AJGH Volume 15 Issue 2

AMSA Journal of Global Health Volume 15 | Issue 2 | October 2021 | Est. 2006

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Proudly sponsored by::

AJGH 2021 Volume 15 Issue 2 ADVISORY BOARD Consists of academic mentors who provide guidance for the present and future direction of AMSA's Journal of Global Health

Dr Claudia Turner Consultant paediatrician and clinician scientist with the University of Oxford and chief executive officer of Angkor Hospital for Children

Professor David Hilmers Professor in the departments of Internal Medicine and Paediatrics, the Centre for Global Initiatives, and the Centre for Space Medicine at the Baylor College of Medicine

Professor Nicodemus Tedla Professor in the school of Medical Sciences at the University of New South Wales

Dr Nick Walsh Medical doctor and public health and regional advisor for viral hepatitis at the Pan American Health Organization / World Health Organization Regional Office for the Americas

Volume 15 | Issue 2 | October 2021

PEER REVIEWERS Professor Christopher Fairley Dr Carl Lavie Dr Kelly Menzel Dr Stephen Bright A/Prof. Richard Matthews Dr Mark Hanly EDITOR-IN-CHIEF MasrurJoarder SENIOR EDITORS Pabasha Nanayakkara Christine Manuel ASSOCIATE EDITORS Shani Nguyen Stephanie Sardinha Rachel Loh Michelle Phu PROMOTIONS DIRECTORS Elisa Lie Lawrence Lin PUBLICATION DESIGNER Sharon Tu PODCAST PRODUCERS Jessica Xue Erica Longhurst Design and Layout © 2021, AJGH Australian Medical Students’ Association Ltd, 42 Macquarie Street, Barton ACT 2600 ajgh@amsa.org.au journal@globalhealth.amsa.org.au Content © 2021, The Authors Cover Design by Christine Manuel Creative Direction by Sharon Tu AJGH is the official student-run, peer-reviewed journal of AMSA Global Health.

Responsibility for article content rests with the respective authors.

Any views contained within articles are those of the authors and do not necessarily reflect the views of AJGH or the Australian Medical Students’ Association.

FAULT LINES

As we prepared to “Unmask” earlier this year, with a level of optimism enviable to the rest of the world, it was our persisting global health challenges which ended up being exposed.

Health systems struggling to accommodate for our sickest patients, corporations profiting off vulnerable people struggling to breathe, botched vaccine rollouts and endless anti-mask- anti-vax- anti-lockdown crowds, are global health challenges finally making the medical world stop and reflect.

Even though the cracks in our health system are coming to the surface, our optimism isn’t fading.

Take a deep breath and turn the pages. We hope you see the light within the fault lines.

Enjoy.

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THE AJGH TEAM

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PRIVATE SALE OF OXYGEN IN INDONESIA,THE COVID-19 HOTSPOT OF ASIA Elisa Lie

COMPLIANCE WITH SEXUALLY TRANSMITTED INFECTION SCREENING FOR PREGNANT WOMEN IN WESTERN AUSTRALIA AMONGST GENERAL PRACTITIONERS IN AN OUTER METROPOLITAN PRACTICE Isabella Ellison

PANDEMICS AMONG A PANDEMIC Co-Morbid Obesity, Depression and COVID-19 Kevin Mao, Filip Stojanovic & Ashwini Wijeweera

DO YOU DREAM OF A DECOLONISED MEDICINE? Tamarangi Keerthipala

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HEALTHY AGEING IN ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE IN TROPICAL AUSTRALIA Ellen Forster

PSYCHEDELICS AS MEDICINE A paradigm shift in psychiatry?

Dilnoor Kaur Hargun

HOW DOES A HEALTH PROFESSIONAL'S RIGHT TO CONSCIENTIOUSLY OBJECT DIFFER BETWEEN AUSTRALIA AND SWEDEN? Jasmine Davis

AUSTRALIA'S VACCINE ROLLOUT ON THE WORLDSTAGE Isabella Vuong

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Private Sale of

Oxygen in

Indonesia, the

COVID-19

hotspot of Asia

Elisa Lie

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With COVID-19 cases running rampant in the most populous country of Southeast Asia, overwhelming their health services, desperate patients and opportunistic salesmen look to the private sale of oxygen.

Currently, laws around the reselling of oxygen at a higher price or hoarding of oxygen tanks at home are vague and too difficult for the already overworked government to regulate.

Questions of ethics and morals loom for those who look from the outside, but fear of inevitable infection and a desperate need for oxygen control those in the epicentre of Indonesia.

Defining the ‘need’ for oxygen is complicated and multi-faceted.

Situation at hand At the time of writing, there have been 3.9 million confirmed cases of COVID-19 in Indonesia alone, with a peak of 56,700 new cases a day in July.[1] This figure is thought to be under-reported, partially due to the unreliable rapid antigen tests commonly used in Indonesia.[2] Additionally, while high traffic to and from rural areas of the country facilitates transmission of the highly infectious virus, rural communities seldom receive healthcare, risking under-detection of COVID-19 cases and under-reporting of attributable 6

deaths.[3] According to the government, more than 120,000 Indonesian lives have been lost to COVID-19, with a current mortality rate of 3.1%.[1] However, these figures have the same issue of unreliability. LaporCOVID-19, an independent website reporting on Indonesia’s pandemic crisis found that the sum of the individual death records of several provinces was higher than what was published by the federal government.[4]

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Indonesia’s healthcare system is overwhelmed. There are insufficient beds for the sick, and hospitals have resorted to treating patients in tents outside their building. Hospitals are asking for volunteer doctors and nurses as many healthcare workers have fallen ill from COVID-19.

Patients are dying before they leave the emergency department. There are simply not enough space, doctors, oxygen, or drugs in Indonesia.[5] Indonesia’s oxygen COVID-19 affects the airways, with symptoms ranging from a mild cough to pneumonia that may progress to acute respiratory distress syndrome or even death. Approximately 14% of those infected with COVID-19 experience severe symptoms and record oxygen saturations of 93%, requiring oxygen therapy.[6]

≤

With an extreme number of COVID19 cases, oxygen stocks in Indonesia have quickly depleted, creating a shortage.[5] A hospital reported 63

patient deaths that were attributable to lack of oxygen access.[7] To combat this, government officials are encouraging the gas industry to produce more medical oxygen, but it is unable to cope with the excessive demand.[7] At the peak of Indonesia’s COVID-19 crisis, approximately 2 million cubic meters of oxygen, or 290 thousand cylinders, was needed in 1 day.[8] Prices are now set to 3 or 4 times higher than normal.[5] Indonesia’s minister of health, Dr Nadia Tarmizi, addressed and condemned private oxygen sales as a contributing factor to decreased stock.

[7] The spokesperson of the Maritime Affairs and Investment Coordinating Ministry has also criticised those hoarding and reselling oxygen, calling the act “a crime against humanity”.[9] Other than these statements, no laws have been implemented to regulate this activity. A law professor from the University of Indonesia argued that a law finalised in 2014, encompassing all trade, could be used to regulate the private sale of oxygen.[10] It threatens up to 12 years imprisonment and a fine of 5 billion rupiah (approximately 480,000 Australian dollars) for unlawful or unethical trade.[10] However, it does not dictate how many oxygen cylinders in a person’s possession are considered as ‘hoarding’ and does not have a guide on how to price oxygen. Hence, there is significant difficulty in regulating private oxygen sales.

Opportunistic salesmen use online shopping applications akin to Amazon 7

Figure 1 – On the left, six listings of oxygen tanks ranging from ~98 to 260 AUD on an online shopping application. On the right, a message in Indonesian detailing “selling oxygen tank … to stock up and be cautious in the current condition, please order,” and a picture of one tank with the price of 450 AUD. Screenshots taken on 19 August 2021.

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or Facebook Marketplace to sell oxygen at an exorbitant price. Some have even resorted to sending messages to acquaintances to find buyers.

CNN has reported that oxygen suppliers would have sold an oxygen tank for approximately 50 AUD in Indonesia prior to the COVID-19 crises in July. This is much lower than current prices.[11] Currently, 33 oxygen tank sellers who inflated prices have been

apprehended by Indonesia’s police force.[12] Two of the criminals admitted to profiting approximately 30,000 AUD.[13] There are challenges to enforcing stringent rules on consumers of private oxygen sales.

When purchasing an oxygen tank from online shopping applications, a prescription is not required. In fact, in many oxygen tank listings, sellers advertise a fast and ‘no questions asked’ service. Therefore, oxygen tanks are highly accessible once 8

buyers find a seller with enough stock.

These listings are not outlawed or condemned by online shopping sites.

With hospitals overwhelmed and not receiving any more patients, those affected by COVID-19 turn to these accessible oxygen tanks to save themselves or their sick family members.[11] Additionally, those with pre-existing medical conditions who need supplementary oxygen need an accessible resource to buy oxygen cylinders.

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The ethics of private oxygen sale When discussing the ethics of Indonesia’s current private oxygen sale situation, many aspects need to be considered.

The benefits of having access to oxygen is indisputable. Without supplementary oxygen, those with severe COVID-19 symptoms may progress to the potentially fatal acute respiratory distress syndrome.[6] Beneficence, according to Beauchamp and Childress, includes a requirement to help others “maximise possible benefits and minimise possible harms”.[14] In public health, it may translate to a positive obligation for the government to make medical oxygen accessible to the public.[14] Regarding non-maleficence, as oxygen is accessible without a prescription, patients may subject themselves to side effects of excessive or inappropriate oxygen use. Studies

have shown that high concentrations of inspired oxygen may cause lung injuries such as tracheobronchitis and diffuse alveolar damage.[16] By allowing the public access to supplementary oxygen without the need for doctors’ advice, the government may have failed to act non-maleficently. However, this rare risk is balanced by the benefits of supplementary oxygen for COVID-19 patients where this intervention could be lifesaving.[14] Considering the side effects of oxygen and the new, ever evolving nature of COVID-19, it can be argued many members of the public are not acting autonomously. To act autonomously, a person needs to fulfil several criteria: act intentionally, with understanding, without external coercion, and without internal coercion. This means patients need to be able to intelligibly tell others about their decision, act within their character traits, and be able to consider other alternatives to the therapy.[14,17] Though otherwise acting autonomously, those purchasing oxygen cylinders without knowledge of the side effects are not adequately informed, and thus, do not have enough understanding to make an autonomous decision.

The issue of justice is the most pertinent. To view the current situation as ethically just, would be to view it via the libertarian theory of distributive justice. This theory sees healthcare services as a market good that should be bought and sold by those who can afford it.[15] Therefore, 9

those who can afford oxygen have justly acquired it. Many may argue that this is unethical as those disadvantaged socially may not be able to access the therapy. An egalitarian view of distributive justice would support an ideal, equitable distribution of the scarce resource which is oxygen.[15] The government hopes for an egalitarian approach in distributing oxygen. It has expressed hopes that all oxygen be left for medical use where it is needed most, while condemning the buying and reselling of oxygen cylinders.[7,9] However, the actualisation of this concept is complicated by defining ‘need’.

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Exploring the concept of need Need is defined by the Merriam Webster Dictionary as “a physiological or psychological requirement for the well-being of an organism”.[18] Those of ill-health very clearly present their genuine need of medical treatment. Severely sick COVID-19 patients, in hospitals or at home, should get access to lifesaving oxygen treatment first in an egalitarian theory. However, in prioritising which group of sick patients to receive oxygen, those in hospitals would have a higher chance of recovering as clinicians are prescribing the therapy, thus this would also be just in a utilitarian approach. A utilitarian approach views a decision as just depending on how successful the likely consequences are.[15]

Those suffering from mild to moderate symptoms of COVID-19 may also feel genuine physiological need for oxygen regardless of their actual oxygen saturation. Anxiety over a potential lack of oxygen could present itself in feeling short of breath, a symptom of low oxygen saturation.[18] This is due to conversion and somatic symptom disorder, a condition where psychological stress is expressed physically.[20] Especially with no access to input from a clinician, this could exacerbate patients’ psychosomatic symptoms.

Additionally, some feel the need to purchase oxygen out of a fear of inevitability. With more than 50,000 new cases a day, they may feel the need to prepare for an ‘inevitable’ infection, especially when they considering elderly family members or precious contacts with extensive comorbidities.

However, in a situation where oxygen is so scarce and the death toll reaches 120,000 it can be argued that prioritising these ‘false’, nonphysiological needs before those who are severely sick is unethical.

With the medical gas business being encouraged to prioritise medical oxygen production and COVID-19 cases starting to decrease, it is hopeful that everyone who needs supplementary oxygen can gain access to it. In the meantime, reducing fear, anxiety and misinformation could potentially help the Indonesian 10

community to prioritise those most vulnerable and needing oxygen.

About the Author Elisa Lie is an Indonesian medical student at Monash University with a passion for equitable health access in the world. She hopes to be a holistic doctor who advocates for their patients.

Correspondence elisa.ramlie@gmail.com Acknowledgements Thank you to all health care workers especially those in Indonesia, currently bravely treating patients.

Special appreciation to Dr Ignasia Irina Setyawati for providing insight to the current situation of Indonesia's frontline healthcare workers which guided some of the article's ethical considerations. Thank you as well to Bradley Denney for the support, help, and encouragement in writing this piece. A special acknowledgement to Rachel Loh for her extraordinary work as an editor who made this article a reality.

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Conflicts of Interest None declared References 1.

Indonesian National Agency for Disaster Countermeasure. Map of COVID-19 Coverage [Internet]. 2021 [cited 2021 Aug 18]. Available from: https://covid19.go.id/peta-sebarancovid19 2.

Lindsey T, Walden M. Indonesia may be on the cusp of major COVID

spike. Unlike its neighbours, though, there is no lockdown yet [Internet].

The Conversation [cited 2021 Aug 18].

Available from: https://theconversation.com/indonesi a-may-be-on-the-cusp-of-a-majorcovid-spike-unlike-its-neighboursthough-there-is-no-lockdown-yet158955 3.

Arisanti N, Pakasi T, Syarhan S. Rural Health Response and Community Preparedness for the COVID-19 Pandemic.

RPCPE [Internet]. 2020 Apr [cited 2021 Aug 19];3(3):8-10.

Available from: https://jurnal.ugm.ac.id/rpcpe/article/ view/59717/30305 4.

Lapor COVID-19. Lapor COVID19 [Internet].

Indonesia: Lapor COVID-19; 2021 [cited 2021 Aug 19].

Available from: https://laporcovid19.org/ 5. Long C. Hospitals are overflowing as second COVID-19 wave worsens in Indonesia, yet to reach its peak [Internet]. Project Hope [cited 2021 Aug 19].

Available from: https://reliefweb.int/report/indonesia/ hospitals-are-overflowing-secondcovid-19-wave-worsens-indonesiayet-reach-its-peak 6.

National Institutes of Health.

Coronavirus Disease 2019 (COVID-19) Treatment Guidelines [Internet]. 2021 Aug [cited 2021 Aug 19]. Available at: https://files.covid19treatmentguidelin es.nih.gov/guidelines/covid19treatme ntguidelines.pdf 7.

Indonesia faces oxygen crisis amid worsening Covid surge [Internet]. BBC News [cited 2021 Aug 19].

Available from: https://www.bbc.com/news/world11

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asia-57717144 8. Market Dynamics. COVID-19 Oxygen Needs Tracker [Internet].

PATH [cited 2021 Aug 20]. Available from: https://www.path.org/programs/mark et-dynamics/covid-19-oxygen-needstracker/ 9. Bhwana P, Antara. Hoarding of Medicines, Oxygen is Crime Against Humanity, says Govt [Internet].

Tempo [cited 2021 Aug 20]. Available from: https://en.tempo.co/read/1480199/ho arding-of-medicines-oxygen-iscrime-against-humanity-says-govt 10.

Syahputra, R. Law Consequences for Oxygen Hoarders in the Pandemic [Internet]. University of Indonesia [cited 2021 Aug 20].

Available from: https://www.ui.ac.id/konsekuensihukum-bagi-penimbun-oksigen-dimasa-pandemi/ 11.

Reuters. Indonesia’s capital sees oxygen prices leap as Red Cross warns of Covid ‘catastrophe’ [Internet]. CNN World; 2021 [updated Jun 30; cited 2021 Aug 20]. Available from: https://edition.cnn.com/2021/06/30/ asia/indonesia-oxygen-prices-covidintl-hnk/index.html 12.

Maharani T. Police: There are 33 Cases of Covid-19 and Oxygen Hoarding Cases [Internet]. Jakarta: KOMPAS.com [cited 2021 Aug 20].

Available from: https://nasional.kompas.com/read/20 21/07/28/16055591/polri-ada-33kasus-penimbunan-obat-covid-19dan-oksigen 13. Ihsanuddin. Two Oxygen

Cylinder Sellers Arrested for Raising Prices, Earns Profits of up to IDR 300 million [Internet].

Jakarta: KOMPAS.com [cited 2021 Aug 20].

Available from: https://megapolitan.kompas.com/read /2021/07/15/18134641/dua-penjualtabung-oksigen-ditangkap-karenanaikan-harga-raup-untung 14.

Beauchamp T. Standing on Principles: Collected Essays Oxford University Press. USA: Oxford; 2010.

15.

Lamont J, Favor C. Distributive Justice. The Stanford Encyclopedia of Philosophy [Winter 2017 Edition].

Stanford; 2017 [cited 2021 Aug 20].

Available from: https://plato.stanford.edu/entries/justi ce-distributive/ 16.

Malhotra A, Schwartzstein R. Pulmonary consequences of supplemental oxygen. In: Manaker S, Finlay G, editors; UpToDate.

[Internet]. UpToDate Inc. [updated 2020 Mar 05; cited 2021 Aug 20].

Available from: https://www.uptodate.com/contents/p ulmonary-consequences-ofsupplemental-oxygen? search=side%20effects%20of%20oxyge n&source=search_result&selectedTitle =2~150&usage_type=default&display_ rank=2#references 17.

Beauchamp T. Informed Consent: Its History, Meaning, and Present Challenges.

Cambridge Quarterly of Healthcare Ethics; 2011.

Chapter 20, From Informed Consent to No Consent; p. 515-523.

18.

Merriam Webster Dictionary.

Need [Internet]. Merriam-Webster Dictionary [cited 2021 Aug 20].

Available from: https://www.merriam12

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webster.com/dictionary/need 19. Stratton S. Acute respiratory failure. In: BMJ Best Practice [Internet]. London: BMJ Publishing Group Ltd. [updated 2021 Aug; cited 2021 Aug 20]. Available from: https://bestpractice-bmjcom.ap1.proxy.openathens.net/topics /en-gb/853 20. Stonnington C, Driver-Dunckley E, Noe K, Locke D. Conversion and somatic symptom disorders. In: BMJ Best Practice [Internet]. London: BMJ Publishing Group Ltd. [updated 2021 Jan; cited 2021 Aug 20]. Available from: https://bestpractice-bmjcom.ap1.proxy.openathens.net/topics /en-gb/989

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Compliance with Sexually

Transmitted Infection Screening

for Pregnant Women in Western

Australia Amongst General

Practitioners in an Outer

Metropolitan Practice

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Isabella Ellison

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Abstract Background: Sexually transmitted infections (STIs) during pregnancy can have adverse health outcomes for both the mother and the unborn foetus. It is important to ensure health practitioners are adhering to the recommended guidelines for screening protocols during the antenatal period.

