impulse response converging to zero. The estimated impulse response of the TCGDP to a unit shock is statistically significant over the whole period. We observed that idiosyncratic shocks of epidemic outbreaks (region as an epidemic cluster) were more sizable in relation to the common shocks. Idiosyncratic shocks are more important than common shocks, with composite shocks driving the dynamics of the idiosyncratic shocks. Pandemic outbreaks starting within a region impact economic activity connected to travel and tourism. National pandemic outbreaks within a region have a larger negative impact on the region's economic activity than the spillover shocks coming from pandemic outbreaks in other regions. The consequences of domestic pandemic shocks are significantly larger with more repercussions than spillover shocks in other regions of the world. Even in a globalized world economy, pandemic outbreaks in one region will have limited impacts on the tourism industry in other regions. However, a pandemic crisis started in a particular region will have a large and significant negative effect on the same region's domestic economy.

To conclude, pandemic shocks have a deeply negative impact on the tourism industry and economy. National pandemic outbreaks (idiosyncratic shocks) are significantly larger and more damaging to outside pandemic outbreaks (common shocks). Spillover negative effects of a pandemic outbreak have a limited impact on the tourism industry and economy as long as the pandemic outbreak started elsewhere does not become a "domestic" pandemic cluster. The difference in the extent of the common versus idiosyncratic shocks consequences comes from the differences in the domestic (region's) tourist industry's diversity and stability, the nation's/region's economic resilience, and the structure and level of technological and institutional development.

Fig. 3 examines a much different pandemic impact: the shocks on the employment dynamics (TCEMP) and the reaction of employment (TCEMP) to a unit shock (IPANDEMIC) over ten years.

Impulse (composite) response functions’ estimate of TCEMP to IPANDEMIC

The median response of employment to the pandemic shock reaches through during the first year (negative effect). The effects of the composite shocks (panel a) are negative and statistically significant (within the 95% confidence intervals). Composite shocks (sum of the common and idiosyncratic) to employment (direct + indirect employment created by the travel and tourism industry) show a pattern similar to the GDP and the tourism industry. The negative impact of a pandemic shock is significant and sizable, with an immediate decline in the employment level during the first year. A one-unit shock (decrease of −100 tourist arrivals) for a pandemic outbreak results in −24 lost jobs contributed by the travel and tourism industry. Thus, the pandemic shock has a significant negative impact not only on the employment level in the travel and tourism (direct) but also on associated sectors in the economy (indirect impact). For a −100,000 drop in tourist arrivals, direct and indirect employment created by the travel and tourism industry declined by −24,000 jobs. A more pronounced shock, a 10-unit increase in IPANDEMIC (one million fewer tourist arrivals) is associated with a decline of - 240,000 jobs in the travel and tourism industry and associated sectors. As expected, epidemic outbreaks have potentially catastrophic negative impacts on the industry as well as the whole economy. A large pandemic outbreak (similar to COVID-19) could cause −10 million tourist arrivals, triggering massive layoffs in the travel and tourism industry and associated sectors by −2.400,000 jobs. A massive −100 million decline in tourist arrivals worldwide (7.14% of the total world overnight visitors in 2018) could start a chain reaction leading to −24 million lost in travel and tourism worldwide (7.54% of the total travel and tourism contribution to the employment in 2018).

Negative effects slow down during the second year, recovering from the initial shock and dampening to zero. The total effect of the pandemic shock is highly persistent, with pandemic shock effects converging to zero after five years. Still, such a large pandemic shock does not show optimistic signs that the travel and tourism industry could return to pre-pandemic employment levels rapidly. We expect the industry to recover slowly during the initial five years, depending on the overall pandemic shock impact to the economy.