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Aim: To identify the proportion of pregnant women screened for STIs correctly in an outer metropolitan general practice in Western Australia, and to ensure appropriate testing is conducted to improve outcomes during the antenatal period.

Methods: 55 pregnant women visiting an outer metropolitan general practice were analysed to gauge compliance with screening for sexually transmitted infections according to the Silver Book Guidelines during antenatal care. The recommended testing for all WA women includes chlamydia, gonorrhea, syphilis, hepatitis B and C and human immunodeficiency virus (HIV) for the initial antenatal visit. If patients were identified as ‘medium’ or ‘high’ risk as per the Silver Book Guidelines, further testing was required for syphilis and HIV at weeks 28, 36, at delivery and the postpartum period. Specifically, the focus of this audit was to review STI screening guidelines at 28 weeks.

hepatitis B, hepatitis C and HIV during their first antenatal visit. One patient was identified as ‘medium’ risk and was not screened correctly according to the guidelines, resulting in 0% success for the 28 week visit.

Conclusions: Compliance of general practitioners at this practice with the Silver Book Guidelines is high for antenatal screening. However, due to the small sample size, repeating the audit with a larger population will improve generalisability and therefore, recommendations for the evolving guidelines for specific sexually transmitted infections.

Learning points: 1. Identifying clinical guidelines which dictate clinical practice 2. Critically reviewing current practice against recommended guidelines 3. Identifying ways to implement change of clinical practice if required

Results: 87% of patients were correctly screened for chlamydia, gonorrhoea and syphilis, and 95% of patients for 15

Introduction Sexually transmitted infections (STIs) occurring during pregnancy can have detrimental effects on both the foetus and the mother.[1,2] Guidelines for STI screening during pregnancy vary both nationally and globally, and are constantly being adapted in accordance with infection outbreaks.

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This audit was conducted at an outer metropolitan general practice in Perth to assess compliance with state government recommendations for STI screening in the antenatal period.

It also aimed to clarify if individuals considered ‘medium’ or ‘high’ risk are identified correctly in accordance with the Silver Book Guidelines, and if they are followed up for repeat testing at 28 weeks, 36 weeks, delivery and post-partum period if required.

By reviewing this general practice’s implementation of the guidelines, real world data of the guidelines’ utility is shown. This will shed light on gaps in implementation of the guidelines and how to bridge them, hopefully preventing missing positive STI results and reducing adverse maternal and fetal health outcomes.

Sexually transmitted infections are a significant issue in Western Australia.

Chlamydia, with 11,580 reported cases in 2019, is the most common notifiable STI in Western Australia.[3] Gonorrhoea notifications reached a 10 year high with 3,927 cases in 2019, being the second most commonly reported STI in Western Australia.[3] Syphilis also reached a 10 year high in Western Australia in 2019, returning

565 positive cases, with the highest incidence in the Kimberly region.[3] From 2010 to 2019, there were five congenital syphilis reports.[3] These congenital syphilis cases could have been prevented had recommended guidelines been followed correctly, appropriate tests ordered by general practitioners and followed through by patients. Currently there is a Perth metropolitan syphilis outbreak,[4] meaning this audit was crucial in determining compliance with STI testing in pregnant women. Women of childbearing age increased by almost sixfold between 2015 and 2019, with 8 notifications of syphilis in pregnant women in the first 6 months of 2020.[4] With STIs rising, there is a need to re-evaluate current testing guidelines to ensure people, including pregnant females, are tested and treated promptly, with appropriate follow-up testing.

The Silver Book Guidelines (Figure 1), recommends all pregnant females undergo chlamydia and gonorrhoea testing (either by PCR swabs or by self-obtained low vaginal swab; SOLVs), and serology for hepatitis B and C, syphilis and HIV. If they are identified as ‘medium’ or ‘high’ risk, then subsequent testing is recommended at 28 weeks, 36 weeks and at delivery. Additional testing is also recommended for those considered ‘high risk’ at 6 weeks following delivery.

The Silver Book Guidelines are continually updated by the Western Australian Department of Health. It is 16

Figure 1: The Silver Book Guidelines for STI screening in pregnant and post-partum women. [10]

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altered when national and international peer-reviewed literature is released, in conjunction with expert opinion from an advisory group, making it the most up-to-date evidence-based practice recommendations.

Methods Case Selection All first trimester pregnant women attending this general practice and undergoing first trimester screening (week 1 to the end of week 12) between 1 January 2019 and 1 October 2020 were selected. These included ‘one-off visits’ and ‘active patients’.

The timeframe was chosen to allow time for follow-up testing at 28 weeks if required. To ensure enough patients were included in the search for both the pilot and the final data analysis, the search included 2019.

20 cases (10% of all eligible patients) were used for the pilot study and 55 patients (28% of all eligible patients) were selected for the final analysis. As this audit was conducted at a primary care location, the numbers were dictated by feasibility, as requested by the supervisor.

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Standards The standards to which the data analysis was compared against were the Silver Book Guidelines, published and recommended by the Government of Western Australia’s Department of Health.[10] Standard 1: 100% of pregnant women attending for antenatal care during the first trimester have the following tests ordered at their booking visit (week 1 to the end of week 12 of the pregnancy): Chlamydia and gonorrhoea (SOLVS or PCR swabs) Hepatitis B and C serology Syphilis serology HIV serology As per the Silver Book Guidelines.

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Standard 2: If patients during this booking visit are identified as medium or high risk, 100% of patients have the following tests ordered at the 28 week visit: Syphilis serology HIV serology As per the Silver Book Guidelines.

Data Collection Collection was conducted by myself, in conjunction with the practice manager.

The antenatal search returned a list of 197 patients. This list of patients was put in alphabetical order by the practice manager to ensure selection bias was removed when selecting patients for the analysis. Patients in this list who did not attend the practice for their first antenatal appointment were

excluded. The first 20 patients were selected for the pilot study, and the subsequent 55 were chosen for the final audit data analysis to remove selection bias.

Medical records of each patient were systematically reviewed by the primary author. Appointments under the antenatal category were then identified and notes were examined to ascertain which tests were ordered.

The ‘investigations’ section of the general practice software was then cross checked to identify if the investigations had been completed and what the results were.

Inconsistencies from the standard, including tests not being ordered, were documented. A threshold of 100% was used for standard 1. If a patient was ‘medium’ or ‘high’ risk, the patient’s medical records were viewed to ensure the appropriate follow-up testing occurred at the 28 week visit. Once again, any test not ordered was documented with a threshold of 100% being used for standard 2.

Data, which included antenatal care investigations at the first trimester visit, as well as the 28 week visit if applicable, was collected manually and entered into an Excel spreadsheet with unique patient identifier codes to ensure confidentiality for analysis.

This was stored on a password protected computer separate to the general practice computer containing patient information.

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Confidentiality and Consent Confidentiality was maintained by allocating each patient a unique identifier code. This was on a separate spreadsheet from the data analysis Excel spreadsheet. The spreadsheet with the patient details will be kept on a locked computer at the general practice.

The data analysis spreadsheet will not contain any identifiable information throughout this audit, maintaining privacy.

RACGP standards state that routine clinical audits are not considered research, and therefore do not require ethics approval.[11]

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Stakeholder Consultation The principal stakeholder group for this audit were the general practitioners at the general practice where the audit was conducted. All practitioners at this practice were audited. Once the audit was complete, a clinical meeting was organised with the clinical practitioners and the practice managers to discuss the results of the audit.

Barriers that may limit the implementation of changes include education surrounding the specific guidelines.

With outbreaks of infections, the criteria for testing can alter slightly. Being unaware of the changes can mean nonadherence to the guidelines. When patients are referred to tertiary centres for the final stages of the pregnancy, it can also be difficult to ensure follow up tests are completed if appropriate.

This would also be a barrier for implementing the potential changes

from the audit.

Results Study sample The pilot study included 20 patients, with a further 55 patients being included in the final study. The average age of patients in the final study was 31.8 years. 49 people reported their ethnicity as Australian, 2 New Zealander, 2 English, 1 Korean and 1 Indian.

Standard 1 Fifty-five pregnant women attending this general practice were identified for data analysis. Of those 55, 7 were incorrectly screened for chlamydia, gonorrhoea and syphilis respectively.

Therefore, 87% of patients were correctly screened when following the Silver Book Guidelines. Three patients were incorrectly screened for hepatitis B, hepatitis C and HIV, meaning 95% were correctly screened, as seen in Figure 2. Compliance with standard 1 was therefore 91%.

Incorrectly screened means that the test was not ordered for the patient when it should have been completed.

Standard 2 There were no patients who were identified as ‘high’ risk patients, and 1 patient was identified as being ‘medium’ risk as per the Silver Book Guidelines. This patient was not followed up at the 28 week visit to repeat the appropriate STI screening, meaning 0% of patients who were considered ‘medium’ or ‘high’ risk were correctly followed up according to the guidelines.

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Figure 2: Graph showing percentage of patients correctly screened for STIs during pregnancy at the first antenatal visit, and at follow-up at 28 weeks if identified as ‘medium’ or ‘high’ risk.

Discussion This analysis of data from an outer metropolitan general practice in Western Australia examined the rates of compliance with sexually transmitted infection screening in pregnant women when compared to the Silver Book Guidelines. The analysis, which included 55 patients, showed that compliance with screening was 91% for chlamydia, gonorrhoea, syphilis, hepatitis B, hepatitis C and HIV during the antenatal visit. Compliance with follow-up testing at 28 weeks if patients were considered ‘medium’ or ‘high’ risk in accordance to the guidelines was 0%.

When analysing this data there were a few considerations. One patient in

particular was not screened for any of the antenatal screening tests. She was, however, noted to be an in vitro fertilisation (IVF) pregnancy which may mean all her screening was completed by the fertility clinic.

Another consideration was the uncertainty around ordering the screening tests and patients following through with the bloods and swabs.

Although the clinicians would be following the guidelines, there would still be a risk of patients not following through with the investigations and therefore, a problem with the screening guidelines. A change that could be implemented would be making it mandatory to take the bloods and swabs at the time of the antenatal visits. However, when 20

reviewing the medical notes for the patients, 32 of the 55 patients stated “bloods and swabs were obtained”.

The remaining patient notes stated “request printed”, suggesting these patients may not have followed through with the tests. After further review of the data, all patients did conduct the tests. When considering re-auditing, an additional element of this study could be looking at tests conducted at the time of the consult compared to tests requested, of which completion is unclear.

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The disjointed nature of antenatal care is also another consideration regarding follow-up of results and testing. Of the 55 patients, 36 were referred to tertiary care, 1 to a private obstetrician and 1 moved overseas.

The others did not contain any notes regarding their antenatal care leading up to their deliveries. However, if these patients were considered ‘medium’ or ‘high’ risk at their first antenatal visit and were followed-up elsewhere, there would be missing data and therefore, inaccurate data collection and analysis.

With regards to standard 2, the small sample size meant producing meaningful analysis was not possible.

Ideally, there would be a larger sample size to increase the statistical power of the analysis. This is one of the main limitations to this audit as the small sample size limits the generalisability of this data analysis.

Repeating this audit with a larger sample size would allow its conclusions to be generalised to the

healthcare system so necessary changes to STI screening for pregnant females can be identified. Auditing general practices enrolled in shared care could help identify the challenges practitioners face in effectively implementing guidelines in that setting.

When auditing this general practice, the standard was set for the practice to reach 100% compliance with the Silver Book Guidelines. Although 100% was not met for standard 1 and 2, overall, data analysis showed strong adherence to screening for standard one. Standard 2’s sample size of 1 again limited the power and therefore, generalisability of the results.

The implications of this audit include supporting adherence to the Silver Book Guidelines, as well as suggesting changes to the guidelines. Local recommendations to the general practice include attending educational workshops, registrar teaching and altering the general practice medical record software to include a drop-down list of investigations listed in the guidelines to ensure user error is removed.

Broader recommendations would be to the Western Australian Health Department to suggest that swabs and samples should be obtained during the general practice antenatal consult, instead of assuming patients will complete the tests themselves.

After discussing these results with the stakeholders, they were pleased with 21

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the adherence to the standard and were open to the recommendations.

They considered adding the list of criteria that places patients into ‘medium’ and ‘high’ risk groups as questions into the antenatal screening guide to remind all practitioners to review the patient’s medical history and to ensure follow-up testing when required. They also agreed to re-audit next year with a larger sample size for improved analysis. Future research would not only increase the sample size to further explore compliance with follow-up testing, but also include general practices across Australia to analyse compliance in different areas. This would be particularly useful in the Goldfields, Kimberly and Pilbara regions as pregnant women in these locations are considered ‘high’ risk.

Conclusion Sexually transmitted infections in pregnancy can have adverse health effects on both the mother and baby.

We must ensure our screening guidelines are appropriate and specific for identifying the STIs which our population is at risk of acquiring. This would allow STIs to be detected early and treated to prevent further transmission. This audit proves high compliance with initial antenatal screening for chlamydia, gonorrhoea, syphilis, hepatitis B and C and HIV. Reauditing with a larger sample size will help in increasing the strength of the study and identifying potential changes needed to enforce the guidelines.

Primary author Isabella Ellison Doctor of Medicine, The University of Notre Dame Fremantle, Australia 4 year degree, currently in final yearstudent Bachelor of Science (Honors) (Medicine), Flinders University, Australia 1 year degree- student Bachelor of Health Sciences, The University of Adelaide, Australia 3 year degree- student About the Author Isabella is a final year medical student studying at The University of Notre Dame, Fremantle. As part of her studies she has completed an audit looking at improving screening of sexually transmitted infections for pregnant women. She has a passion for preventative medicine, particularly for maternal-foetal health.

Contribution: study design, data collection, data analysis, writing of manuscript Secondary author Dr. Ramya Raman FRACGP, MBBS, Dip Child Health, BSS (Psych) About the Author Ramya is a GP in Perth with special interest in women’s and children’s health. She is a medical educator at WAGPET and Senior Lecturer at the School of Medicine, University of Notre Dame, Fremantle. Ramya is deputy Chair of RACGP WA and the Medical Lead for RACGP WA 22

Education.

Contribution: study design, editing manuscript Correspondence Isabella Ellison 2/15 Kingston Avenue West Perth, Western Australia, Australia 6005 Ellison_isabella@hotmail.com 0408815309

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Acknowledgments I want to thank the entire team at Skye Medical for ensuring this audit went as smoothly as possible. They made the data collection uncomplicated and were always happy to help when I struggled with the program. Specifically, thank you to Dr. Ramya Raman for being an incredibly supportive supervisor. She was always available even with a ridiculously busy schedule. Thank you also for encouraging me to publish as without you, this wouldn’t have been written.

I would also like to thank my clinical audit assessor Dr. Lauren Bloomfield.

Dr. Bloomfield is a Senior Lecturer for the School of Medicine at The University of Notre Dame Australia.

She not only provided me with extremely valuable feedback on my audit proposal, but she clarified many areas of the audit process and aided me in altering my audit design to ensure it was both a feasible and successful project.

Conflicts of Interest The authors have no conflicts of interest to declare.

Submission Type: Original research article Submission title: Compliance with sexually transmitted infection screening for pregnant women in Western Australia amongst general practitioners in an outer metropolitan practice Article summary This article is a summary of a recent audit, viewing the screening for sexually transmitted infections for pregnant women in an outer metropolitan general practice.

Keywords Sexually transmitted screening, pregnancy

infections,

Number of figures: 2 Word count: 2387 (excluding title page, abstract, references, figures and tables) References 1. Fontenot HB, George ER. Sexually transmitted infections in pregnancy.

Nurs Womens Health. 2014;18(1):6772.

2. Workowski KA, Bolan GA, Centers for Disease C, Prevention. Sexually transmitted diseases treatment guidelines, 2015. MMWR Recomm Rep. 2015;64(RR-03):1-137.

3. Department of Health WA. The Epidemiology of Notifiable Sexually Transmitted Infections and BloodBorne Viruses in Western Australia 2019. Western Australia: Department of Health, Western Australia; 2020.

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4. Department of Health WA. Metropolitan Perth syphilis outbreak alert. In: Department of Health WA, editor. Perth, Western Australia: Government of Western Australia Department of Health; 2020.

5. Blatt AJ, Lieberman JM, Hoover DR, Kaufman HW. Chlamydial and gonococcal testing during pregnancy in the United States. Am J Obstet Gynecol. 2012;207(1):55 e1-8.

6. Wynn A, Bristow CC, Cristillo AD, Murphy SM, van den Broek N, Muzny C, et al. Sexually Transmitted Infections in Pregnancy and Reproductive Health: Proceedings of the STAR Sexually Transmitted Infection Clinical Trial Group Programmatic Meeting. Sex Transm Dis. 2020;47(1):5-11.

7. Mullick S, Watson-Jones D, Beksinska M, Mabey D. Sexually transmitted infections in pregnancy: prevalence, impact on pregnancy outcomes, and approach to treatment in developing countries. Sex Transm Infect. 2005;81(4):294-302.

8. Ooi C, Dayan L. STIs in pregnancy.

An update for GPs. Aust Fam Physician. 2004;33(9):723-6.

9. RACGP. Guidelines for preventive activities in general practice, 9th edition. 9th ed. East Melbourne, Victoria: The Royal Australian College of General Practitioners; 2018.

10. Department of Health WA. The Silverbook Guidelines.

In: Department of Health WA, editor.

Perth, Western Australia: Sexual Health and Blood-borne Virus Program; 2020.

11. Liaw ST, Tam CW. Research ethics and approval process: A guide for new GP researchers. Aust Fam Physician. 2015;44(6):419-22.

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PANDEMICS AMONG A PANDEMIC:

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Co-morbid obesity, depression & COVID-19

Kevin Mao, Filip Stojanovic

& Ashwini Wijeweera

25

Graphic by Sharon Tu

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Introduction As our world progresses through an era of rapid technological advancement, much of our dependence on completing daily tasks (that our ancestors once did manually) falls upon brainless machinery. From commuting to school/workplace to washing dishes, we no longer have to use our hands or legs to get the job done. Similarly, we no longer depend on homegrown sources of food for our consumption.

With the availability of more convenient food items there is a greater tendency to consume foods that contain more calories than nutrients. This evolution in lifestyle and human behaviour is what has inevitably laid the foundation for the worldwide increase in the prevalence of many non- communicable diseases (NCDs) such as cardiovascular disease, obesity and mental health conditions.

Given this significant correlation between human behaviour and the onset and progression of NCDs, it is imperative that public health professionals and policy makers design effective and multifaceted interventions to prevent the escalation of this NCD pandemic whilst also establishing reliable systems that can measure and followup on the effectiveness of the implemented solutions. Hence, the first step towards designing solutions that address this involves the consideration and analysis of the descriptive epidemiology of the diseases at hand.

As per the World Health Statistics

2020[1], in 2016, NCDs accounted for 71% of all global deaths, and 85% of the 15 million premature deaths (deaths between ages 30 and 70). The four main causes of death were cardiovascular disease (17.9 million deaths), cancer (9.0 million deaths), chronic respiratory diseases (3.8 million deaths), and diabetes (1.6 million deaths). Whilst these statistics go on to support the fact that NCDs are the leading cause of death in the world, they also shed light on some of the major risk factors such as obesity, the use of harmful substances such as alcohol and tobacco and air pollution that contribute to the prevalence of these deadly diseases.

From 1999–2000 through to 2017– 2018, the prevalence of obesity increased from 30.5% to 42.4%, and the prevalence of severe obesity increased from 4.7% to 9.2%. In addition to this, it has also been reported that since 2000, the global age standardised prevalence of obesity among adults (18 years and older) has increased by 1.5 times, and the prevalence in children (5–19 years) is seen to have more than doubled (from 2.9% to 6.8%) in 2016[1].

Obesity is a major health concern but unfortunately, many fail to understand this because the effects of obesity are not instantaneous.

Before the COVID-19 pandemic gained traction, the world was already in the middle of an obesity pandemic that is further exacerbated by the negative effects of pandemic control[2].

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Numerous studies have shown that obesity is an independent risk factor for severe illness and death from COVID-19[2-5].

In a recent population cohort study, OpenSAFELY, there was a clear correlation between excess weight and the severity and risk of dying of COVID-19[6]. In reality, the effects of obesity manifests over years, in that the harm it brings about has an additive effect on the body causing the risks of developing complications to increase progressively. In addition to the many ‘visible’ complications that obesity may beget, there also exists a perturbing bilateral relationship between obesity and depression. For instance, a study conducted by Haregu et.al (2020)[7] on the correlation and synergistic association with NCDs among Australian men found that men with comorbid depression and obesity, had 7.6 times the risk of diabetes, 6.7 times the risk of hypertension and 4.3 times the risk of high cholesterol. The lingering effects of comorbid depression on one’s life is further demonstrated through a systematic review that was carried out by O'Neill et.al[8] in which they concluded that depression is a major predictor of work outcomes following a myocardial infarction. Not only does this elucidate the strong relationship between NCDs and depression but also goes on to highlight the fact that the ramifications of this correlation on global health systems are significant and simply cannot be ignored.

Almost half Australian inhabitants, aged 16 - 85 years experience a mental illness at some point in their lifetime[11], it is crucial for effective psychological support to be put into place. This silent disease is rapidly gaining ground to be one of the most prevalent NCDs in today’s society[12].

The COVID-19 crisis has placed the world under lockdown. It has altered our regular life regimes, making things that we took for granted in the past appear to be a luxury. The link between lockdown and NCDs exists in the fact that lockdown increases the risk factors which lead to their development. This means that while we are staying safe from the pandemic, we have never been more at risk of developing obesity, depression and cardiovascular diseases.

Additionally, multi-morbidities bring about additional pressures on health systems as it taps into multiple aspects of an individual’s life and as mentioned previously, global health systems are required to carry out comprehensive interventions to help combat it. To do this, careful consideration of how the disease is manifesting itself in the population (i.e. what the symptoms are and the specific social groups it tends to manifest more in) and what its social, physical and psychological impacts are must be carried out. With many resources being invested into reducing the spread of COVID-19, it is only likely that the world will witness yet another albeit ‘silent’ pandemic- the NCD pandemic.

27

Although there has been a rapid increase in wellbeing and public health measures in an attempt to alleviate the exacerbation of NCDs, many are blanket approaches that do not contextualise unique cultural and societal factors for different at-risk groups[9, 10]. This article aims to summarise current interventions and proposed novel strategies.

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Risk Factors Poor mental health and wellbeing are a major risk factor for the development of depression, which is a common comorbidity found to accelerate the development of NCDs. The sensation of loneliness, which arises from the inhibition of social interactions, creates an environment which is conducive to negative rumination.

This is further highlighted by the increased incidence of accidental drug overdoses and readdiction events since the beginning of the COVID-19 pandemic[13]. In addition, we rely upon our peers as social support networks with whom we can share our emotions to gain advice on how to deal with them. However, with restrictions implemented and diluting our ability to seek support through promoting a culture of isolation, the COVID-19 pandemic is leaving those who have underlying symptoms of anxiety and depression in an extremely vulnerable position.

One key strategy that is essential to combating the risk of developing NCDs is physical exercise. Exercise effectively burns off visceral fat and

prevents its accumulation, which has been linked to increased incidences of obesity, cardiovascular disease, and diabetes.

However, COVID-19 protocols have identified the close contact and sharing of equipment in gyms and fitness infrastructures as a catalyst to the spreading of COVID19. Additionally, community run exercise programs and fitness groups have seen a closure under implemented restrictions. This means that the benefit of increased motivation and determination which is seen when exercising in a group is lost. Thus, while people still have the capacity to exercise at home, it will not be as efficient or as productive.

With reduced income due to a loss of jobs, and less access to shops due to more time locked indoors, society is seeking convenient and cheaper fatty foods in preference to preparing healthy meals. The COVID- 19 situation has led to a revolutionary advancement in the online food delivery industry and according to a 2021 McKinsey and Company publication, the online ordering market is now ‘four to seven times larger than they were in 2018’[14].

Hence, lockdown has established a culture which promotes the living of a sedentary lifestyle, a major risk factor to the development of NCDs. Obesity is already placing an immense burden on the health care system, with the Australian Bureau of Statistics' National Health Survey revealing that 67% of Australian adults are obese[15]. This worrying statistic will inevitably rise through the lack of 28

avenues available for productive physical exercise during this pandemic. Australians must modify their lifestyles to incorporate healthier dieting and greater physical activity, as this is critical to combat the threat that a sedentary lifestyle, inflicted by COVID-19 restrictions, has on the development of NCDs. Furthermore, the COVID-19 impact on population health should not be the only focus of health policy changes, but rather a motivating force for policymakers and public health experts to discuss and integrate long term strategies to help support those in need. The risk factors from COVID-19, although devastating, should not distract from the insidious risk factors underlying all NCDs. As explored further, we as a community must shift our focus from short term symptomatic relief solutions to sustainable strategies.

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Solutions It is without a doubt that we as a global population are amidst one of humankind’s most challenging and arduous times. As the epidemiology of SARSCoV-2 is gradually being elucidated and further allowing the better characterisation of its reverberating consequences, it is time our attention is drawn towards the prophylaxis and therapy of the pandemic. In addition, it is integral to implement effective and convenient methods of measuring the impact and validity of the proposed solutions.

The proposed strategies should seek to culminate individual, community

and government efforts in order to develop a deliverable that is an efficient use of resources.

As COVID-19 takes its toll on our community, anxiety, stress and worry will gradually settle in and leave its mark[16]. The “new norm” reality of working from home, temporary unemployment, home-schooling of children and lack of physical contact with loved ones is a difficult alteration towards one’s lifestyle. This report presents a review of the current and recommended strategies in proposal to help Australians and the entire international community manage their heightened state of anxiety and uncertainty. For those population groups of increased risk such as health care workers, those placed in quarantine, individuals living in unsafe home situations and the unemployed and casualised workforce, we must consider tailored approaches to reduce their mental health burden. It is critical to highlight the disproportionate effect on the mental wellbeing of our elderly population who may already be subject to isolation, loneliness and lack of independence.

As the unemployment rate surges, high job insecurity and increased economic burden has resulted in immense financial strain across Australia’s communities.

In an Australia National University study, ‘in the absence of policy interventions, the post-COVID-19 poverty gap would have tripled’[17].

Practical support in terms of 29

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increased JobSeeker and employment placement programs in conjunction with financial resources such as relief packages and grants are essential in helping to reduce the mental health burden of the current situation.

During such times where individuals should remain a safe distance apart to minimise contracting the virus, inperson therapy sessions may cause anxiety and are impossible for those in self- isolation. As a result, additional telepsychiatry items will assist the increase in mental health prevalence (18). It has been suggested that COVID-19 was an important motivation for the success of telemedicine in global clinical practice[19]. As we continue to harness the power of technology, the implementation of telephone/online mental health services has the potential to re-engage the significant proportion of the community being placed in quarantine and isolated from social interaction. This includes the provision of mobile applications and to maximise the benefits of established online treatment platforms such as the Black Dog Institute, Lifeline, Beyond Blue, Kids Helpline, Suicide Call Back Service and a number of other services[11].

The importance of such support platforms is evident in a 30 per cent increase in BeyondBlue calls since restrictions were enforced and a record 50,000 views on their discussion forum. The government’s initiatives to provide ten additional Medicare subsidised psychological therapy sessions for those inhabiting in restricted postcodes is a step in the

right direction. The design and delivery of social support can also effectively minimise boredom, depression and aid in the management of stress. This can be up or down scaled in the form of small community interventions such as online activities for residents of the public housing complexes put in lockdown or the establishment of partnerships with the recreation sector to provide not only entertainment but a communication route whereby education and health knowledge can be accessed by those in need[18].

It has been shown extensively in the literature that a barrier to health guideline compliance within the multicultural community is the lack of culturally appropriate and accessible information catering to non-English speakers[20-23]. As we witness the rise of the digital and social media age, the frequency of non-peer reviewed and unvalidated sources of rumour, myth, misinformation, sensationalist media coverage and the plethora of ‘expert’ opinions has fuelled community fear, paranoia and panic. To counteract the spread of such threat-based information through platforms such as WhatsApp, Facebook, Wechat, many communities are forced to turn towards for information, our government and health institutes should continue to provide convenient access to free, culturally appropriate and accurate information regarding the current status and projections of COVID-19. This may 30

further include a centralised source of information that educates Australians about the clinical nature of COVID19, its symptoms, risk factors and prevention recommendations in different languages and suited for various age groups.

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An additional recommendation would be to establish active engagement platforms for the public.

Rather than unilaterally focusing on the dissemination of mass media publications, we urge governing and community representative bodies to establish interactive consultation sessions, focus groups and online town halls; these have been shown to have high rates of engagement and effectiveness in delivering key messages[24].

It is integral that we provide additional, much needed support systems for health care workers where studies have shown that our frontline fighters experience higher anxiety than the general community[18]. An ongoing program of mental health monitoring for impacted healthcare workers as well as mental health screening support for patients should be established to minimise further mental health complications. A variety of potential interventions has been highlighted by the RACGP, however, effective implementation into hospitals and clinics requires further consultation and the involvement of clinical champions [25].

Evaluation The next step after the implementation of prevention and reduction strategies is the continual evaluation and re- designing of policy and interventions to ensure the maximal impact on public welfare.

An evaluation plan, summarised in (Figure 1,[26]), is important for characterisation of the goals, objectives and impact of the proposed program, elucidating the purpose, key stakeholders and resources needed for the provision of the strategy, specifying the design, data collection methods and tools and disseminating the health promotion evaluation as the basis of future program improvement and optimisation[26].

This rapid advancement of technology has been proposed to be an effective method to reduce the prevalence of NCDs, its comorbidities and improve mental health in populations[27].

Similarly, novel digital evaluative tools have presented new possibilities and increased capabilities for program evaluation and data analysis.

However, limitations involving the constantly changing digital environment, difficulty in identifying meaningful outcomes and poor engagement with digital interventions are inherent in the traditional evaluation framework presented in Figure 1. Achieving the goal of reducing mental illness rates, preventing obesity and observing a reduction in the negative impacts of COVID-19 will require the constant provision and improvement of solution strategies. The Outcome 31

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improvement of disease burden reduction strategies. The approach broadly involves prevalence reduction through preventative interventions that reduce the incidence of new cases and clinical interventions that are effective enough to therapeutically treat the condition. The other wing of the model is the outcome optimisation teams whereby specific individuals who are skilled in effective data use to improve key outcomes, address complex administrative issues, implementation difficulties and stakeholder relation management are needed in conjunction with adequate resources for the effective delivery of technology-facilitated wellbeing preventions in built with outcome optimisation towards key public health targets.

Figure 1: Evaluation planning framework for health promotion and disease control programs Optimisation Model, illustrated diagrammatically in (Figure 2[27]), has been proposed as an effective method of consistent monitoring and

Conclusion It is acknowledged that the proposed interventions discussed come with difficult financial and resourcing complications, however, beginning with smaller interventions before scaling up can show immense benefits. As the world shakes amidst these uncertain times, the viral pandemic has had devastating effects on the global health of each and every one of us. However, with great hardship, comes great change. We have been once again reminded during the COVID-19 pandemic, the inherent disparities and flaws within our public health system and the terrible consequences of noncommunicable diseases.

Obesity, mental health conditions and other 32

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Figure 2: Outcome optimization model NCDs are no longer able to hide in the shade of society. Rather we as a community are forced to assess the impact of NCDs and question our contribution as a society that is overly dependent on technology, marginalised the importance of health and accepted the fate of stagnation and convenience.

Collaboration, honesty, and empathy are the core values that our society must learn to value if we are to continue to stand strong in the face of the unknown future.

About the Author Kevin is an aspiring public health focused clinician-scientist working to integrate bench-to-bedside discoveries into the global community utilising population health measures. Kevin is interested

in exploring the intersectionality and entirety of the healthcare pipeline, from drug discovery, clinical trials to commercialisation and community implementation.

Through his professional experiences in biomedical research, public health and business development, Kevin ultimately endeavours to champion and empower his fellow peers and colleagues to join him in forging a multidisciplinary global career. He has been a long time swimmer and drummer. Kevin is currently a Doctor of Medicine candidate with the University of Melbourne.

Filip: I am a medical student studying at the University of Melbourne who has a great passion for endocrinology and global health. Being in a country where we are often shielded from the 33

hardships less developed nations endure, I have learnt to not take anything for granted. This realisation has inspired me to do what I can to raise awareness about and fight for the cause of equality. When I am not busy with university studies, I am an avid tennis and table tennis player, and you will catch me with friends at the Australian Open every year.

Correspondence Ashwini: I am currently a third-year Biomed student and I am undertaking a major in genetics (and loving it!). I have a deep interest for understanding the genetic basis of complex diseases such as cancer and type 2 diabetes and how our genes interact with our environment to bring about disease onset and progression. I am also a global health enthusiast and I strongly advocate for engaging with the wider community, to educate and spread the notion of 'prevention over cure' with hopes of fostering a community that prioritizes good health and wellbeing.

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Correspondence kevin.mao@amsa.org.au Acknowledgements We would like to acknowledge Professor Brian Oldenburg for all his invaluable advice during the research, drafting and reviewing of the manuscript.

Conflicts of Interest None declared

References 1. World health statistics 2020: monitoring health for the SDGs, sustainable development goals.

Geneva: World Health Organization; 2020.

Available from: https://apps.who.int/iris/bitstream/h andle/10665/332070/9789240005105eng.pdf?ua=1 2. Caci G, Albini A, Malerba M, Noonan DM, Pochetti P, Polosa R. COVID-19 and Obesity: Dangerous Liaisons. J Clin Med. 2020;9(8).

3. Syed AA, Soran H, Adam S. Obesity and covid-19: the unseen risks. BMJ. 2020;370:2823.

4. Le Brocq S, Clare K, Bryant M, Roberts K, Tahrani AA, writing group form Obesity UK, et al. Obesity and COVID-19: a call for action from people living with obesity. Lancet Diabetes Endocrinol. 2020;8(8):652-4 5. Foldi M, Farkas N, Kiss S, Zadori N, Vancsa S, Szako L, et al. Obesity is a risk factor for developing critical condition in COVID-19 patients: A systematic review and meta-analysis.

Obes Rev. 2020.

6. Tan M, He FJ, MacGregor GA. Obesity and covid-19: the role of the food industry. BMJ. 2020;369:2237.

7. Haregu TN, Lee JT, Oldenburg B, Armstrong G. Comorbid Depression and Obesity: Correlates and Synergistic Association With NonCommunicable Diseases Among Australian Men. Preventing Chronic Disease. 2020; 17(190240):51.

8. O'Neil A, Sanderson K, Oldenburg B. Depression as a predictor of work resumption following myocardial infarction (MI): a review of recent research evidence. Health Qual Life 34

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Outcomes. 2010 Sept 6; 8:95 9. O’Neil A, Jacka F, Quirk S, Cocker F, Taylor C, Oldenburg B et al. A shared framework for the common mental disorders and NonCommunicable Disease: key considerations for disease prevention and control.

BMC Psychiatry.

2015;15(1).

10.

Isaranuwatchai W, Teerawattananon Y, Archer R, Luz A, Sharma M, Rattanavipapong W et al.

Prevention of non-communicable disease: best buys, wasted buys, and contestable buys. BMJ. 2020:141.

11.

Health Do. Mental Health Department of Health: Department of Health; 2020 12. Stein D, Benjet C, Gureje O, Lund C, Scott K, Poznyak V et al.

Integrating mental health with other non-communicable diseases. BMJ. 2019;:295.

13. Patel I, Walter L, Li L. Opioid overdose crises during the COVID-19 pandemic: implication of health disparities. Harm Reduction Journal.

2021;18(1).

14. Ahuja K, Chandra V, Lord V, Peens C. Ordering in: The rapid evolution of food deliver [Internet]. McKinsey & Company Home Technology, Media & Telecommunications. 2021 [cited 30 September 2021]. Available from: https://www.mckinsey.com/industrie s/technology-media-andtelecommunications/ourinsights/ordering-in-the-rapidevolution-of-food-delivery 15. Australian Bureau Of Statistics.

National Health Survey: First results.

2018.

16. Health Do. Looking after your mental health during coronavirus (COVID-19) restrictions.

2020.

Available from: https://www.health.gov.au/news/healt h-alerts/novel-coronavirus-2019ncov-health-alert/ongoingsupportduring-coronavirus-covid19/looking-after-your-mental-healthduring-coronavirus-covid19restrictions.

17. Phillips B, Gray M, Biddle N. COVID-19 JobKeeper and JobSeeker impacts on poverty and housing stress under current and alternative economic and policy scenarios. ANU Centre for Social Research and Methods. 2021.

18. Mental Health Ramifications of COVID-19: The Australian context Black Dog Institute 2020.

19. Tran B, Hoang M, Vo L, Le H, Nguyen T, Vu G et al. Telemedicine in the COVID-19 Pandemic: Motivations for Integrated, Interconnected, and CommunityBased Health Delivery in ResourceScarce Settings.