Panel (b) in Fig. 3 shows the spillover effects of a pandemic shock starting in another region and spilling over to a specific (domestic) region. Unlike the pandemic impact on the GDP spilling over to other world regions, labor markets associated with the travel and tourism industry are highly globalized and volatile. Common spillover shock effect is large and statistically significant (within 95% confidence limits), reaching through in the first year (immediate negative impact) of the pandemic episode. For a −100,000 tourist arrival decline, it can be expected that −18,000 jobs (direct + indirect effects) will be lost. Common shock dynamics follow composite shock dynamics, reaching through in the first year and slowing down with a modest recovery in the second year. The pandemic effect on employment contributed by the travel and tourism sector worldwide remains highly persistent over five years. Large pandemic shocks, like −100 million lost tourist arrivals, would result in −18 million laysoff worldwide (5.67% of the total world contribution of the travel and tourism sector to employment in 2018). Pandemic shocks have a sizeable negative effect on the highly globalized tourism labor market, as we can see from Fig. 3 . Pandemic shock originating in one region and having immediate negative effects on the domestic labor market is rapidly and extensively spilling to other world regions' labor markets (travel and tourism). A catastrophic pandemic crisis leading to 1 bn lost tourist arrivals would devastate the travel and tourism industries worldwide, causing −180 million lost jobs (56.7% of the world's total travel and tourism contribution to employment). Half of the travel and tourism industry and associated sectors worldwide would face economic collapse. Common shocks resulting from the pandemic crisis show significant spillover, transferring negative effects of the crisis from the domestic tourism labor market to the foreign. Global labor markets in the tourism industry are more vulnerable and volatile to the spillover effects of the pandemic crisis compared to the spillover effects on national economies.

A pandemic crisis starting (domestic) idiosyncratic shock (panel c in Fig. 3 ) has a negative and statistically significant impact on employment. The same pattern as in the composite and common shock dynamics is also visible in the idiosyncratic shock (domestic) in the region. Pandemic outbreaks starting within a region have an immediate negative impact on the travel and tourism sector at the employment level. The median impact is large and negative, reaching through in the first year and swiftly dying out in the second year. In the third year, the negative effect on employment reappears, converging to zero in the next two years. The impact of the pandemic crisis on employment in the domestic market is persistent and shows a medium-term pattern. The case is similar in the common shock; a domestic pandemic cluster (unit shock in IPANDEMIC) will bring down employment in the travel and tourism industry and associated sectors. For −100 lost tourist arrivals, −14 jobs will be lost in the domestic (regional) tourism industry. Although the negative impact does not appear significant at the start (same as an illusion with the linear and exponential growth), its cumulative effects are staggering. A total of −140,000 job positions will disappear in the region due to a regional pandemic crisis, causing - 1 million tourist arrivals. Over a decline of −100 million lost tourist arrivals to a region, the total number of job positions strayed will hit −14 million. Such a shock will bring a sizable negative effect on the region. For example, in Africa (in 2018) the travel and tourism industry contributed to 24.3 million jobs. Losing −14 million in the case of Africa, with a total of 24.3 million job positions related to tourism, would be devastating (−57.6% of the total jobs in Africa's tourism industry). The shocks starts slowly (from −14 job positions lost) and rapidly grows to −14 million, bringing a catastrophic unemployment crisis to the tourism industry and economy. From the impulse response function, we observe that no region is immune to the pandemic impact on the domestic tourism labor market. However, the final level of the negative impact depends on the importance of the tourism industry in the economy (share in the GDP) and other micro/macroeconomic factors associated with institutional and economic policy efficiency.

When we compare the median and the average (mean) composite, common, and idiosyncratic responses of employment to the pandemic crisis, the level of impact varies across regions (figures not presented here for space constraint). Further study on the determinants of heterogeneous responses across regions regarding employment to the pandemic impact (also at a national level) demands attention to better understand the mechanism behind pandemic shocks on the tourism industry.

Pandemic shock (IPANDEMIC) results in the decline of tourist arrivals transmitted to tourist spending (SPEND). Fig. 4 illustrates the negative impact of the pandemic crisis on foreign visitor tourist spending. First, we look at the composite shock impulse response (panel a), which resembles the pattern we discovered for TCGDP and TCEMP. The negative impact of the shock reaches through during the first year (immediate effect), reversing to normality during the second year. In the third year, we can see a second negative impact slowly converging to zero during the next two years. A unit shock in IPANDEMIC (−100,000 tourist arrivals) results in a −0.24 bn US$ decline in tourism spending. After the peak in the first year, the median impulse response of tourist spending to the pandemic shock declines but continues to persist in the medium term (five years). Unlike the response of employment to the pandemic crisis and similar to the output response, tourist spending response to a unit shock is more pronounced in the case of idiosyncratic shocks.