Frontiers in Psychiatry. 2020;11.

20. Harrison R, Walton M, Chitkara U, Manias E, Chauhan A, Latanik M et al. Beyond translation: Engaging with culturally and linguistically diverse consumers.

Health Expectations.

2019;23(1):159-168.

21. The Department of Health. People from culturally and linguistically diverse backgrounds. Canberra: The Department of Health; 2006.

22. Weng E, Mansouri F, Vergani M. The impact of the COVID-19 pandemic on delivery of services to CALD communities in Australia 35

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[Internet]. 2nd ed. Melbourne: Alfred Deakin Institute for Citizenship and Globalisation; 2021 [cited 30 September 2021]. Available from: https://apo.org.au/sites/default/files/r esource-files/2021-08/aponid313720.pdf 23. Wild A, Kunstler B, Goodwin D, Onyala S, Zhang L, Kufi M et al.

Communicating COVID-19 health information to culturally and linguistically diverse communities: insights from a participatory research collaboration. Public Health Research & Practice. 2021;31(1).

24. Jayawardena A, Romano S, Callans K, Fracchia M, Hartnick C. FamilyCentered Information Dissemination: A Multidisciplinary Virtual COVID-19 “Town Hall”. Otolaryngology–Head and Neck Surgery. 2020;163(5):929930.

25. Søvold L, Naslund J, Kousoulis A, Saxena S, Qoronfleh M, Grobler C et al. Prioritizing the Mental Health and Well-Being of Healthcare Workers: An Urgent Global Public Health Priority. Frontiers in Public Health.

2021;9.

26. Cabarkapa S, King J, Ng C. The psychiatric impact of COVID-19 on healthcare workers.

Australian Journal of General Practice.

2020;49(12):791-795.

27. Gary Leong KW. Obesity and COVID-19: golden opportunity for family health change2020; (24).

Available from: https://insightplus.mja.com.au/2020/ 24/obesity-and-covid-19-goldenopportunityforfamily-healthchange

28. Round R, Marshall, B & Horton, K. Planning for effective health promotion evaluation. In: Services VGDoH, editor. Melbourne 2005.

29.

Taylor CB, Ruzek JI, Fitzsimmons-Craft EE, Sadeh-Sharvit S, Topooco N, Weissman RS, et al.

Using Digital Technology to Reduce the Prevalence of Mental Health Disorders in Populations: Time for a New Approach. J Med Internet Res. 2020;22(7):17493.

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Volume 15 | Issue 2 | October 2021

Check Out the AJGH

It's home to some fantastic short form writing, opinion pieces and reflections.

The AJGH blog is availablee through our website. https://globalhealth.amsa.org.au/s/stories

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Volume 15 | Issue 2 | October 2021

Learn. Apply. Retain.

Study medicine from anywhere.

https://www.lecturio.com

38

DO YOU DREAM OF A

DECOLONISED MEDICINE?

Volume 15 | Issue 2 | October 2021

Tamarangi Keerthipala

39

Medicine is truly global.

No, it’s not. But that’s the dream, right?

Before it can be global, it is local. That is why every culture developed its own intricate medical theories.

Traditional Chinese Medicine used the philosophical concept of yin-yang to explain illness.[1] Aboriginal healing explained it as social and spiritual dysfunction.[2] Ancient Greek physicians hypothesised there was a mind-body explanation.[3] However, with the dissection of executed criminals by 16th century Belgian physician, Andreas Vesalius, came the rapid domination of science as the great explainer and the rapid abandoning of spirituality to create the ‘evidence-based’ modern biomedical model.

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Three centuries later, modern medicine had spread across the world alongside colonisation. Despite great progress, the medicine we learn today may reflect some restrictive colonial traits. These include the lingering characteristics that modern medicine is superior, impersonal, limited to certain patient demographics and only about curing disease.

Serving a global community means addressing these characteristics. It means “challenging the hegemony” of the biomedical perspective and making space for views “traditionally marginalised within a colonial framework”.[4]

By addressing each characteristic, this article describes an approach to building a truly global, decolonised medicine – one that acknowledges both superficial and hidden biases, makes space for alternative health systems, delivers culturally humble doctors, and maintains relevance to all people and places.

The story starts with symptoms The Medical Board of Australia mandates that every medical school must bestow to students an “appreciation for cultural diversity” and the “skills and attitudes required for medical practice in a culturally diverse society”.[5] However, the implementation of this teaching is left up to each individual medical school.

The result is the annual injection of fresh-eyed interns into the workforce, all with varying degrees of cultural safety understanding, if any at all.

The story starts at the superficial biases: the symptoms, signs, and screens. It starts with asking why malignant melanoma is five times more likely to be incorrectly identified on dark-skinned patients than fair-skinned patients.[6] It starts with understanding that simply learning about the appearance of cyanosis in darker skin tones could feasibly contribute to decreasing a BAME (black and minority ethnicity) patient’s risk of mortality.[7] It starts with realising that the ‘textbook patients’ – heterosexual, Caucasian males with high incomes – are simply not representative of our diverse patient population. A 2018 study on 40

the representations of race and skin tone in medical textbook imagery found that 74.5% of clinical images represent light skin tones and just 4.5% of images represent dark skin tones.[8] We can appreciate the tip of the ‘colonial iceberg’ by recognising that even imagery in clinical education vastly privileges the Caucasian patient.

The Hidden Iceberg Visualising the reality of medicine’s colonial undertones starts with acknowledging the hidden structural, historical, research and cultural biases of modern medicine.

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Most western-following healthcare systems are structured to support those at the top of the post-colonial hierarchy – i.e., the ‘textbook patients’.

Structural biases in education and policy disadvantage certain groups: Women who suffer from a serious MI are half as likely to be treated properly in Australian hospitals as men and twice as likely to die after discharge.[9] Up to 2% of the Australian population are transgender or gender diverse (TGD),[10] and yet Australian medical schools spend an average of 0-5 hours on teaching LGBTQI healthcare content during pre-clinical years.

[11] Indigenous patients with endstage kidney disease are less likely than non-Indigenous Australians to be wait-listed for kidney

transplantation. Barriers within policy and practice have produced this outcome.[12] We must also openly acknowledge medicine’s historical biases – its dark past of racist abuse in the name of scientific advancement. How do we know how to repair vesico-vaginal fistulae? Dr Marion Sims, heralded today as the ‘father of gynaecology’ developed surgical techniques for this condition by experimenting on enslaved black women without anaesthesia nor consent. How do we know the natural history of untreated syphilis? Six hundred black men were recruited so that doctors could document it.[7] Despite this chequered past, there is still something not quite right with how we deliver healthcare to people of colour. Research is urgently needed to understand why black women are five times more likely to die and Asian women twice as likely to die compared to white women.[7] We should also acknowledge modern medicine’s biases in research. While science’s perceived neutrality has won it its title as ‘the closest approximation of the truth’, we should acknowledge that there are often biases within research production and regulation – not just because of methodological flaws – but also due to the unavoidable entanglement of research with political and commercial interests. A 2017 Cochrane review found that research sponsored by pharmaceutical companies was more 41

likely to report conclusions that were favourable to the sponsor than studies not receiving industry sponsorship.

[13] The biases within modern medicine extend beyond research and are seen socially in the formation of cultural pockets of health beliefs within western medicine itself. A classic comparative study of modern medicine in western countries found the following [14]: French populations are less obsessed with hygiene and more focused on liver health Americans are germ-averse and favour ‘fighting’ disease Germans consume high levels of cardiovascular drugs The British are stoic supporters of the NHS and prefer to ‘soldier on’ during illness We should not assume that just because medicine has science as its base, it is somehow immune to the influences of culture.

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Once we have acknowledged our biases, the next step in decolonising is to recognise that modern medicine is not the only option for healthcare.

One option, not option one A characteristic ‘colonial’ trait of modern medicine is its dominance as the exclusive, incontestable approach to healthcare.

This inherent superiority can be traced back to a colonial-era belief that a culture’s dominance justifies its encroachment

and eradication of other cultures.[4] Thus, alternative healthcare approaches (e.g., Traditional Chinese Medicine, Indian and Sri Lankan Ayurvedic medicines, Aboriginal traditional healing) have been buried under the weight of medical paternalism and ‘doctor knows best’ ideology.

Before we go on, let’s take a moment to problematise the label ‘conventional medicine’ (i.e., modern/western medicine) especially when juxtaposed against ‘alternative medicine’. The latter encompasses a “whole gamut of diverse healing traditions with far-reaching historical, geographical and cultural roots which represent the vast majority of healthcare provision worldwide”.[15] We often forget that, for millennia, traditional healing practices were mainstream, as opposed to the youthful ‘alternative’: evidence-based medicine.

But it’s true. ‘Modern’ and ‘traditional’ medical knowledge are indisputably different. Traditional Eastern healing theorises that health should pave the road to ‘enlightenment’ of body, mind, and spirit.[7] Contrastingly, modern medicine heralds ‘enlightenment’ as a ‘progressive’ 18th century era of abandoning spirituality for science. The antagonism between traditional and modern practice perpetuates the belief that only one approach can be right. Yet these two systems have more similarities than we are led to believe.

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Starting from the diagnostic frameworks, there are parallels between modern and traditional practices.

Traditional Chinese Medicine (TCM) is rooted in four diagnostic methods: inspection, auscultation, interrogation, and palpation which mirror the ‘history’ and ‘examination’ components of the modern clinical method.[1]

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Ethical guidelines for medical practice are not unique to modern medicine.

Ayurvedic medicine, practised for millennia in India and Sri Lanka, had Shashtra (precepts) outlining ethical principles including the prohibition of animal testing for research.[16] The first treatise on Islamic medical ethics (Adab-al-tabīb: practical ethics of the physician) was established by ninth century Arab physician, Al Ruhāwī.[17] The book states that a doctor was “expected not only to perform to the best of their capacity in treating their patient, but also to be a model citizen in their society”[17] – a sentiment shared by contemporary doctors who are held to a higher moral standard.

In addition, Indigenous knowledge of medicinal plants has contributed greatly to the development of modern pharmaceuticals. Traditional healing has been the source of many life-saving biomedical discoveries – morphine, artemisinin, paclitaxel.[7] However, modern appropriation of traditional treatments is not limited to pharmaceuticals – meditation, yoga and tai chi have all been rebranded in western cultures as

beneficial health practices.

Furthermore, TCM’s innovative invention of a human pox inoculation (variolation) inspired Edward Jenner’s smallpox vaccination which eradicated the virus forever.[1] Considering the similarities between modern and traditional systems including their global usage and susceptibility to cultural influences, there may be reason to look beyond modern versus traditional antagonism and imagine an integrated co-delivery: a ‘medically pluralistic, person-centred’ healthcare approach.

Imagine an ‘integrated medicine’ After recognising that modern medicine is not the only healthcare option for a globalised population, the next step in decolonisation is to make space for alternative schools of medical knowledge to create a medically pluralistic approach.

Medical pluralism denies that any healthcare system exists as a discrete and unquestionable entity.[4] Connecting traditional medical bodies to modern healthcare facilities empowers the patient to navigate the health system and heal themselves according to their cultural preferences. This especially implants self-sufficiency back into Indigenous peoples and may strengthen crosscultural trust in modern medicine as a truly ‘global’ system.

The united delivery of modern medicine and Aboriginal healing in 43

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NT’s Warlpiri people is a great example of integrated medicine. The pillars of Warlpiri medicine include Ngangkari (traditional healers), Yawulu (healing songs) and herbal medicine. Aboriginal Health Workers (AHWs) bridge the ‘cultural chasm’ between the traditional and Western worldviews. The NT Department of Health’s first policy on Aboriginal health stated that traditional medicine was “recognised”, “supported” and a “vital part of Aboriginal healthcare”.

[2] Government support for Ngangkari and AHWs allow for the concurrent use of traditional and modern medicine or ‘two-way medicine’, a term coined by AHWs to describe this bicultural approach. The principle is “if you can use what is best in modern medicine together with what is best in traditional healing, the combination may be better than either one alone.” [18] Traditional medicine can boost the self-confidence of Aboriginal people and improve the delivery of health services to Aboriginal communities.

[2] Medical pluralism can decolonise medicine externally and structurally, but true decolonisation relies on the abandonment of internal prejudices at the level of individual doctors.

Abandon the culture of no culture Modern medicine’s trademark is its claim to ‘neutrality’. While this refers to being evidence-based, it can also manifest as a dominant ‘culture of no culture’ that can lead to ignorance in medical professionals towards their

own internal cultural prejudices.[14] The first step therefore in tackling this is the incorporation of cultural safety training into medical education. Cultural safety (as opposed to cultural competence) moves the focus to clinicians’ perspectives and away from political correctness around the ‘exotic other’ patient. The aim is to develop ‘cultural humility’ that provides physicians with the consciousness to navigate any intercultural exchange without assuming superiority.

These ideas are the roots of Western medicine: Hippocrates, heralded as the ‘father of Western medicine’, and his fellow physicians worked not only as skilled observers and prescribers but also as the servants of Asklepios, the Greek god of healing.[19] Since their deeds were in service of Asklepios, there was less danger that doctors might become heroic or superior – humility was developed due to the embracing of culture.

Cultural humility in modern medicine should bring questions of class, caste, race, gender, ability, and sexuality into an intelligent dialogue with each other, instead of ignoring the link between cultural identity and the healthcare experience. Ultimately, a ‘culturally conscious’ medicine would be personalised to these different identities, and incredibly, ancient medicine was.

TCM embraced the diversity within every patient by personalising management based on a myriad of 44

factors including climate, sex, age and body constitution.[1] Ayurvedic medicine was guided by the uniqueness of each individual, which was determined through a detailed history of not only their symptoms but their diet, family, psychological context and personality.[20] Ancient medicine understood that there was no ‘one-size-fits-all’ approach to healthcare due to both physiological and sociocultural differences. It is this principle that has perhaps led to a deficiency in evidence behind traditional medicine: whilst modern research methods depend on controlled populations and a single primary endpoint, traditional medicine individualises treatments and encompasses a range of endpoints for mind and body.[7]

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After embracing cultural differences to personalise the healthcare experience, the next step is to visualise a truly ‘global’ system that fights not just for the ill and the infirmaries, but for all people and places.

For all people and places COVID-19 has exposed the fragility of our health systems and the stark disparity in the distribution of health resources.[4] This has re-emphasised the importance of training future doctors in global health trends and practices since medicine is and has always been, a global profession.

A truly ‘global’ medicine should support a changing planet. Let’s consider one pertinent global issue:

climate change. Again, we can look to the uncolonized past of traditional medicine to learn how our system can change for the better.

Modern climate change action resonates with Indigenous ideas of planetary health which focus on the peaceful interconnection of planet, environment, and human beings.[6] Aboriginal healing practices consider “all life forms, human, animal, planet and mineral as part of one vast unchanging network of relationships”.

[2] Ayurvedic medicine considers humans as open systems – exchanging matter, energy, and information with their environment.

This crucial ancient belief unites human health with planetary health.

[20] The connection between the climate and our health has been increasingly researched and we now know that between 2030 and 2050, there will be 250,000 additional deaths annually due to climate change’s effects on the social determinants of health.[21] Adopting the ancient perspective of interconnected human and planetary health can help us approach future practice through a global mindset.

Until then As dreamers, we can imagine an integrated medicine that makes space for marginalised perspectives, promotes culturally humble health workers, and serves all people and places. A system, free from restrictive colonial traits, that cares for everyone and every ‘one’.

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As future doctors, however, we should realise the complexity of this dream: it expects health to be diverse yet undivided, universal yet personal.

Integrating these opposing concepts will be our challenge as future physicians.

Until then, here’s to a truly global medicine - and to dreams coming true.

About the Author Tamarangi Keerthipala is a 2nd year medical student from the University of Adelaide in South Australia.

Correspondence

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tamarangi.keerthipala@amsa.org.au References 1. Cai J. Medicine in China. In: Selin H, editor. Encyclopaedia of the history of science, technology and medicine in non-western cultures.

3rd ed. Dordrecht: Springer; 2016.

2. Devanesan D, Maher P. Medicine of the Australian Aboriginal People.

In: Selin H, editor. Encyclopaedia of the history of science, technology and medicine in non-western cultures.

3rd ed. Dordrecht: Springer; 2016.

3.

Mantri S. Holistic medicine and the western medical tradition. AMA Journal of Ethics. 2008;10(3):177-180.

4.

Wong SHM, Gishen F, Lokugamage AU. Decolonising the medical curriculum: humanising medicine through epistemic pluralism, cultural safety and critical consciousness. London Review of Education. 2021;19(1):1-22.

5. Assessment and accreditation of medical schools: standards and procedures.

Kingston: Australian Medical Council Limited; 2011.

6. Lyman M, Mills JO, Shipman AR. A dermatological questionnaire for general practitioners in England with a focus on melanoma; misdiagnosis in black patients compared to white patients.

Journal of European Academy of Dermatology and Venereology. 2017;31(4):625-628.

7.

Lokugamage AU, Ahillan T, Pathberiya SDC. Decolonising ideas of healing in medical education.

Journal of medical ethics.

2020;46(4):265.

8.

Louie P, Wilkes R. Representations of race and skin tone in medical textbook imagery. Social Sciences & Medicine. 2020;202:38-42.

9.

Khan E, Brieger D, Amerena J, Atherton JJ, Chew DP, Farshid A, et al.

Differences in management and outcome for men and women with ST-elevation myocardial infarction.

Medical Journal of Australia.

2018;209(3):118-123.

10.

Cheung AS, Wynne K, Erasmus J, Murray S, Zajac JD. Position statement on the hormonal management of adult transgender and gender diverse individuals.

Medical Journal of Australia.

2019;211(3):127-133.

11. Sanchez AA, Southgate E, Rogers G, Duvivier RJ. Inclusion of Lesbian, Gay, Bisexual, Transgender, Queer and Intersex Health in Australian and New Zealand Medical Education.

LGBT Health. 2017;4(4):295-303.

12. Khanal N, Lawton PD, Cass A,

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McDonald SP. Disparity of access to kidney transplantation by Indigenous and non-Indigenous Australians.

Medical Journal of Australia.

2018;209(6):261-266.

13.

Lundh A, Lexchin J, Mintzes B, Schroll JB, Bero L. Industry sponsorship and research outcome.

Cochrane Database Syst Rev. 2017;2(2):MR000033.

14.

Payer L. Medicine and culture.

2nd ed. First Owl Book Ed; 1996.

15.

Sodi T, Bojuwoye O. Cultural Embeddedness of Health, Illness and Healing: Prospects for integrating Indigenous and Western Healing Practices. Journal of Psychology in Africa. 2011;21(3):349-456.

16.

De Zoysa A, Palitharathne CD. Medicine in Sri Lanka: Traditional Medical Knowledge, Its History and Philosophy. In: Selin H, editor.

Encyclopaedia of the history of science, technology and medicine in non-western cultures.

3rd ed.

Dordrecht: Springer; 2016.

17.

Nagamia HF. Medicine in Islam.

In: Selin H, editor. Encyclopaedia of the history of science, technology and medicine in non-western cultures.

3rd ed. Dordrecht: Springer; 2016.

18.

Saloojee H. When there is no doctor: a village health care handbook for Africa. British Medical Journal.

1998;317:1532.

19.

Dargert G. The origins of western medicine. In: The Snake in the Clinic: Psychotherapy’s Role in Medicine and Healing. London: Taylor & Francis Group; 2016.

20.

Mazars G. Medicine in India: āyruveda. In: Selin H, editor.

Encyclopaedia of the history of science, technology and medicine in non-western cultures.

3rd ed.

Dordrecht: Springer; 2016.

21. Craggs A. Climate change and health [internet]. World Health Organisation [cited 2021 Aug 28].

Available from: https://www.who.int/newsroom/fact-sheets/detail/climatechange-and-health

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HEALTHY AGEING IN ABORIGINAL AND TORRES STRAIT ISLANDER PEOPLE IN TROPICAL AUSTRALIA

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Ellen Forster

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Acknowledgement I would like to acknowledge the traditional owners of the lands on which I reside, the land of the Boon Wurrung people of the Kulin Nations.

I pay my respects to their elders past, present, and future, and acknowledge the critical role that Aboriginal and Torres Strait Islander people play in improving the health of their community through selfdetermination.

Declaration of Contribution and Conflict of Interest This assignment submission is a requirement for my current Masters of Public Health and Tropical Medicine degree. I declare that the work presented here is completely my own and does not contain any material previously published elsewhere by another author, except where appropriate references have been made. This work has not been a part of any other university degree or diploma submission. The views and opinions outlined in this article are my own and do not represent any organizations or institutions that I am affiliated with. I declare that I have no conflicts of interest.

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ABSTRACT Introduction: Healthy ageing requires a multidisciplinary public health strategy and is an essential element to support Aboriginal and Torres Strait Islander health in northern Australia. The increased burden of disease in the Aboriginal and Torres Strait Islander population compared to the non-Indigenous

population can be attributed to the historical and current effects of colonisation on the social determinants of health. A number of national and state government policy frameworks, and research funding, are in-place to support healthy ageing of Aboriginal and Torres Strait Islander people. These initiatives are conducted on a foundation of collaboration, health sovereignty and self-determination to support connection to country, kinship structures, and cultural identity.

Methods: The aim of this review is to critically appraise the public health approaches to healthy ageing in the Aboriginal and Torres Strait Islander population who reside in the tropical regions of Australia.

Relevant manuscripts were identified through searches of online databases, bibliographies of included texts, grey literature and websites.

Results: Healthy ageing initiatives in Indigenous communities require a multifaceted and combined approach with connection to culture, community and country at the core.

It must incorporate community participation, self-determination and sovereignty, at all stages of policy, research, planning and program delivery.

Studies consulting Indigenous communities on their perceptions of healthy ageing initiatives reported preference for programs that were flexible, culturally safe, community centred, judgement free and accessible. This supported the 49

delivery of programs through preexisting Aboriginal or Torres Strait Islander controlled health services, increasing participation acceptance and long-term sustainability.

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Conclusion: The findings of the review support the implementation of a public health program that is long-term, co-designed, decolonised and multifaceted, in order to address the broader social and environmental determinants of health that work within the tropical regions of Australia.

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Table of Contents Acknowledgement Declaration of Contribution and Conflict of Interest

49

49

Abstract

49

Background

52

Aim & Method

54

Determinants of Health

55

Public Health Strategies

55

59

Ethical Considerations

60

Conclusion

61

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Policy and Leadership Challenges

51

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BACKGROUND The focus of public healthcare in Australia is shifting towards healthy ageing, preventing noncommunicable diseases and improving the social determinants of health in older Australians. Healthy ageing refers to a multidisciplinary approach that aims to optimise and maintain physical, social, and mental wellbeing for older adults in the community.[1]

people who represent 3.3% of the population but have 2.3 times higher burden of disease and a life expectancy 10 years below nonIndigenous Australians.[2, 3] In northern Australia (Figure 1), where approximately a quarter of Aboriginal and Torres Strait Islander people live, the tropical climate influences the lifestyle, health, and connection to land.[4]

The healthy ageing strategy is vital to Aboriginal and Torres Strait Islander

The Australian Government monitors the progress of policies, reforms and

Figure 1: Geographic distribution of the Indigenous population, 30 June 2016 [5] 52

funding towards Aboriginal and Torres Strait Islander health through the Aboriginal and Torres Strait Islander Health Performance Framework (HPF) report.[3] It measures the impact of the national and state-based initiatives per the categorisation of health status and outcomes – the determinants of

health and health system performance.

Healthy ageing outcomes are the result of a combined approach between direct aged care policies and indirect holistic approaches to Indigenous health. A number of the key government programs for healthy ageing are listed in Table 1.

Government Funded Initiatives for Aboriginal and Torres Strait Islander Health Policies

Initiative

Key Points

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NATIONAL Closing the Gap Framework 2008 National Agreement on Closing the Gap – 2020[5]

Framework redesigned in 2020 followed by a $46.5 million contribution to build the capacity of community-controlled health services

Indigenous Australian Health Programs (IAHP)[6]

$33 million provided to improve primary health care delivery for Indigenous Australian

Indigenous Voice[7]

Senior advisory group, generating national and regional co-designed groups to provide recommendations to Australian government

National Aboriginal and Torres Strait Islander Health Plan 2013-2023[8]

This plan has 20 implementation goals of which six are related to healthy ageing, including Indigenous-specific health checks, immunisation for influenza and pneumonia, alongside health screening for diabetes, hypertension and renal function.

Currently the plan is being redeveloped to realign with the National Agreement on Closing the Gap

Remote and Aboriginal and Torres Strait Islander Aged Care Service Development Assistance Panel (SDAP)[9]

Employs local solutions to support aged care providers in building capacity and become more culturally sensitive and responsive 53

National Aboriginal and Torres Strait Islander Flexible Aged Care Program (NATSIFACP) [10]

Funds organisation to deliver culturally safe aged care to older Indigenous Australians close to home and community

Indigenous Advancement Strategy (IAS)[11]

Delivers funds to a number of programs that three priority areas for Aboriginal and Torres Strait Islander health care, of which ‘Building safe communities’ is important for healthy ageing in community

STATE Northern Territory: Northern Territory Aboriginal Health Plan 2015-2018[12]

Set of strategic directions currently being renewed to improve health and wellbeing and ensure cultural security in health services

Queensland: Making Tracks towards closing the gap in health outcomes for Indigenous Queenslanders by 2033 – Policy and Accountability Framework[13]

Overarching policy framework with 5 key priority areas for sustainable intervention across lifespan and health service continuum

Western Australia Aboriginal Health and Wellbeing Framework 2015-2030 [14]

Set of principles and priority areas for improving health outcomes of Indigenous population in WA

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Table 1. Government Funded Initiatives for Aboriginal and Torres Strait Islander Health Policies [3]

In recent decades, aged care reforms and reviews continue to report insufficient improvement in Aboriginal and Torres Strait Islander aged care.[15] This prompted the 2018 investment of $5.6 million into research focused explicitly on healthy ageing in Aboriginal and Torres Strait Islander peoples.[16] This was a necessary commitment, given the findings of the 2021 Royal Commission into Aged Care Quality

and Safety reporting a significant lack of culturally safe and accessible aged care for Aboriginal and Torres Strait Islander people.[17]

AIM & METHOD The aim of this review is to critically appraise the public health approaches to healthy ageing in Aboriginal and Torres Strait Islanders communities who reside in the tropical regions of Australia. Relevant manuscripts were 54

identified through searches of online databases, bibliographies of included texts, grey literature and websites.

The literature sources included: published data, peer-reviewed publications, and online resources.

Criteria for inclusion were articles that addressed and evaluated either public health programs or health ageing in Australian and Torres Strait Islander people.

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DETERMINANTS OF HEALTH An analysis conducted by the Australian Institute for Health and Wellbeing (AIHW) demonstrated that more than half of the health gap in Indigenous Australians was determined by a set of social and health risk factors.[18] The determinants of health are a spectrum of systematic variations that either improve or worsen health outcomes, often interconnected on an individual, cultural and environmental level. The generalised determinants of health commonly relate to one’s education, employment, income, and location.

However, the circumstances in which Indigenous Australians grow, live and work are further influenced by cultural identity, kinship structures, connection to traditional lands, and both the historical and contemporary impact of colonisation in Australia.

[19, 20] A “healthy [and] strong connection to culture and country” is identified as the central pillar in building national Aboriginal and Torres Strait Islander health programs.[21] According to the

AIATSIS, the term 'Country’, “is often used by Aboriginal peoples to describe the lands, waterways and seas to which they are connected. The term contains complex ideas about law, place, custom, language, spiritual belief, cultural practice, material sustenance, family and identity."[22] Embedded in Aboriginal culture is the strong sense of obligation to tend to Country,[23] evidenced by higher rates of happiness and health in communities who can fulfil those obligations of environmental resource management.[24, 25] Unfortunately, tropical environments are showing evidence of decline due to pollution, feral animals, wildfires, illegal fishing, climate disasters and other disruptive practices.[26] Tropical regions also tend to have a higher proportion of the population living regionally or rurally where there is an increased risk of climate disasters.[27] The added concern of increased communicable and noncommunicable diseases, rapid demographic growth and environmental shifts, makes public health program implementation and access to health services challenging.

PUBLIC HEALTH STRATEGIES The National Aboriginal Community Controlled Health Organisation (NACCHO) have adopted a holistic definition for health of Aboriginal and Torres Strait Islander people. “’Aboriginal health’ means not just the physical well-being of an individual but refers to the social, emotional and cultural well-being of the whole 55

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Community in which each individual is able to achieve their full potential as a human being thereby bringing about the total well-being of their Community. It is a whole of life view and includes the cyclical concept of life-death-life.”[28] This holistic and multifaceted view is consistent with our understanding of the determinants of health and broader societal influences of health in Aboriginal and Torres Strait Islander people. Therefore, addressing health related concerns requires an equally multifaceted and collaborative approach for effective and sustainable healthy ageing.[29] In one study, Aboriginal and Torres Strait people defined healthy ageing as more than just getting older; rather the ability to retain their key role as cultural leaders in the community.

[30] Further, public health strategies for Aboriginal and Torres Strait Islander communities must address the ongoing effects of colonisation as a fundamental determinant of health.

This is due to the continued effects of territorial removal, destruction of people, culture, language and the lack of self-determination.[31] Selfdetermination is the right to shape one’s own social, cultural and economic progression. Historically, Aboriginal people have been criminalised, persecuted and heavily regulated under the guise of disease management and healthcare.[32] Therefore, it is crucial to reinstate the decision-making capacity of Aboriginal and Torres Strait Islander communities to manage ill-health

and wellbeing on their own terms.

Furthermore, consideration of the holistic model of health for Aboriginal and Torres Strait Islander people, communities and Country is influenced by the context of territorial sovereignty.

Before Australia was colonised, Aboriginal and Torres Strait Islander people assert that they had been selfgoverning and maintained sovereignty of the lands, which were not ceded.[33,34] There are many Aboriginal and Torres Strait Islander people who claim sovereignty and the ability to govern their own lives. It would mean that they would have greater control and selfdetermination over their lives with limited government input on affairs relating to Indigenous issues.[35] One proposed approach to ensure self-determination of the community is a co-design process; members from the community are given positions of power to influence the design process, thus empowering Aboriginal Australians to shape the program to meet their community’s needs.[36, 37] One study undertaken to understand the primary concerns of Aboriginal Australians during ageing reported chronic health conditions, social and emotional well-being and difficulties accessing health services.

[38] Unfortunately, the current health system does not adequately meet the complex needs of the ageing Indigenous population.

Whilst there have been numerous 56

successful and sustainable codesigned health programs, governed

by Aboriginal and Torres Strait Islander communities, there have only been two successfully published co-designed programs directly targeting healthy ageing in Aboriginal and Torres Strait Islander people that have set the stage for further collaborative development of healthy ageing initiatives. The Heart Health Program [39] and the Ironbark Program [40], as summarised in Table 2.

The Victorian Department of Health have outlined 10 key areas of

importance in a healthy ageing program [29]: healthy eating, active living, tobacco-free living, reducing harmful alcohol and drug use, improving mental health, preventing violence and injury, improving sexual health, supporting age-friendly environments, participation in society, and optimising the management of health and healthcare.

Conversely, the preferences and priorities identified

by Aboriginal and Torres Strait Islander people on healthy ageing and overall health interventions are far more complex and detailed and summarised in Table 2.

Heart Health Program[39] Public Health Program Overview

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Key features to success

Weekly exercise and education (through yarning), provide by an Aboriginal Medical Service to improve outcomes of cardiac rehabilitation Aboriginal-specific program Culturally safe environment Talking circles or yarning circles instead of didactic teaching Co-design with Aboriginal stakeholders

Table 2.

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Ironbark Program[40] Weekly exercise and education (through yarning), provide by an Aboriginal Medical Service to improve outcomes of cardiac rehabilitation Local Aboriginal management Culturally relevant resources Ongoing availability Accessible for <65-year olds Supervised exercise and education Community elders had strong word of mouth referral rates Social benefits

Study

Community Identified Priorities

Healthy Ageing Older Aboriginal Australians Health Concerns and Preferences for Healthy Ageing Programs, Wettasinghe et al., 2020 [38]

Physical and cognitive activities Social interaction Health education Culturally safe care and transport for access Family, community, cultural identity and empowerment regarding ageing

First Nation Elders’ perspectives on healthy ageing in NSW, Australia, Coombes et al., 2018 [30]

Importance of maintaining self-worth and involvement in the community Reduction of the stereotypes about Aboriginal and Torres Strait Islanders Delivery though an established Indigenous organisation

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General/Other Health My Life My Lead report, Australian Department of Health, 2017 [41]

Culture is central to wellbeing Racism within health and other systems must be addressed Intergenerational trauma needs to be acknowledged and addressed Support of governments for long-term, location-based approaches that honour participation and community priorities

Yarning about fall prevention: community consultation to discuss falls and appropriate approaches to fall prevention with older Aboriginal and Torres Strait Islander people, Lukaszyk et al., 2017 [42]

Falls programs should not be physically demanding and enable confidence to engage irrespective of ability Chance to tailor program to the health needs and ownership of the participants Culturally safe, flexible, and judgement free On-going long-term programs that enable periods of adjustment and followup Delivery by professional who will add value to the engagement and exercise

Table 3. Summary of studies that report on the preferences and priorities of Aboriginal and Torres Strait Islander people regarding public health programs 58

The preferences and priorities summaries in Table 2 and 3, have been qualitatively analysed to generate suggested public health initiatives that could be combined into a multifactorial healthy ageing program. These are listed below;

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The primary focus of new public health initiatives would be the provision of accessible and regular cultural safety training to multi sector service providers in the community (including health, emergency, council, crisis support, child protection). The aim is to decolonise public health and address the systemic racism that perpetuates poor outcomes so that individuals feel safe and supported in their community.

This is achieved by creating broader cultural humility in health through education, organisational reform and policy to encourage development of culturally responsive practitioners.

Hopefully, improving the broader impact and interaction between the determinants of health.

Many ACCHO’s are well versed in providing flexible and safe health care to catered to the community they serve. However, it is important for health services to support the ACCHO is providing this care. This support may be in the provision of resources and facilities, collaborating with specialists or other people to create collaborative evidence-based healthcare, or encouraging the involvement of staff to engage ACCHO through referrals and patient education in acute and specialist care.

The partnership between the mainstream health sector and Aboriginal Community Controlled Health Organisations (ACCHOs) should be optimised through the development of a framework that outlines the requirement and importance of Aboriginal and Torres Strait Islander representation and collaboration in the delivery of health programs. Utilising the relationship ACCHOs have with the Aboriginal and Torres Strait Islander community to build on pre-existing trust and familiarity with the physical venue as a cultural safe space, previous knowledge on access and transport, and comfort in the connection to culture and community members.

The framework and partnership between health sector and ACCHO can then be used to create a pathway of collaboration if support requested by an ACCHO to deliver their health services and programs.

Irrespective of the approach, all programs should involve consultation with community members to identify what are their values, health concerns, preferred methods and requested supports.

POLICY AND CHALLENGES

LEADERSHIP

The disconnect between cultural knowledge, western research and health policy is detrimental to Indigenous health outcomes. Healthy ageing involves balancing competing interests, funding priorities, decisionmaking processes and the latest research to coordinate a successful 59

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programmatic response. In doing so a number of operational and political challenges are encountered. These may be nuances in the creation and management of external stakeholder relationships that are reliant on election cycles, funding, governance structures, and risk of public, professional or media scrutiny. On the other hand, there is a lack of Aboriginal and Torres Strait Islander representation to help guide the processes at all levels of health and aged care.[43] Institutions at a government and policy level have historically implemented a discriminatory and paternalistic approach to health care of Aboriginal and Torres Strait Islander peoples.

Therefore, it is important to ensure that Aboriginal and Torres Strait Islander people have sufficient representation, resource allocation and decision-making capacity. This can be done through governance and accountability frameworks that document the protocols relating to Indigenous involvement at all levels.

Alternatively, it is important to consider the leadership dynamics within Aboriginal and Torres Strait Islander communities.

Older Aboriginal people can often be recognised as Elders. Aboriginal Elders are regarded as custodians of cultural knowledge and lore which allows them to pass down their beliefs, and are recognised as mentors, and caregivers in their community kinship structures [44].

The design of a healthy ageing program must acknowledge and

respect the pivotal role these individuals play in determining the health and wellbeing of their community. This is vital when considering that far north Australia is more likely to have Aboriginal and Torres Strait Island communities that continue to engage and promote a strong inter-community governance structure, that determines how they look after their land, their families and their health [45].

ETHICAL CONSIDERATIONS Public health programs are concerned with improving the health of the population as a whole, and as a result they risk overriding informed consent and individual autonomy.

This is a major concern for programmes involving Aboriginal and Torres Strait Islander people, where it is crucial to advocate for the rights that enable self-determination.

It is therefore important that community education and participation are central to public health approaches to ensure trust, sustainability and effectiveness. This will ensure that it is the health priorities of the community and not those of the governing body, for which the intervention is being tailored. Furthermore, it is important that governance and accountability frameworks have a clear and transparent method for reporting and evaluating the effectiveness, receptibility and sustainability of the program, allowing professionals to ensure outcomes align with specific cultural determinants of health.

Ideally, a health program would be 60

delivered in a way that supports and respects the continued application of important customs, traditions and practices without restricting or requiring unnecessary modification.