Impulse (composite) response functions’ estimate of SPENDING to IPANDEMIC

Panel (b) in Fig. 6 shows that the effect of the common shocks to a unit shock (−100,000 tourist arrivals) is −0.07 bn US$ of lost tourist spending. The common shocks impact is less pronounced to the composite, meaning that spillover effects of the pandemic crisis from one region to another are limited. Tourism service markets are highly globalized, but, according to our results, more robust and less volatile to pandemic shocks compared to the tourism labor markets. Pandemic crises that originated in other regions in our sample have a limited impact on foreign tourist spending in the domestic region. The impact, as shown in Fig. 4 , is statistically significant at a 95% confidence interval, reaching a peak in the first year and converging to zero in 3 years. Double-dip impact is less pronounced when compared to the impact on output or employment. We can conclude that the spillover impact of a pandemic crisis is displaced from one world region to another but is less profound when the pandemic impact starts within the region. A pandemic outbreak starting within a particular (domestic) region (idiosyncratic shock in panel c) exhibits more striking negative effects on tourism spending than a pandemic impact migrating from outside regions. The impact of a pandemic unit shock measured by impulse response (idiosyncratic shock) shown in Fig. 4 points out that tourist spending declines by −0.22 bn US$ for a decrease of −100,000 tourist arrivals. Compared to the spillover effects (common shocks) of −0.07 bn US$, we can see that domestic pandemic crises (response to idiosyncratic shocks) have three times (−0.22 bn US$) the number of devastating effects on tourist spending. The median impulse response reaches through during the first year after the shock, converging to zero in the second year with a double-dip in the third year. The pandemic impact of the idiosyncratic shock on tourist spending persists in the medium term (five years). Domestic pandemic outbreaks hit the domestic tourism sector and economy hard. For a −1 million of lost tourist arrivals, the domestic travel and tourism industry and economy loses −2.2 bn US$ in tourism spending. Larger crises, such as COVID-19, that could cause −100 million lost tourist arrivals could also cause regions to lose about −220 bn US$ (14% of the world tourism spending in 2018).

Estimated potential (COVID-19) impact on employment in the travel and tourism industry worldwide.

Impulse response estimates of the composite, common, and idiosyncratic pandemic shocks on tourism created the GDP, employment, and tourism spending present median responses. Average responses vary across regions, meaning regions show variances in the response estimates (the difference between the median and average estimates to shocks). This study does not present figures for the mean response estimates to shocks due to space constraints. Using PSVAR, we also assess median response estimates to pandemic shocks to capital investments: INV = Investment - Capital investment, both private and public (in real US$ bn), and government investments (GOV) = government individual expenditures on travel and tourism (in real US$ bn). Including these PSVAR estimates allows us to access the total impact of the pandemic crisis on the overall travel and tourism industry. Since calculations demand numerous tables and figures, we do not present them here due to publishing constraints, but we do give a summary and discussion in the concluding remarks.

Pandemic outbreaks have potentially devastating effects on the travel and tourism industry worldwide according to the evidence obtained from the PSVAR models in this paper. Policymakers and practitioners in the tourism industry should pay significant attention and adapt future economic and management policies accordingly. Empirical evidence of this study supports this thesis, providing robust evidence to hold the pandemic shocks' theory. PSVAR relies on structural and reduced-form modeling and historical series data to obtain empirical links between pandemic shocks and main indicators in the travel and tourism industry.

However, since COVID-19 is a new pandemic outbreak for which we do not have reliable historical series data, we have to estimate the economic impacts of COVID-19 on the tourism industry worldwide using empirical knowledge gained with PSVAR modeling. The same PSVAR empirical knowledge gained in this study gives us the empirical background we need to develop a business dynamics model to test the economic impact of the current COVID-19 pandemic crisis.

5. Estimating COVID-19 pandemic shock economic impact on the world and the regional travel and tourism industry

To evaluate the impact of COVID-19 on the travel and tourism industry worldwide, we set up a dynamic model (not presented here due to space constraints). From the estimated PSVAR models, we take parameters on the empirical link between TCGD, TCEMP, SPEND, GOV, INV, and IPANDEMIC shock. Estimated parameters reflect the empirical link from past pandemic episodes from 1980 to 2019 but say little about the empirical link of the above variables (COVID-19). To measure the potential impact of COVID-19, we recalibrate estimated parameters to correct for the knowledge we now have on COVID-19. Our dynamic model includes recalibrated PSVAR parameters, R 0 for COVID-19, a proxy for government responses ( Hale et al., 2020 ), country's/region's economic policy responses (RBA Research International), the share of export in the GDP, the travel and tourism sector share in the GDP, the phase of the financial cycle (credit-to-GDP gaps - BIS data), private debt share in the GDP, and tourist arrivals under three scenarios. We set up the number of international tourist arrivals under three different scenarios.

The first scenario is a lockdown as it occurred during March 2020 and continuing in April (scenario one from January 1, 2020 to April 1, 2020). The second scenario projects the continuation of the lockdown from April 1, 2020 to August 1, 2020. The third and worst scenario of the pandemic outbreak projects it staying in the environment until the end of 2020 (scenario three from August 1, 2020 to December 31, /2020). We use the above-explained building blocks to build a dynamic model for estimating the potential impact of COVID-19 on the travel and tourism industry worldwide.

Fig. 5 shows the estimate of the potential COVID-19 impact on the travel and tourism industry at the world and regional levels (regions according to the WTTC) under different scenarios. The first scenario is already in place (actual scenario) since we are well beyond its time duration: January 1, 2020 to April 1, 2020. This is the best-case scenario, assuming the pandemic outbreaks to be under control during April 2020 and a complete worldwide lockdown is revoked.

Estimated potential (COVID-19) impact on output in the travel and tourism industry by world regions.

The numbers in Fig. 5 present losses in the real GDP (TCGDP) in the travel and tourism industry (in US$ bn 2000 constant prices). Numbers in Fig. 5 stand for the GDP the travel and tourism industry could create but lost due to the outbreak of COVID-19. Under scenario 1, the world will suffer economic costs equal to −2.2 trillion US$ or −4.54% of the world's GDP. The actual scenario (scenario 1) tells us we can expect the world's GDP to fall by −4.54% in 2020. The world will experience a new recession phase amounting to a −4.54% GDP decrease if scenario 1 persists. We can see that pandemic economic shocks are significant and substantial (even under the best actual scenario). The costs are much higher even now under scenario 1 than policymakers and practitioners expected when COVID-19 first appeared in China. Thus, we can call scenario 1 an actual or inevitable economic cost that the world will face because of the COVID-19 outbreak.

Fig. 5 shows how the pandemic economic shock spillover effects vary across world regions. Advanced economic regions like the Americas, Europe, NortheEast Asia, Asia Pacific, and Northern America will experience significant declines in the GDP, from −853 bn US$ in Europe to −895.6 in Northeast Asia. The Americas and the Asia Pacific will face a significant decline in the GDP, with the Americas losing 1.5 trillion US$ and Asia Pacific 1.1 US$ trillion. In absolute numbers, other world regions will face a significantly lower amount in terms of dollar amounts, but in relative terms (their share in the lost GDP), they will face the same recession pressure as advanced regions. The region's potential recession is a consequence of a domestic pandemic shock and limited to a minor spillover effect of the pandemic shock from other regions. The reason lies in the economic lockdown policies that regions adopted to fight COVID-19. However, common shocks or spillover effects for COVID-19 are significantly more substantial when compared to the same effects for SARS (2002), H1N1 (2009), or MERS (2012). According to the actual situation and actual scenario (scenario 1), regions will face recession ranging from a decline in the GDP from −2.09% (Central Asia) to −7.82% (Caribbean).

Scenario 2 describes an undergoing scenario (April 2020). It shows that the adverse macroeconomic effects of the COVID-19 pandemic crisis are much worse than policymakers and analysts expected when the crisis started. With the COVID-19 outbreak and lockdown continuing to August 1, 2020, the world economy will face a decline in output of −9.80%. Again, advanced regions will be affected the most (due to a drop in a large number of tourist arrivals) with the Americas facing −10.93%, Europe −8.33%, and Southeast Asia −9.88%. However, less developed regions like Africa (−10.08%) and North Africa (−10.03) could also experience significant recession. For less-developed regions, the dynamics of tourist arrivals are somewhat different (due to climate and environment), so their economic losses are more significant under the second scenario than under the first. Other regions, on average (−8.69%), will experience a pandemic shock with an output drop ranging from the lowest, - 4% in Central Asia, to the highest, −16.34% in the Caribbean and −9.59% in Oceania.

The third scenario, from August 1, 2020 to December 1, 2020, is the more severe scenario in our model (if lockdown continues to end of this year). The average drop in output under scenario 3 equals −12.72% for all regions in the sample. Regions with a significant share of tourism contribution to output, as in the Caribbean (−23.69%) and Oceania (−14.97%), will face significant idiosyncratic shocks impact. The less-developed regions of Africa (−14.95%) and North Africa (−14.97%) will experience a cascade effect resulting from both idiosyncratic and common shocks disrupting the supply–demand mechanism. Such regions will experience a double impact resulting from the domestic effects of the outbreak on the economic activity that amplified the worsening economic conditions abroad. Total world output if the lockdown continues to the end of 2020 will reach levels (−14.20%) far worse than the 2008 economic crisis and constitute the biggest plunge after WWII. The plunge depends mainly on the lockdown conditions that, if relaxed, will move recession scale more toward scenario 2.