CONCLUSION

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Aboriginal and Torres Strait Islander health is a multi-factorial concept off physical, social, emotional and cultural well-being of the individual, their Community and Country. The findings of the review support the implementation of a public health program that is long-term, codesigned, decolonised and multifaceted.

It is therefore encouraged that healthy ageing initiatives for Aboriginal and Torres Strait Islander communities should be designed, delivered and evaluated in collaboration with the people they service and the affiliated ACCHO. Health services and practitioners should support this collaboration by enhancing cultural safety and prioritising the importance of selfdetermination and representation in health.

About the Author I am a current medical at Monash University and public health student at James Cook University, working at the Victorian Department of Health.

This role is in public health policy and project management for the implementation monitoring and evaluation of the Covid-19 vaccine.

This is following a year of research at the National Trauma Research Institute (NTRI) at the Alfred Health whilst undertaking my honours degree.

Correspondence ekfor2@student.monash.edu References 1.

Commonwealth of Australia.

National Strategy for an Ageing Australia.

Canberra Australian Government 2001.

2. Australia Institute of Health and Welfare.

Deaths in Australia.

Canberra AIHW, 2020.

3. Australian Institute of Health and Welfare. Aboriginal and Torres Strait Islander Health Performance Framework - Summary report 2020.

Canberra: Australian Government 2020.

4. Australian Institute of Health and Welfare. Australia’s Health Canberra: AIHW2018.

5. Commonwealth of Australia.

Closing the Gap Report 2020,: Australian Government, 2020.

6. The Department of Health. The Indigenous Australians’ Health Programme . Australian Government, , Canberra 2018. https://www1.health.gov.au/internet/ main/publishing.nsf/Content/indigen ous-programme-lp.

7. Australian Government. Indigenous Voice. Commonwealth of Australia.

2020. https://voice.niaa.gov.au/#.

8. Australia Institute of Health and Welfare. Tracking progress against the Implementation Plan goals for the Aboriginal and Torres Strait Islander Health Plan 2013–2023. Canberra: Commonwealth of Australia,2020.

9. Department of Health. Remote and Aboriginal and Torres Strait Islander Aged Care Service Development 61

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Assistance Panel (SDAP).

Commonwealth of Australia,, Canberra.

2021. https://www.health.gov.au/initiativesand-programs/remote-andaboriginal-and-torres-strait-islanderaged-care-service-developmentassistance-panel-sdap.

10. Department of Health. National Aboriginal and Torres Strait Islander Flexible Aged Care Program.

Commonwealth of Australia, , Canberra, .

2020. https://www.health.gov.au/initiativesand-programs/national-aboriginaland-torres-strait-islander-flexibleaged-care-program.

11.

Agency NIA. Indigenous Advancement Strategy.

Commonwealth of Australia, , Canberra 2021. https://www.indigenous.gov.au/indig enous-advancement-strategy.

12. Health NTDo. Aboriginal health policy.

Northern Territory Government Darwin 2016. https://health.nt.gov.au/professionals /aboriginal-and-torres-straitislander-health/aboriginal-healthpolicy.

13. Health Q. Making Tracks toward closing the gap in health outcomes for Indigenous Queenslanders by 2033 Policy and Accountability Framework. Brisbane, 2010.

14. Government of Western Australia.

WA Aboriginal Health and Wellbeing Framework 2015–2030.

Perth Department of Health, 2015.

15. Commonwealth of Australia.

Legislated Review of Aged Care.

Canberra Department of Health, 2017.

16. Hunt G. $5.6 million for research into healthy ageing of Agoriginal and Torres Strait Islander People.

Canberra: Australian Government Department of Health 2019.

17. Commonwealth of Australia. Royal Commission into Aged Care Quality and Safety, Final Report: Care, Dignity and Respect. Canberra 2021.

18. Australian institute of Health and Welfare. Australia’s Health 2020: Social Determinants and Indigenous Health Canberra2020.

19. King M, Smith A, Gracey M. Indigenous health part 2: the underlying causes of the health gap.

The lancet. 2009;374(9683):76-85.

20.

Kingsley J, Townsend M, Henderson-Wilson C, Bolam B. Developing an exploratory framework linking Australian Aboriginal peoples’ connection to country and concepts of wellbeing.

International journal of environmental research and public health. 2013;10(2):678-98.

21. Australian Government. National Aboriginal and Torres Strait Islander Health Plan 2013-2023. Canberra Commonwealth of Australia 2013.

22. AITSIS. Welcome to Country. https://aiatsis.gov.au/about/who-weare.

23. Garnett ST, Sithole B, Whitehead PJ, Burgess CP, Johnston FH, Lea T. Healthy country, healthy people: policy implications of links between Indigenous human health and environmental condition in tropical Australia. Australian Journal of Public Administration. 2009;68(1):53-66.

24. Burgess CP, Johnston FH, Bowman DM, Whitehead PJ. Healthy 62

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country: healthy people? Exploring the health benefits of Indigenous natural resource management.

Australian and New Zealand Journal of Public Health. 2005;29(2):117-22.

25. Johnston FH, Jacups SP, Vickery AJ, Bowman DM. Ecohealth and Aboriginal testimony of the nexus between human health and place.

EcoHealth. 2007;4(4):489-99.

26. Garnett ST, Woinarski JC, Crowley GM, Kutt AS. Biodiversity conservation in Australian tropical rangelands.

Wild rangelands: conserving wildlife while maintaining livestock in semi-arid ecosystems.

2010:191-234.

27. Evans J. Mapping the vulnerability of older persons to disasters.

International journal of older people nursing. 2010;5(1):63-70.

28. National Aboriginal Community Controlled Health Organisaiton (NACCHO). Aboriginal Community Controlled Health Organisations (ACCHOs).

2021. https://www.naccho.org.au/acchos.

29. Batchelor F, Haralambous B, Lin X, Joosten M, Williams S, Malta S et al. Healthy ageing literature review.

Final Report to the Department of Health and Human Services.

Retrieved from …; 2016.

30.

Coombes J, Lukaszyk C, Sherrington C, Keay L, Tiedemann A, Moore R et al. First Nation Elders’ perspectives on healthy ageing in NSW, Australia. Australian and New Zealand journal of public health.

2018;42(4):361-4.

31. Editorial. Self-determination and Indigenous health. The Lancet 2020. doi: https://doi.org/10.1016/S0140-

6736(20)31682-2.

32. Walsh AM, Rademaker L. Why self-determination is vital for Indigenous communities to beat coronavirus. The Conversation 2020.

33.

Kevin Gilbert, ‘Aboriginal Sovereign Position: Summary and Definitions’ (1994) 13(1) Social Alternatives 13.

34. Behrendt L, Jorgensen M, Vivian A. Self-Determination: Background Concepts, Scoping paper 1 prepared for the Victorian Department of Health and Human Services, for State of Victoria. Department of Health and Human Services, Melbourne. 2016:125.

35. Fenley, J. 2011, “The National Aboriginal Conference and the Makarrata: Sovereignty and Treaty Discussions, 1979 - 1981”, Australian Historical Studies, Volume 42, pg. 372 – 389.

36.

Ottmann G. Exploring community-based aged care with aboriginal elders in three regional and remote Australian communities: a qualitative study. Social Work & Policy Studies: Social Justice, Practice and Theory. 2018;1(001).

37. Durey A, McEvoy S, Swift-Otero V, Taylor K, Katzenellenbogen J, Bessarab D. Improving healthcare for Aboriginal Australians through effective engagement between community and health services. BMC Health Services Research. 2016;16(1):113.

38. Wettasinghe PM, Allan W, Garvey G, Timbery A, Hoskins S, Veinovic M et al. Older aboriginal Australians’ health concerns and preferences for healthy ageing programs.

63

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International journal of environmental research and public health. 2020;17(20):7390.

39. Dimer L, Dowling T, Jones J, Cheetham C, Thomas T, Smith J et al.

Build it and they will come: outcomes from a successful cardiac rehabilitation program at an Aboriginal Medical Service.

Australian Health Review.

2013;37(1):79-82.

40.

Lukaszyk C, Coombes J, Sherrington C, Tiedemann A, Keay L, Mackean T et al. The Ironbark program: Implementation and impact of a community‐based fall prevention pilot program for older Aboriginal and Torres Strait Islander people.

Health promotion journal of Australia. 2018;29(2):189-98.

41. Australian Government. My Life My Lead Opportunities for strengthening approaches the social determinants and cultural determinants of Indigenous Health.

Canberra: Department of Health, 2017.

42. Lukaszyk C, Coombes J, Turner NJ, Hillmann E, Keay L, Tiedemann A et al. Yarning about fall prevention: community consultation to discuss falls and appropriate approaches to fall prevention with older Aboriginal and Torres Strait Islander people.

BMC public health. 2018;18(1):1-9.

43. LoGiudice D. The health of older Aboriginal and Torres Strait Islander peoples. Australasian Journal on Ageing. 2016;35(2):82-5.

44. Waugh E, Mackenzie L. Ageing well from an urban Indigenous Australian perspective. Australian Occupational Therapy Journal.

2011;58(1):25-33.

45. Gwynn J, Lock M, Turner N, Dennison R, Coleman C, Kelly B et al.

A boriginal and T orres S trait I slander community governance of health research: Turning principles into practice. Australian Journal of Rural Health. 2015;23(4):235-42.

64

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Volume 15 | Issue 2 | October 2021

Graphic by Christine Manuel

65

PSYCHEDELIC

MEDICINE

Volume 15 | Issue 2 | October 2021

A paradigm shift in psychiatry?

Dilnoor Kaur Hargun

66

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Using psychedelics as medicines is not a novel idea. Indigenous cultures have used psychoactive plants and fungi in healing rituals for thousands of years.[1] The 1950s and 1960s saw a wave of clinical studies investigating psychedelic medicines for the treatment of mood disorders and alcohol dependence, but prohibitive laws then halted research. Notably, in 1971, the United Nations classified most classic psychedelics as Schedule I drugs for having no medicinal value and high abuse liability, contrary to available evidence.[2] Over the last two decades, there has been a psychedelic science renaissance with increased global research and funding, and psychedelic medicines are now on the cusp of widespread acceptance.

Today, there is promising evidence that psychedelic medicines can treat various mental illnesses and substance use disorders, which affect over one billion people globally.[3] Yet, psychedelics remain politicised and stigmatised.

Psychedelic medicine represents a potential breakthrough treatment in psychiatry and given the excessive human, social, and economic costs associated with mental illnesses, increased government funding and support is merited.

Psychedelics Psychedelics are a class of psychoactive substances that induce an acute altered state of consciousness, known as the psychedelic experience (or trip),

through agonistic activity at serotonin 2A receptors.[4] The classic psychedelics are LSD, psilocybin, mescaline, and DMT. The psychedelic experience involves changes in perception, cognition, emotion, and sense of self. These include visual hallucinations, sensory alterations, lateral thinking, novel insights, positive emotions, social and nature connectedness, and mysticaltype experiences.[5] Effects primarily depend on the specific drug and drug dosage but are modulated by nondrug factors such as personality traits, prior drug experiences, mood, the environment, and music, known as the set and setting.[6] Safety Classic psychedelics are physiologically safe on their own and are not neurotoxic or addictive.

Adverse effects are usually mild and acute, including nausea, headaches, increased heart rate, anxiety, and rarely, psychotic symptoms.[7,8] Instances of persistent psychosis or hallucinogen persisting perception disorder, where perceptual changes persist after the trip, are very low and associated with unsupervised settings and polysubstance use.[9] The risk is further mitigated by the exclusion of people with a personal or family history of psychotic or manic symptoms.

In large-scale epidemiological studies, psychedelic use is not associated with an increased risk of mental health issues and may even be protective for psychological distress and suicidality.[10,11] 67

Psychedelics can induce distressing thoughts and emotions; however, this can confer therapeutic benefit if individuals are supported to move from avoidance to acceptance of these internal events.[12] Supervision also reduces the risk of physical harm.

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Mental illnesses In today’s mental health crisis, mental illnesses account for 13% of disabilityadjusted life years and contribute to 14% of deaths globally.[13,14] The burden of disease is rising, yet available medications have residual symptoms and intolerable adverse effects in many patients.[15] Importantly, most current medications work to reduce the symptom burden and are not curative.

Conversely, psychotherapies, such as cognitive behavioural therapy, can cure some mental illnesses.

Psychedelic-assisted psychotherapy is emerging as a new paradigm where psychedelics are used as an adjunct to facilitate therapy. The therapeutic mechanism of action is not yet known; however, there are some hypotheses. During the psychedelic experience, increased neural entropy, plasticity, and altered connectivity in key brain regions work to briefly relax high-level beliefs about the self and the world.[12,16,17] In the context of therapy, this brief relaxation allows beneficial revision of pathological high-level beliefs, such as fearavoidance beliefs.[12] Some therapeutic benefit may also be due to a persisting, increased sense of

connectedness to the self, others, and the world as a sense of disconnection mediates some mental illnesses.[18] Psychedelics therapy increases nature connectedness and time spent in nature, which is associated with psychological wellbeing.[19] Mysticaltype experiences, typified by a sense of oneness and awe, are also associated with higher treatment efficacy.[20] Clinical trials of psychedelic therapy are promising for many mental illnesses: depression, anxiety, posttraumatic stress disorder (PTSD), anxiety associated with lifethreatening illnesses, obsessivecompulsive disorder, social anxiety in adults with autism, and anorexia.[7,8] A recent meta-analysis of placebocontrolled trials found psychedelic therapy to be safe, tolerable, and efficacious with a large mean effect size.[21] There was an almost immediate onset of action and persistence on long-term follow-up after one to three doses. However, studies are limited by small, nondiverse samples and ineffective blinding due to noticeable drug effects.[22] MDMA MDMA (ecstasy) is another psychoactive substance with therapeutic benefits. It is classified as an entactogen as it acts on both serotonin and catecholamine receptors to induce unique emotional effects, and less perceptual changes.

[23] MDMA is thought to facilitate therapy by reducing the fear response when recalling traumatic memories, 68

increasing empathy for the self and others, promoting trust with the therapist and increasing insights into memories and beliefs.[24]

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Clinical trials suggest that MDMAassisted therapy is safe and effective for treating PTSD.[25,26] Notably, in a recent Phase III trial of ninety patients, MDMA-assisted therapy significantly reduced PTSD symptoms and functional impairment after one dose, even in those with comorbid mental illnesses.

[27] However, the study is limited by a short follow-up of two months.

Substance use disorders Although the global prevalence of substance use disorders is increasing, the public health response remains inadequate, especially in low- and middle-income countries.[3] Available treatments have high relapse rates and while classic psychedelics show promise, there is a paucity of studies. A meta-analysis of six randomised trials from the 1950s and 1960s showed that a single dose of LSD increased rates of alcohol abstinence[28].

However, these studies lack the methodological rigour of today’s research. Recent open-label trials suggest psilocybinassisted therapy can reduce drinking days and days with heavy drinking in alcoholism and reduce nicotine withdrawal symptoms and promote smoking cessation in nicotine addiction{Andersen, 2021 #75}.[29] In one study, after a single dose of psilocybin with cognitive behavioural therapy significantly, two-thirds of

participants were still abstinent from cigarette smoking on one year followup.[30] However, larger phase II and III studies are needed to support this preliminary evidence.

The global opioid epidemic has high associated mortality.[31] Ibogaine is a hallucinogenic alkaloid derived from the native African T. iboga shrub which has been used for ceremonial purposes for hundreds of years.[32] Recent animal and human studies suggest that ibogaine, and its metabolic product noribogaine, can treat opioid dependence.[33,34] A notable study in New Zealand, where it is legal, demonstrated reduced opioid withdrawal symptoms and cravings, lower depressive symptoms, and sustained abstinence on one year follow-up after one ibogaine treatment.[35] However, ibogaine and noribogaine are associated with cardiac arrhythmias and fatalities, even under medical supervision.[33] A recently synthesised nonhallucinogenic analogue of ibogaine with similar anti-addictive and antidepressant effects in animal models, but no adverse effects, is promising, yet human studies are needed.[36] What about everyone else?

Health is defined as a “state of complete physical, mental, and social well-being, and not merely the absence of disease” and psychedelics are shown to increase wellbeing across these domains.[37] In individuals without a diagnosed disorder, psychedelic use may improve mood, 69

increase creativity, meaning, mindfulness, and positive personality traits of openness, conscientiousness, and agreeableness.[38,39] It is also associated with feelings of connectedness, empathy, and trust, as well as pro-social behaviours.[39,40] Importantly, psychedelic use is not associated with adverse mental health outcomes and may even be protective.[10] From an ethical lens, this aligns with principles of beneficence, non-maleficence, autonomy, and cognitive liberty: the right to self-determination of one’s cognition and consciousness.

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Moreover, psychedelic research should not be restricted to psychiatric disorders. There is very preliminary evidence for psychedelics in treating chronic pain, cluster and migraine headaches, neurodegenerative diseases and ischaemic stroke, amongst others.[2,41] These are areas well worth exploring.

Future directions In the late 1960s, two decades of promising research was halted as psychedelics were associated with the counterculture movement and, as part of the global war on drugs, they were heavily restricted and stigmatised.[42] The United Nations classifying psychedelics as Schedule I drugs in 1971 led many countries to follow suit, despite evidence that they were safe and non-addictive, and had promising medicinal value. Despite renewed global interest, psychedelic research continues to face legal, social, and economic barriers.[43]

Given their therapeutic potential and the growing burden of mental illnesses, increased government funding and support is essential to allow large Phase III trials and expedite the clinical evaluation of psychedelic medicines. Psychedelics medicines have been approved as breakthrough therapies in some parts of the world, and in Australia, MDMA and psilocybin are available as Special Access Scheme Category B drugs, with patients evaluated on a case-by-case basis.[44] Before widespread acceptance, accredited training programs need to be developed for mental health professionals to safely administer psychedelic-assisted therapy.

Psychedelic medicines should also be supported by the Pharmaceuticals Benefit Scheme to ensure equitable access.

Furthermore, whilst low-income nations and ethnic minorities are disproportionately affected by psychiatric disorders, they are underrepresented in psychedelic research. Notably, 83% of participants in clinical studies are non-Hispanic Caucasian people.[45] Despite psychedelic medicine’s roots in indigenous healing practices, indigenous and diverse cultural perspectives are often marginalised.

Diverse perspectives generate innovative insights, and an inclusive approach ensures traditionally disadvantaged populations equally benefit from increased global interest in psychedelic medicines.[1] Ultimately, psychedelic medicines 70

represent a paradigm shift which, when tempered with caution based on clinical evidence rather than historical and social biases, may transform the field of psychiatry and beyond.

About the Author Dilnoor is a medical student at the University of New South Wales passionate about global health research and anthropology. She is interested in psychedelic medicines and health disparities due to structural violence.

Correspondence dilnoorkh@gmail.com Conflicts of Interest None declared

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Acknowledgements None References 1. George JR, Michaels TI, Sevelius J, Williams MT. The psychedelic renaissance and the limitations of a White-dominant medical framework: A call for indigenous and ethnic minority inclusion.