Fig. 6 shows estimates the potential impact of COVID-19 on the labor (and associated) markets in the travel and tourism industry.

Fig. 6 also shows that the connected industries’ labor market will be significant and negative. As expected, the impact will be more substantial in regions more dependent on the travel and tourism industry. The Asia Pacific region under scenario 1 will lose 56.6 million jobs due to COVID-19. A large part of the region's travel and tourism industry, with 186 million jobs, will suffer a significant shock if not counterbalanced by government measures to fight the adverse effects of COVID-19 on the labor markets. Potential negative impacts multiply as lockdowns continue or countries retain strictly controlled border regimes (as announced by France and other EU members, at least to September 2020). Under these conditions, the second scenario applies, with the Asia Pacific regions losing a million jobs in the travel and tourism industry. Under the first scenario, the Americas could loss −19.9 million jobs, an actual scenario if we observe the last data for the United States with more than 15 million unemployment claims by March 21, 2020. In Canada, jobless claims in the same period peaked at 2.13 million with the model predictions fitting the data quite well. Northeast Asia could experience −38.4 million jobs lost in the travel and tourism industry under the first scenario, with South Asia reaching −22.4 million. The impact will be on a “tsunami” level for the Caribbean, losing almost 46% of the total jobs in the industry. Scenario 1 will hit the world by large force with −164.5 million jobs lost in the travel and tourism industry. Although scenario 1 is the actual scenario now (April 2020), the estimated impact is ample, but recovery is still possible since the average recovery time in the travel industry is estimated between 10 and 12 months. However, if the lockdown continues with travel limitations imposed, the second scenario could bring severe challenges to the travel and tourism sector well beyond the sector's resilience threshold.

Under scenario 2, jobless claims worldwide could hit 354.7 million with direct jobless claims in the travel and tourism labor markets reaching −118 million. Regions experiencing the most significant declines in employment (in absolute numbers) will be Asia Pacific (−108.2 million), Northeast Asia (−73.5 million), South Asia (−43 million), and Southeast Asia (−31.8 million). The total impact of COVID-19 on the travel and tourism labor market under various scenarios will depend, to a large extent, on the government's economic response to fight the virus.

Under the first and the second scenarios, governments’ economic response is essential but still not a last resort; under scenario 3, governments’ support to fight COVID-19 economic damages becomes crucial. Total jobless claims in the world could reach −514.8 million depending on two main factors: (1) if the entire tourist season is lost and (2) governments’ strength and speed of response.

Tourists’ spending in the travel and tourism industry worldwide will experience a drop ranging from −1.5 US$ bn to −771.7 US$ bn (see Fig. 7 ).

Estimated potential (COVID-19) impact on tourists’ spending in travel and tourism industry worldwide.

On the world level, tourist spending will drop from −604.8 US$ bn (scenario 1) to −1.9 US$ trillion (scenario 3). Regions most affected (in absolute numbers) will be the Americas (−138.3 to −419.1 US$ bn), Asia Pacific (−235.7 to −673.4 US$ bn), Europe (−192.9 to −771.7 US$ bn), Northeast Asia (−115.3 to −329.5 US$ bn), Central Asia (−1.5 to −4.2 US$ bn), North Africa (−9.0 to – 29.1 US$ bn), and sub-Saharan Africa (−11.8 to −38.2 US$ bn)—and these regions have the lowest absolute numbers in tourist spending. All other regions, as we can see from the tables, ranging from Central Asia (−1.5 US$ bn) to Europe (−771.7 US$ bn). Scenario 1 (as an actual scenario) shows the full extent of the pandemic crisis for the travel and tourism industry worldwide. Scenarios 2 and 3 show a profound impact on the crisis if pandemic outbreaks continue. On the world level, −1.3 US$ trillion in tourist spending will be lost under scenario 2 and −1.89 US$ trillion under scenario 3. The region most affected by the pandemic crisis will be the Asia Pacific due to its dependence on the travel and tourism industry. Policymakers and tourism practitioners can observe that scenario 1 is an affordable scenario for the travel and tourism industry. Under this scenario, the industry could recover from the crisis (regain lost income) in 15 months. However, scenarios 2 and 3 do not offer such optimistic conditions. Scenario 2 presents the resilience threshold, the point beyond which the travel and tourism industry will need massive government bailouts and incentives to recover from the crisis. Scenario 3 is the worst scenario that could take the travel and tourism industry back to the income levels of 2009 or even 1980. The third scenario would need a massive government support plan for the travel and tourism industry, similar to the one developed for the financial industry during the great recession of 2008.