Journal of Psychedelic Studies. 2020;4(1):4-15.

2. Garcia-Romeu A, Kersgaard B, Addy PH. Clinical applications of hallucinogens: A review. Exp Clin Psychopharmacol. 2016;24(4):229-68.

3. Rehm J, Shield KD. Global Burden of Disease and the Impact of Mental and Addictive Disorders.

Curr Psychiatry Rep. 2019;21(2):10.

4.

Nichols DE. Psychedelics.

Pharmacol Rev. 2016;68(2):264-355.

5. Swanson LR. Unifying theories of psychedelic drug effects. Frontiers in pharmacology. 2018;9:172.

6. Studerus E, Kometer M, Hasler F, Vollenweider FX. Acute, subacute and long-term subjective effects of psilocybin in healthy humans: a pooled analysis of experimental studies.

Journal of psychopharmacology.

2011;25(11):1434-52.

7. Cipriani A, Furukawa TA, Salanti G, Chaimani A, Atkinson LZ, Ogawa Y, et al.

Comparative efficacy and acceptability of 21 antidepressant drugs for the acute treatment of adults with major depressive disorder: a systematic review and network metaanalysis. Focus. 2018;16(4):420-9.

8. Dos Santos RG, Bouso JC, AlcázarCórcoles MÁ, Hallak JE. Efficacy, tolerability, and safety of serotonergic psychedelics for the management of mood, anxiety, and substance-use disorders: a systematic review of systematic reviews. Expert review of clinical pharmacology. 2018;11(9):889902.

9. Litjens RP, Brunt TM, Alderliefste G-J, Westerink RH. Hallucinogen persisting perception disorder and the serotonergic system: a comprehensive review including new MDMA-related clinical cases.

European Neuropsychopharmacology.

2014;24(8):1309-23.

10.

Krebs TS, Johansen P-Ø.

Psychedelics and mental health: a population study.

PloS one.

2013;8(8):e63972.

11.

Johansen P-Ø, Krebs TS. Psychedelics not linked to mental health problems or suicidal behavior: 71

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A population study. Journal of psychopharmacology. 2015;29(3):2709.

12. Carhart-Harris RL, Friston KJ. REBUS and the Anarchic Brain: Toward a Unified Model of the Brain Action of Psychedelics. Pharmacol Rev. 2019;71(3):316-44.

13. Vigo D, Thornicroft G, Atun R. Estimating the true global burden of mental illness. The Lancet Psychiatry.

2016;3(2):171-8.

14. Walker ER, McGee RE, Druss BG. Mortality in mental disorders and global disease burden implications: a systematic review and meta-analysis.

JAMA psychiatry. 2015;72(4):334-41.

15. Organization WH. Depression and other common mental disorders: global health estimates. World Health Organization; 2017.

16. Carhart-Harris RL. How do psychedelics work? Current opinion in psychiatry. 2019;32(1):16-21.

17. Ly C, Greb AC, Cameron LP, Wong JM, Barragan EV, Wilson PC, et al. Psychedelics Promote Structural and Functional Neural Plasticity. Cell Reports. 2018;23(11):3170-82.

18. Carhart-Harris RL, Erritzoe D, Haijen E, Kaelen M, Watts R. Psychedelics and connectedness.

Psychopharmacology.

2018;235(2):547-50.

19. Gandy S, Forstmann M, CarhartHarris RL, Timmermann C, Luke D, Watts R. The potential synergistic effects between psychedelic administration and nature contact for the improvement of mental health.

Health Psychology Open.

2020;7(2):2055102920978123.

20. Roseman L, Nutt DJ, Carhart-

Harris RL. Quality of acute psychedelic experience predicts therapeutic efficacy of psilocybin for treatment-resistant depression.

Frontiers in pharmacology.

2018;8:974.

21. Luoma JB, Chwyl C, Bathje GJ, Davis AK, Lancelotta R. A metaanalysis of placebo-controlled trials of psychedelic-assisted therapy. Journal of Psychoactive Drugs.

2020;52(4):289-99.

22. Muthukumaraswamy S, Forsyth A, Lumley T. Blinding and expectancy confounds in psychedelic randomised controlled trials. Expert Review of Clinical Pharmacology.

2021(justaccepted).

23. Riedlinger TJ, Riedlinger JE. Psychedelic and Entactogenic Drugs in the Treatment of Depression.

Journal of Psychoactive Drugs.

1994;26(1):41-55.

24. Sessa B. MDMA and PTSD treatment:“PTSD: from novel pathophysiology to innovative therapeutics”. Neuroscience letters.

2017;649:176-80.

25. Jerome L, Feduccia AA, Wang JB, Hamilton S, Yazar-Klosinski B, Emerson A, et al. Long-term followup outcomes of MDMA-assisted psychotherapy for treatment of PTSD: a longitudinal pooled analysis of six phase 2 trials. Psychopharmacology.

2020;237:2485-97.

26. Mithoefer MC, Feduccia AA, Jerome L, Mithoefer A, Wagner M, Walsh Z, et al. MDMA-assisted psychotherapy for treatment of PTSD: study design and rationale for phase 3 trials based on pooled analysis of six phase 2 randomized controlled trials.

72

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Psychopharmacology.

2019;236(9):2735-45.

27. Mitchell JM, Bogenschutz M, Lilienstein A, Harrison C, Kleiman S, Parker-Guilbert K, et al. MDMAassisted therapy for severe PTSD: a randomized, double-blind, placebocontrolled phase 3 study. Nature Medicine. 2021;27(6):1025-33.

28. Krebs TS, Johansen P-Ø. Lysergic acid diethylamide (LSD) for alcoholism: meta-analysis of randomized controlled trials. Journal of Psychopharmacology.

2012;26(7):994-1002.

29. Andersen KA, Carhart‐Harris R, Nutt DJ, Erritzoe D. Therapeutic effects of classic serotonergic psychedelics: A systematic review of modern‐era clinical studies. Acta Psychiatrica Scandinavica.

2021;143(2):101-18.

30. Johnson MW, Garcia-Romeu A, Cosimano MP, Griffiths RR. Pilot study of the 5-HT2AR agonist psilocybin in the treatment of tobacco addiction.

Journal of psychopharmacology.

2014;28(11):983-92.

31. Whiteford HA, Degenhardt L, Rehm J, Baxter AJ, Ferrari AJ, Erskine HE, et al. Global burden of disease attributable to mental and substance use disorders: findings from the Global Burden of Disease Study 2010.

The lancet. 2013;382(9904):1575-86.

32. Underwood MS, Bright SJ, Les Lancaster B. A narrative review of the pharmacological, cultural and psychological literature on ibogaine.

Journal of Psychedelic Studies.

2021;5(1):44-54.

33. dos Santos RG, Bouso JC, Hallak

JE. The antiaddictive effects of ibogaine: A systematic literature review of human studies. Journal of Psychedelic Studies. 2017;1(1):20-8.

34. Belgers M, Leenaars M, Homberg JR, Ritskes-Hoitinga M, Schellekens AF, Hooijmans CR. Ibogaine and addiction in the animal model, a systematic review and meta-analysis.

Translational psychiatry.

2016;6(5):e826-e.

35. Noller GE, Frampton CM, YazarKlosinski B. Ibogaine treatment outcomes for opioid dependence from a twelve-month follow-up observational study. The American journal of drug and alcohol abuse.

2018;44(1):37-46.

36. Cameron LP, Tombari RJ, Lu J, Pell AJ, Hurley ZQ, Ehinger Y, et al. A non-hallucinogenic psychedelic analogue with therapeutic potential.

Nature. 2021;589(7842):474-9.

37. Callahan D. The WHO definition of'health'. Hastings Center Studies.

1973:77-87.

38. Nour MM, Evans L, Carhart-Harris RL. Psychedelics, Personality and Political Perspectives. J Psychoactive Drugs. 2017;49(3):182-91.

39. Pavalache-Ilie M, Cazan A-M. Personality correlates of proenvironmental attitudes. International Journal of Environmental Health Research. 2018;28(1):71-8.

40. Blatchford E, Bright S, Engel L. Tripping over the other: Could psychedelics increase empathy?

Journal of Psychedelic Studies.

2021;4(3):163-70.

41. Castellanos JP, Woolley C, Bruno KA, Zeidan F, Halberstadt A, Furnish T. Chronic pain and psychedelics: a 73

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review and proposed mechanism of action. Regional Anesthesia & Pain Medicine. 2020;45(7):486-94.

42. Puspanathan P. Psychedelic research in Australia: Breaking through the stigma. Australian and New Zealand Journal of Psychiatry.

2017;51(9):940-1.

43. Bright S, Williams M. Should Australian psychology consider enhancing psychotherapeutic interventions with psychedelic drugs?

A call for research. Australian Psychologist. 2018;53(6):467-76.

44. Inserra A. Current status of psychedelic therapy in Australia and New Zealand: Are we falling behind?

Australian & New Zealand Journal of Psychiatry. 2019;53(3):190-2.

45. Michaels TI, Purdon J, Collins A, Williams MT. Inclusion of people of color in psychedelic-assisted psychotherapy: A review of the literature.

BMC psychiatry.

2018;18(1):1-14.

74

HOW DOES A HEALTH

PROFESSIONAL'S RIGHT TO

CONSCIENTIOUSLY OBJECT

ABORTION DIFFER BETWEEN

AUSTRALIA AND SWEDEN?

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Jasmine Davis

75

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This essay provides a comprehensive comparative policy analysis of Australia and Sweden of health professionals’ right to conscientious objection (CO) in the context of abortion. CO is a term given to the act of an individual objecting to performing a legal duty due to moral, religious or ethical grounds.[1] This analysis will focus on comparing policy content, and highlighting the policy implications for South Australia based on the Swedish approach to CO.

claim CO against abortion, being one of only a few countries to not allow CO in their abortion legislation.[4,5] CO is not frequently reported as an issue impacting women’s access to abortion in Sweden.[6] However, in 2014 two midwives sued an employer who ended their contract after learning they claimed CO against abortion, sparking debate in the nation as to whether CO should be allowed.[6,7] In recent times, the topic of CO has been prevalent in both jurisdictions.

In March 2021, South Australia (SA) became the latest state in Australia to completely decriminalise abortion through the Termination of Pregnancy Act 2021 (SA) (SA Act).

[2] The SA Act includes clauses pertaining to CO, allowing practitioners to conscientiously object to providing abortion services.[3] The SA Act highlights that there is no right of objection, and that practitioners must participate in abortion if it is necessary to save the woman’s life.

When practitioners do object, the SA Act requires that they refer the woman to another practitioner who does not hold a CO.[4] In Australia, abortion laws and policies vary between states and territories, and due to this, this analysis will focus on South Australia specifically as the most recent state to undergo reform.

Australia and Sweden are both socially and economically developed, however their policy positions on CO differ greatly. International bodies such as the International Federation of Gynaecology and Obstetrics (FIGO) claim that health professionals have a right to object to participating in procedures which contravene their personal beliefs.[8] However, extensive research has concluded that CO in many circumstances can impact women’s access to safe and timely abortion.[9,10] An examination of the reasons behind Sweden and Australia’s differing policy positions warrants exploration provides greater insight into how CO is best managed in order to ensure women have safe and timely access to legal abortion services.

In the Swedish Abortion Act 1974 (SFS 1974:595) (Swedish Act) practitioners have no legal right to

Policy Content Policy Objectives The objectives of South Australia’s policy position on CO is to balance both the woman’s right to abortion alongside the practitioner’s right to freedom of conscience.[11] This is a 76

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common objective among most Australian state and territory laws, as well as professional bodies that support CO.[12] The Swedish government’s policy position on CO is grounded in Swedish labour law, rather than abortion law. These labour laws claim that all individuals, regardless of their occupation, have a right to decide the nature of their work.[13] The objective of Sweden’s policy position however, is to place the provision of public health services above individual practitioners’ legal rights. In circumstances where an individual has an objection to providing abortion, an employer can decide not to employ that person if it is likely to impact the health services’ ability to provide abortion services.[14] Policy Outcomes As the SA Act is new, the policy outcomes are yet to be determined.

However, the likely outcomes of the South Australian policy position can be anticipated based on the experience of other Australian jurisdictions with comparable legislative frameworks such as Victoria. Victoria holds a similar policy position on CO in the context of abortion, and Section 8 of the Abortion Law Reform Act 2008 (Vic) (Victorian Act) states that CO is permitted, however objecting practitioners must refer the woman to a non-objecting doctor, and they must assist the woman in an emergency.[14] Research in Victoria has shown that CO to abortion is

misused by doctors, who at times do not refer the woman, attempt to delay women’s access or claim CO for reasons other than a genuine moral, religious or ethical opposition.[15] Currently, there is no research in South Australia on this issue, however there are clear gaps in the legislation, potentially providing opportunity for practitioners to similarly misuse CO. In Sweden, the policy position to not include CO rights in law was relatively uncontroversial.[19] The conversation around abortion in the country has previously been absent, with CO in particular not being a part of common discourse when speaking about abortion access.[15] The outcomes of this policy position have been that abortion is easily accessed in the country, and practitioners who do have a conscientious objection often find work in other areas of healthcare.

[14] Recommendations In South Australia, there is a need for regulation of CO to ensure women do not face barriers to accessing abortion because of conscientious objection.[15] The inclusion of referral requirements are one positive step which South Australia has taken to reduce the impact of CO on women’s access. Key recommendations for South Australian policy makers include: (1) Further research and analysis of the outcomes of the SA Act to determine whether or not practitioners are following mandatory referral, and if CO is impacting access in South Australia; and (2) oversight of practitioners should be examined, 77

with potential solutions such as formal registration and disclosure of CO status of practitioners made available to women seeking abortion.[16] CO is likely to remain part of Australian abortion legislation for the near future, however Australian advocates and policy makers can look to Sweden’s policy position in future reform to remove CO as a barrier to women accessing abortion.

About the Author Jasmine Davis is a dual Doctor of Medicine and Master of Public Health student at The University of Melbourne. She has previously completed a Bachelor of Biomedicine.

Originally from regional Victoria, Jasmine has a deep interest in rural medicine and health equity, and is passionate about advocating for those with poorer health outcomes. Jasmine currently sits on the AMSA National Executive as National Projects Officer and has previously held roles in AMSA Global Health, AMSA Convention and AMSA Rural Health teams.

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Correspondence jasmine.davis@amsa.org.au Conflicts of Interest Submitted as an assignment for University Acknowledgements None References

1. United Nations Human Rights office of the High Commissioner.

Conscientious Objection to Military Service [Internet]. Geneva: United Nations Publishing Service; 2013 Feb [cited 2021 May 30]. Available from: https://www.ohchr.org/Documents/Pu blications/ConscientiousObjection_en. pdf 2. SBS News. ‘Historic day for women’ as abortion officially decriminalised in South Australia [Internet]. Crows Nest: SBS News; 2021 Mar 3 [cited 2021 May 30].

Available from: https://www.sbs.com.au/news/historicday-for-women-as-abortion-officiallydecriminalised-in-south-australia 3.

South Australian Parliament.

Termination of Pregnancy Act 2021 [Internet]. South Australia: South Australian Parliament; 2021 Mar 11 [cited 2021 May 30]. Available from: https://www.legislation.sa.gov.au/LZ/V /A/2021/TERMINATION%20OF%20P REGNANCY%20ACT%202021_7/2021.7 .UN.PDF 4. Fiala C, Gemzell Danielsson K, Heikinheimo O, Guðmundsson JA, Arthur J. Yes we can! Successful examples of disallowing 'conscientious objection' in reproductive health care.

European Journal of Contraception and Reproductive Health Care. 2016 Jun;21(3):201-6.

5. Munthe C. Conscientious refusal in healthcare: the Swedish solution.

Journal of Medical Ethics. 2017 Apr;43(4):257-259.

6. Selberg R. The midwife case and conscientious objection: new ways of framing abortion in Sweden.

International Feminist Journal of Politics. 2020;22(3):312-334.

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7. International Campaign for Women’s Right to Safe Abortion.

Sweden: Where conscientious objection to abortion is not recognised by law [Internet].

Sweden: International Campaign for Women’s Right to Safe Abortion; 2017 Mar 17 [cited 2021 May 30].

Available from: https://www.safeabortionwomensri ght.org/news/sweden-whereconscientious-objection-toabortion-is-not-recognised-in-law/ 8. FIGO Committee for the Ethical Aspects of Human Reproduction and Women's Health.

Ethical guidelines on conscientious objection.

Reproductive Health Matters. 2006 May;14(27):148-149.

9. The University of Melbourne.

Doctors’ conscientious objection to abortion can affect women’s health: study [Internet]. Parkville: The University of Melbourne; 2019 Jan 31 [cited 2021 May 30]. Available from: https://about.unimelb.edu.au/newsr oom/news/2019/january/doctorsconscientious-objection-toabortion-can-affect-womenshealthstudy#:~:text=Under%20Section%20 8%20of%20the,profession%20who%2 0does%20not%20object 10. Chavkin W, Leitman L, Polin K; for Global Doctors for Choice.

Conscientious objection and refusal to provide reproductive healthcare: a White Paper examining prevalence, health consequences, and policy responses. International Journal of Gynaecology and Obstetrics. 2013 Dec;123 Suppl 3:S41-S56.

11. Williams J, Plater D, Brunacci A, Kapadia S, Oxlad M. Abortion: A review of South Australian Law and Practice [Internet]. Adelaide: South Australian Law Reform Institute; 2019 [cited 2021 May 31]. Available from: https://law.adelaide.edu.au/system/file s/media/documents/201912/Abortion%20Report%20281119.pdf 12. Australian Medical Association.

Conscientious Objection – 2019 [Internet]. Barton: Australian Medical Association; 2019 Mar 27 [cited 2021 May 31].

Available from: https://ama.com.au/positionstatement/conscientious-objection2019#:~:text=1.2%20A%20conscientious %20objection%20occurs,the%20circums tances%20under%20professional%20sta ndards 13. Munthe C. Conscientious refusal in healthcare: the Swedish solution.

Journal of Medical Ethics. 2017 Sep 1;43(4):257-259.

14. Victorian Parliament. Abortion Law Reform Act 2008 – Sect 8 [Internet].

Victoria: Victorian Parliament; 2008 [cited 2021 May 31]. Available from: http://www5.austlii.edu.au/au/legis/vic /consol_act/alra2008209/s8.html 15. Selberg R. New ways of framing abortion in Sweden [Internet]. Sweden: International Feminist Journal of Politics; 2019 Oct 28 [cited 2021 May 31].

Available from: https://www.ifjpglobal.org/blog/2019/8 /8/new-ways-of-framing-abortion-insweden 16. Chavkin W, Swerdlow L, Fifield J. Regulation of Conscientious Objection to Abortion: An International Comparative Multiple-Case Study.