Fig. 8 shows the impact of COVID-19 on investment flow in the tourism industry worldwide. Investment flow in the tourism industry will face large adverse shocks because of the negative expectations of the industry, and tourist practitioners do not have many choices to alter these conditions. Experiences from SARS (2002) and H1N1(2009) show that a recovery period in the number of tourist arrivals beyond the pandemic crisis and travel constraints lift-off last, on average, one year. Under such conditions, planning new investments in the industry is not expected. Another negative aspect is freezing investments and postponing future investments, since the recovery phase will involve price competition, not diversification of tourism supply (re-branding, innovation). Tourism practitioners should rewrite investment plans for the next two years, linking investments (if any) to price competition during the recovery phase and to product competition afterward.

Estimated potential (COVID-19) impact on capital investment in the travel and tourism industry worldwide.

As shown in Fig. 8 , the world level travel and tourism industry will face a massive decrease in the total capital investments, and total capital investments in the travel and tourism industry on the world level will drop by −362.9 US$ bn under scenario 1. Regions with the most significant decline as the one with the highest inbound arrivals and share in the GDP. The highest drop of capital investments is for the Americas (−106.4 US$ bn) and Asia Pacific (−188.5), followed by Northeast Asia (−92.9), Northern America (−83.9), and Europe (−83.4). Such a massive decline, even under the best scenario 1, will send the tourism industry back to the total capital investment levels of 2004. Scenario 2 estimates that travel and tourism industry capital investments could drop to the 1989/1990 levels. Since capital investments are essential for tourism growth, a decrease in capital investment will also result in the decline of future inbound arrivals. According to our model, capital investments on the world level will decline by 781.5 US$ bn. The decline under scenario 3 is even more significant, reaching −1.1 US$ trillion of lost capital investments in the travel and tourism industry. The tourism industry will have to abandon innovation and product development, facilitate touring visitors, experience development, and mobilize efforts to deliver consumer experience through increasing traveler confidence and reducing perceived traveling risks.

In the short run, the total capital investment decline across regions will reshape the tourism industry worldwide. The level of strength in the restructuring process will depend on the pandemic dynamics and the scenarios in place. Capital investments in the travel and tourism industry show a high level of volatility. Risk condition realization, in the form of exogenous factors (pandemic outbreaks, terrorism, environmental disasters) or endogenous factors (financial and business cycles), will result, on average, in a −15 to −20 percentage points drop in the level of capital investments in the tourism industry. The recovery period for the investments, unlike the conditions in tourist arrivals or spending, is long, lasting on average two years to return to positive figures and 8–9 years to return to pre-crisis levels. The larger the plunge in capital investments, the longer the recovery period and convergence time to pre-crisis levels.

Model results (scenarios 1–3) show that aggregate indicators in the travel and tourism industry will register a significant fall in 2020. Tourism industry competitiveness and resilience will be tested as never before and will require meaningful public and private efforts to recover from the COVID-19 pandemic outbreak.

6. Discussion

Using PSVAR on data from 1995 to 2019 and system dynamic modeling (real-time data parameters connected to COVID-19), we estimated the potential impact of the current pandemic crisis on the tourism industry worldwide. Empirical studies on pandemic outbreaks and their impact on the tourism industry are not found in the literature. The COVID-19 pandemic outbreak will have an unmatched negative impact (vast decline in inbound tourism arrivals) on the travel tourism industry worldwide, and we empirically investigated those impacts in this study. Negative shocks will be significant, not just in the short run but also in the long run, and it will take several years for the industry to recover. The summary of our empirical results on a world level, demonstrated in the various scenarios, shows that the travel and tourism industry's contribution to the GDP will decline from −4.1 US$ trillion to −12.8 US$ trillion. In addition, the total tourism industry contribution to employment will fall from −164.506 million to −514.080 million jobs, and lost inbound tourist spending will plunge from −604.8 US$ bn to −1.9 US$ trillion with a fall in capital investments of −362.9 US$ bn to −1.1 US$ trillion.

Unlike past pandemic crises with idiosyncratic shocks having dominant effects, COVID-19, because of the travel restrictions and border closures, reveals large commons shocks (globalization effect) on the domestic tourism industry. During previous pandemic crises, like SARS (2002) and H1N1(2009), the domestic tourism industry suffered from idiosyncratic (domestic) shocks. Once pandemic cases were no longer registered, the tourist industry started to return (bouncing effect)—the extent of which depended on the risk perception, risk aversion, income levels, and hysteresis ( Mao et al., 2010 ). Past studies note the high resilience of the tourism industry to shocks (WTTC, 2019), and the number of months needed to recover in the tourism sector decreased from 26 to 10 months on average from 2001 to 2018. However, this time it could be different.

Past pandemic crises operated mostly through idiosyncratic shocks' channels, exposing domestic tourism sectors to large negative shocks. Once domestic shocks disappeared (zero infection cases), inbound arrivals started to revive immediately. With the COVID-19 pandemic crisis, global effects in the form of common shocks multiply the intensity of the crisis. Thus, a country with no COVID-19 alert (idiosyncratic shocks) will not experience an immediate bounce-back effect of inbound arrivals if other countries do not withdraw the COVID-19 alert (common shock). For example, a COVID-19 alert can be lifted for the European region, but arrivals from China will not revive if the alert is not lifted for China as well. Pandemic crises such as COVID-19 show multiplier effects through both idiosyncratic and common shock channels, resulting in a much deeper crisis compared to past pandemic episodes. Past pandemic episodes were limited to idiosyncratic shocks and constrained common shocks. Now, the interaction of both idiosyncratic and common shocks is stretching the tourism industry to the limits. Another important interaction is with the financial cycles. Pandemic cycles appearing at the peak of financial cycles, as in this time, intensify the negative pandemic impacts, limiting the economic response of business and government. Capital investments and employment plunge, real wage and household income abruptly drop, resulting in a decline in aggregate consumption. In the condition of high private and public outstanding debt, both private initiative efforts in the tourism sector and the government's economic policy instruments to revive the industry are limited.

Krueger et al. (2020) show that the rational relocation of economic activities across sectors is a strong mitigation force, even though the government is not explicitly intervening. According to the findings of the Swedish Model Solution, agents need to adjust their sectoral actions independently to ensure that the economic and human costs of the COVID-19 crisis are substantially modulated without government interference.

While idiosyncratic shocks caused by pandemic episodes in the past disrupted the domestic tourism industry, the economy's aggregate consumption remained robust to a point (relying on other sectors). With COVID-19 causing global lockdowns, disrupting circular flows and economic transmission channels, both the tourism industry (idiosyncratic shock) and the rest of the economy (common shock) are under stress. It is the first case in modern times that a pandemic episode caused a global worldwide economic disruption on this scale. It starts with a crisis in the tourism sector and amplifies through financial cycles (current levels of private and public outstanding debt).

Policy must be resilient in the face of change and/or adaptive to various eventualities. In order to avoid this relatively short-term occurrence from having a long-term "scarring" impact, a major priority should be an economic policy response that supports the companies concerned. In addition, helping people who lose their income is important as well continuing to provide the needed public services. Eventually, policy makers will examine whether broader measures will be necessary to help employees who are losing their jobs or facing pay cuts ( Emerson and Johnson, 2020 ; McKee and Stuckler, 2020 ). The environmental hazards impact on tourism ( Halkos and Zisiadou, 2020 ) shows expected heavy economic losses for the most developed countries and significant deaths for the least developed countries.

7. Conclusion

Policy makers and practitioners in the tourism industry must develop a new crisis-readiness mechanism to fight the current pandemic crisis as well as future pandemic crises. To do so, they must gain empirical knowledge on the nature and actual extent of the COVID-19 crisis. For now, this has not happened, and scenarios developed by them significantly underestimate the potential effects of the COVID-19 pandemic crisis. Kirby (2020) recalls that central banks expect rapid tightening, representing the sharp fall in sovereign bond yields worldwide. Various countries are offering different economic assistance programs.

Policy makers and practitioners in the tourism industry need to gain knowledge of the impact of the pandemic crisis on the tourism industry and economy. In this study, we acquire the same knowledge by examining the historical effects of past pandemic outbreaks corrected the real-time parameters of COVD-19. A four-part economic strategy is required: (1) accept economic losses, (2) protect health, (3) support people experiencing a sudden loss of income by broadening existing security network programs, and (4) protect productive capacity and use economic production capacity to the fullest extent possible as soon as the virus has diminished ( Marron, 2020 ).