Health and Human Rights. 2017 Jun;19(1):55-68.

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COVID-19

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Australia's Vaccine Rollout on the World Stage Isabella Vuong

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Graphic by Sharon Tu

August 2021 In February 2021, Australia’s federal government planned to vaccinate all Australian adults against the coronavirus disease 2019 (COVID-19)

by October.[1] To reach this goal, the government created a three-phase plan as part of the national roll-out strategy.[2] Currently, 30% of Australia’s eligible population have been fully vaccinated, corresponding to a global ranking below the top 50, according to The New York Times’ COVID World Vaccination Tracker.

[3,4] In the interim, the government abandoned this October double vaccination target and cited the goal as no longer achievable.[1] This article will explore the reasons behind Australia’s slow rollout of vaccines and propose potential solutions for the future.

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Why the delays?

A cautious government Whilst countries with highly successful vaccination strategies like the United Kingdom (UK) were proactive and signed agreements with vaccine companies during clinical trials, Australia was cautious and waited on the results of these trials from AstraZeneca and Pfizer.[5] This may have been a sensible choice by the Morrison Government since Australia’s COVID-19 crisis was minimal compared to other countries due to effective measures put in place to control cases in each state and

territory.[6,7] Indeed, the benefit of this strategy was that it provided the opportunity for health experts to observe rollout strategies in different countries as well as vaccine efficacy and adverse effects.[8] However, this decision made by the government ultimately failed because Australia faces a vaccine shortage whilst struggling to control the Delta strain COVID-19 outbreak in New South Wales and other states and territories.[9] This vaccine shortage is a problem because patients immunised with either the Pfizer or AstraZeneca vaccine had their risk of hospitalisation reduce by over 90%.[9] Consequently, the urgent allocation of extra vaccines to prioritise the most-affected local government areas in Sydney was required, including Pfizer doses redirected from NSW’s regional and rural supply.[9] Furthermore, the government did not account for limitations of vaccine delivery and storage, including the need for cold-chain storage of the Pfizer vaccine. [10] Long term storage of the vaccine requires ultra-cold temperatures of -90°C to -60°C, while up to two weeks is permitted for storage of the vaccine in domestic freezer temperatures of -25°C to -15°C and up to 5 days for domestic refrigerator temperatures of 2°C to 8°C.[10] As the government was slow to set up mass vaccination clinics, the system was consequently overly reliant on larger hospitals with access to appropriate storage, while general practices were only able to deliver

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AstraZeneca vaccines.

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Vaccine purchases In 2020, the Australian government secured agreements for the supply of four COVID-19 vaccines: AstraZeneca, UQ-CSL v451, Pfizer and Novavax.[1] However, later in the year, the Novavax vaccine was excluded from the government’s primary vaccination strategy, with doses originally expected to arrive in the second half of 2021 delayed until 2022.[11] The company attributed this delay to manufacturing issues, which affected the supply of data regarding the vaccine provided to the Australian Therapeutic Goods Administration (TGA) for assessment and approval.

[11] The decision to secure the AstraZeneca and UQ vaccines was on the basis that they could be produced locally.[12] However, the development of the UQ vaccine did not proceed past phase 1 of clinical trials after participants received false positive results in HIV tests, meaning that issues with screening would occur if the vaccine were to be used in the community.[13] Consequently, the local production of vaccines became solely reliant on AstraZeneca, causing problems later on during the rollout when international supplies of Pfizer were delayed and problems with AstraZeneca emerged, which will be expanded on later.[14,15] The outcome of the UQ vaccine was unpredictable. However, the

government should have secured a more diverse selection of vaccinations to prepare for these potential setbacks, rather than rely on just two locally produced vaccines.

The UK was successful in their vaccination rollout as they were proactive with securing multiple COVID-19 vaccines from different companies, which contributed to high vaccination coverage in the population and flexibility in the case of vaccine failures.[16] Delivery delays The AstraZeneca and Pfizer vaccines are the only two vaccines currently being distributed throughout Australia.[17] Although the AstraZeneca vaccine was eventually produced locally, Australia was initially 100% reliant on imports, which partially explained the slow start to the vaccine rollout.[12] The disadvantage of international shipping was delivery delays, evident across Australia. This was not only due to complications with importing the vaccine, but also supply shortages since the vaccine was being distributed to multiple nations.[18] In November 2020, Pfizer had already signed contracts for approximately 1 billion doses in 34 countries.[19] Shortages in Europe due to AstraZeneca being unable to meet its supply targets sparked a reaction by the European Union (EU), who restricted Pfizer and AstraZeneca vaccine exports to some countries including Australia.[14] The

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restrictions gave EU citizens priority until their domestic orders were met and allowed EU member nations where the vaccine was produced to refuse to authorise exports to non-EU countries.[14] With the EU denying the approval of 3.1 million vaccines to be imported into Australia in January 2021, further delays resulted.[14] This was then followed by Italy blocking the export of 250,000 AstraZeneca doses to Australia in March.[14] These events were detrimental to Australia’s vaccine rollout as Australia was heavily reliant on imports at the time, with AstraZeneca doses just being released towards the end of March by local manufacturer, CSL. [12,20]

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Delivery delays also occurred within Australia due to geographical challenges.[21,22] During the 2021 wet season, flash-flooding and road closures affected areas in Sydney and coastal New South Wales.[21,22] Therefore, this further compromised vaccine deliveries, especially to various remote and regional communities.[21,22] These issues may not have been as pertinent to other countries with geographically concentrated populations, such as Singapore and Israel.[8,23] Federal and state government inconsistency In June 2021, the Prime Minister made a statement opposing medical advice, encouraging Australians aged 18-40 years who wanted the AstraZeneca vaccine to talk to their doctor and ‘get the jab’.[24] The intent

was to extend the availability of vaccines to a wider population.[24] However, this statement was disputed by state governments, particularly by Queensland’s Chief Health Officer Jeannette Young, who stood by the advice from the ATAGI that the Pfizer vaccine was the preferred vaccine for those aged 16 to under 60 years.[15,25] This was on the basis of the risk versus benefits profile, where the risk and severity of thrombosis and thrombocytopenia syndrome (TTS) was higher in the 50-59 year old age group with the AstraZeneca vaccine, compared to the risks associated with contracting the virus.

[15] The evolving medical advice was expected due to the rapidly changing course of disease and the ongoing influx of new data. However, the problem seemed to lie in the inconsistent advice and lack of communication between the federal and state governments.

This inconsistency generated confusion amongst the Australian community and may have contributed to vaccine hesitancy with AstraZeneca, which was detrimental to Australia’s vaccination campaign that was already reliant on AstraZeneca doses.

In addition to the discrepancies in governmental health advice, there were many other factors that contributed to vaccine hesitancy, such as misinformation and fear mongering through wide-spread antivaccination campaigns, safety and efficacy concerns and distrust in government and health organisations.

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[26,27] These factors posed problems to reaching high vaccine coverage in Australia and across the world, highlighting the importance for governments to address these issues and concerns appropriately.

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Lessons from overseas Comparing Australia’s vaccine rollout to other countries is difficult due to varying populations, geographical concentrations, severity of outbreaks and capabilities to locally produce a supply of vaccines.[8] Regardless, strategies such as those implemented in Israel, one of the most successful countries in vaccinating its population against COVID-19, can be utilised in Australia to improve rates of inoculation.[23,28] Israel is a world leader in the vaccination rollout.[28] One reason was that their government arranged for modifications to the packaging of vaccine doses so that smaller quantities could be transported to specific areas, such as aged-care and retirement homes, Indigenous and rural communities.[28] Australia can learn from their sustainable storage and distribution of vaccines that ensured high-risk populations had access to doses and wastage was minimised.[28] Also, Israel has a digitalised healthcare system, giving the advantage of rapid and effective communication.[23] Their vaccination scheduling was simplified as health organisations were able to find and contact target groups throughout the different phases of

their rollout.[23] Vaccine confidence was promoted through tailored messaging to diverse populations via multiple media outlets, such as social media, organisational websites and mass media.[28] This tailored messaging involved working with community leaders including religious leaders, social media influencers and trusted health professionals to encourage local community engagement and cooperation.[28] Israelis were also given an incentive to get vaccinated through the ‘Green Pass’ initiative, which allowed those aged 12 and over with a vaccination/recovery certificate or a negative test, to enter complexes holding over 100 people (e.g. restaurants, bars, cultural/sporting events, houses of worship).[29] This was a step to reopening society and benefitted their economy.[23] Conclusion Australia had a slow start to the vaccination rollout compared to most economically developed countries around the world, due to a cautious government, poor vaccine purchase choices, delays in vaccine delivery and inconsistent advice. As the rollout begins to accelerate, improvements can be made to work towards minimising serious illness due to COVID-19 and easing restrictions and lockdowns. Nations that excelled in their vaccine rollout, such as Israel, had effective distribution methods, promoted vaccine confidence, incentivised their citizens to be

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immunised and, most importantly, provided clear communication to build public trust and confidence.

Apart from clearer and more congruent communication from the government regarding vaccination advice, Australia can introduce initiatives suitable to the Australian population to encourage vaccination, such as food or recreational vouchers.

[30] In addition, more decentralised vaccination sites including mobile hubs and drive through vaccination centres, should be introduced to not only increase access to the vaccine in more communities, but to enhance the convenience of receiving immunisations. Ultimately, the goal is to reach herd immunity and with children and adolescents, especially those under 12 years old yet to have an approved vaccine, double vaccinating the eligible adult population is essential.[15] However, with Australia’s slow vaccination coverage, herd immunity is not likely a feat in the foreseeable future.

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About the Author Isabella Vuong is a 4th yr Bond University medical student, with special interests in child and refugee health. She is a co-president of the Bond University Paediatric Club.

Correspondence isabella.vuong@student.bond.edu.au Conflicts of Interest None declared

Acknowledgements None References 1. Remeikis A. From the front to the back of the queue: how Australia’s vaccine rollout unravelled. The Guardian. Published July 9, 2021.

Accessed 22th July, 2021. https://www.theguardian.com/australi a-news/2021/jul/09/from-the-frontto-the-back-of-the-queue-howaustralias-vaccine-rollout-unravelled 2. Department of Health. Australia's COVID-19 vaccine national roll-out strategy.

Australian Government Department of Health. Published January 7, 2021. Updated February 17, 2021. Accessed 25th July, 2021. https://www.health.gov.au/sites/defau lt/files/documents/2021/01/covid-19vaccination-australia-s-covid-19vaccine-national-roll-out-strategy.pdf 3. Department of Health. COVID-19 Vaccine Roll-out.

Australian Government Department of Health.

Published July 31, 2021. Accessed 31st July, 2021. https://www.health.gov.au/sites/defau lt/files/documents/2021/07/covid-19vaccine-rollout-update-31-july2021.pdf 4. Holder J. Tracking Coronavirus Vaccinations Around the World. The New York Times. Updated July 31, 2021. Accessed 31st July, 2021. https://www.nytimes.com/interactive /2021/world/covid-vaccinationstracker.html 5. Mintzes B, Parker L, Chiu K. Should Australians be worried about waiting for a COVID vaccine?. The

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University of Sydney. Published December 4, 2020. Accessed 25th July, 2021. https://www.sydney.edu.au/newsopinion/news/2020/12/04/shouldaustralians-be-worried-aboutwaiting-for-a-covid-vaccine.html 6. Mintzes B, Parker L, Chiu K. Should Australians be worried about waiting for a COVID vaccine?. The University of Sydney. Published December 4, 2020. Accessed 25th July, 2021. https://www.sydney.edu.au/newsopinion/news/2020/12/04/shouldaustralians-be-worried-aboutwaiting-for-a-covid-vaccine.html 7. Saunokonoko M. Not a race? The graphs that rank Australia dead last. 9 News. Published June 30, 2021.

Accessed 25th July, 2021. https://www.9news.com.au/national/c oronavirus-australia-dead-last-inoecd-for-vaccinatedpeople/51dbd565-25fe-4e07-891f2c689c39c467?ocid=Social-9News 8. Cheng J, Souisa H, Jackson W. How does Australia's vaccination efforts compare with other Asia-Pacific countries?. ABC News. Published April 18, 2021. Accessed 25th July, 2021. https://www.abc.net.au/news/202104-18/how-australia-vaccinationcampaign-compare-asiapacific/100068864 9. Willis O. NSW is adapting its COVID vaccine strategy. Should we be diverting vaccines there too?. ABC News. Published August 2, 2021.

Accessed 30th August, 2021. https://www.abc.net.au/news/health/2

021-08-02/nsw-adapting-covid-19vaccine-strategy/100335702 10.

Department of Health Therapeutic Goods Administration.

Wider storage and transportation conditions for the Pfizer COVID-19 vaccine now approved. Australian Government Department of Health.

Published April 8, 2021. Accessed October 4, 2021. https://www.tga.gov.au/mediarelease/wider-storage-andtransportation-conditions-pfizercovid-19-vaccine-now-approved 11. Martin S. Major delay in Australian government’s Novavax deal, with 51m doses not expected until 2022. The Guardian. Published July 27, 2021.

Accessed 30th August, 2021. https://www.theguardian.com/australi a-news/2021/jul/27/major-delay-infederal-governments-novavax-dealwith-51m-doses-not-expected-until2022 12. Department of Health. Australia’s vaccine agreements.

Australian Government Department of Health.

Updated May 26, 2021. Accessed 23th July, 2021. https://www.health.gov.au/initiativesand-programs/covid-19vaccines/covid-19-vaccinegovernment-response/australiasvaccine-agreements#university-ofoxfordastrazeneca 13. UQ. Update on UQ COVID-19 vaccine.

The University of Queensland. Published December 11, 2020. Accessed 23th July, 2021. https://www.uq.edu.au/news/article/2 020/12/update-uq-covid-19-vaccine 14. Hawke J. European Union denies

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claim it blocked shipment of 3.1 million AstraZeneca COVID vaccines to Australia. ABC News. Published April 7, 2021. Accessed 24th July, 2021. https://www.abc.net.au/news/202104-07/eu-denies-blocked-shipmentover-3-million-vaccines-toaustralia/100052134 15. Department of Health. ATAGI statement on revised recommendations on the use of COVID-19 Vaccine AstraZeneca, 17 June 2021. Australian Government Department of Health. Published June 17, 2021. Accessed 23th July, 2021. https://www.health.gov.au/news/atagi -statement-on-revisedrecommendations-on-the-use-ofcovid-19-vaccine-astrazeneca-17june-2021 16. Randall T, Sam C, Tartar A, Cannon C. Covid-19 Deals Tracker: 9.6 Billion Doses Under Contract.

Bloomberg. Updated March 10, 2021.

Accessed 30th August, 2021. https://www.bloomberg.com/graphic s/covid-vaccine-tracker-globaldistribution/contracts-purchasingagreements.html 17. Swain S. How to get a COVID-19 vaccination: State-by-state guide. 9 News. Published July 30, 2021.

Accessed 31th July, 2021. https://www.9news.com.au/national/c oronavirus-vaccine-update-australiastate-by-state-guide-who-can-getcovid19-vaccine-explainer/103ad605d711-4b06-8334-8f26731561b1 18. Boffey D. Italy blocks export of 250,000 AstraZeneca vaccine doses to Australia. The Guardian. Published

March 5, 2021. Accessed 23th July, 2021. https://www.theguardian.com/world/ 2021/mar/04/italy-blocks-export-of250000-astrazeneca-vaccine-dosesto-australia 19. Martino M. Chris Bowen says other countries struck deals for a billion doses of the Pfizer vaccine before Australia signed its agreement.

Is he correct?. ABC News. Published March 11, 2021. Accessed 23th July, 2021. https://www.abc.net.au/news/202103-11/fact-check-pfizer-vaccinedeals-made-around-theworld/13233572 20. CSL. Local Manufacturing of COVID-19 Vaccine Reaches Final Stages. CSL. Published February 12, 2021. Accessed 30th August, 2021. https://www.csl.com/news/2021/2021 0212-local-manufacturing-of-covid19-vaccine-reaches-final-stages 21. Tsirtsakis A. ACCHOs face challenges of vaccine rollout to remote communities.

RACGP. Published February 5, 2021. Accessed 24th July, 2021. https://www1.racgp.org.au/newsgp/pr ofessional/acchos-face-logisticalchallenges-of-vaccine-rollo 22. SBS. Flooding disrupts COVID-19 vaccine deliveries in NSW. SBS News.

Updated March 21, 2021. Accessed 24th July, 2021. https://www.sbs.com.au/news/floodin g-disrupts-covid-19-vaccinedeliveries-in-nsw 23.

Philo H. Israel’s COVID vaccination success. KPMG. Published 2021. Accessed 26th July, 2021.

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https://home.kpmg/xx/en/home/insi ghts/2021/04/israel-covidvaccination-success.html 24. Khorshid O. Changes to vaccine rollout - doorstop transcript from AMA President Dr Omar Khorshid.

AMA. Published June 29, 2021.

Accessed 26th July, 2021. https://www.ama.com.au/media/chan ges-vaccine-rollout-doorstoptranscript-ama-president-dr-omarkhorshid 25. Layt S. ‘This is getting silly’: Qld CHO defends her AstraZeneca vaccine advice. Brisbane Times.

Published July 1, 2021. Accessed 26th July, 2021. https://www.brisbanetimes.com.au/na tional/queensland/this-is-gettingsilly-qld-cho-defends-herastrazeneca-vaccine-advice20210701-p585wt.html 26.

Trogen B, Pirofski LA. Understanding vaccine hesitancy in COVID-19. Med (N Y). 2021;2(5):498501. doi:10.1016/j.medj.2021.04.002. https://www.ncbi.nlm.nih.gov/pmc/ar ticles/PMC8030992/ 27. Eniola K, Skyes J. Four reasons for COVID-19 vaccine hesitancy among health care workers, and ways to counter them. American Academy of Family Physicians. Published April 27, 2021. Accessed October 4, 2021. https://www.aafp.org/journals/fpm/bl ogs/inpractice/entry/countering_vacc ine_hesitancy.html 28. Choi Y, Stall NM, Maltsev A, et al.

Lessons Learned from Israel’s Vaccine Rollout. Ontario COVID-19 Science Advisory Table. Published February 1, 2021. Accessed 26th July,

2021. https://covid19sciencetable.ca/sciencebrief/lessonslearned-from-israels-vaccine-rollout/ 29. Israeli Ministry of Health. What is a Green Pass?. Israeli health.gov.

Published 2021. Accessed 26th July, 2021. https://corona.health.gov.il/en/directi ves/green-pass-info/ 30. Baker E. Million-dollar cash prizes and free eggs offered to encourage COVID-19 vaccinations.

ABC News. Published May 24, 2021.

Accessed 26th July, 2021. https://www.abc.net.au/news/202105-24/australia-covid-19-incentivesto-encourage-vaccinations/100161624

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