Our study demonstrates that pandemic crises have long-lasting negative effects on the tourism industry and economy. Estimated negative effects are far beyond those observed during past pandemic crises. Future pandemic crises should be dealt with promptly, and to do so, policy makers and practitioners need effective contingency plans. Our study shows that the pandemic effects of COVID-19 on the tourism industry share the effect of a common shock. A revival of the tourism industry worldwide will need cooperation rather than competition to minimize the costs of COVID-19. Mandel and Veetil (2020) estimated that global production decreased by 7% when only China locked down, but it decreased by 23% at the peak of the crisis when other countries implemented lockdown. As the shock propagates across the world economy, such immediate consequences are compounded due to buyer–seller ties. In the optimistic and unlikely scenario of an end to all lockdowns, the world economy takes about one quarter period to achieve a new balance. If partial lockdowns persist, recovery time will likely be considerably longer.

Our sample was limited to 185 countries divided across regions according to WTTC methodology. We used annual data and the PSVAR auto-regression model and system dynamics. Monthly data availability enabled the use of other time series modeling techniques, which improved empirical knowledge overall. Further studies should move in that direction and involve larger and longer time series samples to improve model accuracy and robustness. Our study is a modest contribution to the field of pandemic economics and tourism, and we hope it will encourage further research on this critical issue.

CRediT authorship contribution statement

Marinko Škare: Data curation, Conceptualization, Methodology, Software. Domingo Riberio Soriano: Supervision, Validation, Writing - review & editing. Małgorzata Porada-Rochoń: Visualization, Writing - original draft.

Acknowledgement

Comments from the Editor and three anonymous reviewers are gratefully acknowledged.

The project is financed within the framework of the program of the Minister of Science and Higher Education under the name ``Regional Excellence Initiative'' in the years 2019–2022; project number 001/RID/2018/19; the amount of financing PLN 10,684,000.00.

Biographies

M. Škare is Vice Rector for Research, arts and Cooperation, at the University of Juraj Dobrila in Pula. He was awarded the Juraj Dobrila University Prize and Istrian country (2013–2014) for the development of social sciences. He is editor-in-chief of the journal Economic Research, Taylor & Francis (Routledge group). He received a high honor degree from the Croatian parliament “National Science Award in 2014″ as recognition for exceptional research results. He serves on the editorial board of several internationally recognized journals and reviewers for WoS-ranked journals and as member of the Board of Governors of ACIEK. He is author of 140 scientific articles and majority of them in the ISI ranked journals.

Domingo Enrique Ribeiro-Soriano is Professor of Business Administration at the University of Valencia, Spain, Associate Editor of the Journal of Business Research, Elsevier, Senior editor of the European Journal of International Management, Inderscience, and Chair of the Cathedra Entrepreneurship: Being student to entrepreneur’ – Grupo Maicerías Españolas Arroz DACSA. He has published more than 100 papers in ISI ranked journals and has had a guest editing role in more than 25 issues of journals cited in the SSCI of Thomson Reuters-Clarivate. He has worked in Ernst & Young Consulting and was Director of European Community Programs.

Małgorzata Porada-Rochoń is associate Professor of Finanse at the University of Szczecin, Poland. Investator of several national and international research projects as well as author/coauthor of more than 50 publications. Expert in economic and financial evaluation of projects co-financed from EU funds.

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Cultural Relativity and Acceptance of Embryonic Stem Cell Research

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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.

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]

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.

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[36] Association for the Advancement of Blood and Biotherapies.  https://www.aabb.org/regulatory-and-advocacy/regulatory-affairs/regulatory-for-cellular-therapies/international-competent-authorities/saudi-arabia

[37] 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

[38] 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

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). Autonomy and paternalism in Shared decision‐making in a Saudi Arabian tertiary hospital: A cross‐sectional study. Developing World Bioethics , 23 (3), 260–268. https://doi.org/10.1111/dewb.12355 ; Bukhari, A. A. (2017). Universal Principles of Bioethics and Patient Rights in Saudi Arabia (Doctoral dissertation, Duquesne University). https://dsc.duq.edu/etd/124; Ladha, S., Nakshawani, S. A., Alzaidy, A., & Tarab, B. (2023, October 26). Islam and Bioethics: What We All Need to Know . Columbia University School of Professional Studies. https://sps.columbia.edu/events/islam-and-bioethics-what-we-all-need-know

[39] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). Understanding and attitudes of the Jordanian public about clinical research ethics.  Research Ethics ,  17 (2), 228-241.  https://doi.org/10.1177/1747016120966779

[40] Ababneh, M. A., Al-Azzam, S. I., Alzoubi, K., Rababa’h, A., & Al Demour, S. (2021). 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.

Mifrah Hayath

SM Candidate Harvard Medical School, MS Biotechnology Johns Hopkins University

Olivia Bowers

MS Bioethics Columbia University (Disclosure: affiliated with Voices in Bioethics)

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