AJGH Volume 15 Issue 1

Unmasked AMSA Journal of Global Health

Volume 15 | Issue 1 | June 2021 | Est. 2006

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AJGH 2021 Volume 15 Issue 1 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

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PEER REVIEWERS Dr Joanne Durkin Dr Shinwoo Choi Dr David Legge Dr Eleonor Marcussen EDITOR-IN-CHIEF MasrurJoarder SENIOR EDITORS Pabasha Nanayakkara Christine Manuel ASSOCIATE EDITORS Shani Nguyen Michael Tanner Tanish Rao Stephanie Sardinha Rachel Loh Michelle Phu PROMOTIONS DIRECTORS Elisa Lie Lawrence Lin 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 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.

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UNMASKED Peel through layers of Skin, Fat and Bone Let us seek to find that which we long Deeper and deeper We dig in our search Knowing what's buried Is meant to be unearthed Through soil, bedrock and lava To get to the untouched bottom Go down the rabbit hole with us, In AMSA's Journal of Global Health Remove your mask and turn the page To unmask is to reveal what is fact To unmask is to unveil hidden truths.

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THE AJGH TEAM

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STNETNOC

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THE MIDAS TOUCH A world without touch is a world without connection Erica Longhurst

COVID-19, RACISM AND ENVIRONMENTALISM Why intersectional activi matters Georgia Brown

COVID-19 VACCINATION Which vaccination path should we follow?

Nitika Govind

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COVID-19 HAS UNMASKED THE GLOBAL HEALTH THREAT OF POPULIST LEADERS Michael Tanner

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NATIONALISM AND VACCINE SECURITY Mansimran Loyal

CAN OUR APPROACH TO SEASONAL INFLUENZA CHANGE? The impact of pandemic prevention on seasonal influenza Anna Postema

UNMASKED: AUTISM IN WOMEN Jacqueline Bredhauer

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COVID-19 HAS UNMASKED THE GLOBAL HEALTH THREAT OF

POPULIST LEADERS

Volume 15 | Issue 1 | June 2021

Michael Tanner

“Medicine is a social science,” opined Alexander Virchow, a physician whose name echoes down the halls of medicine’s history. “And politics is nothing but medicine on a larger scale”.[1] 2020 was, for many, the first year in which was witnessed the effect of public policy on health. It also unmasked the incompetence of a host of global leaders who rode to power a wave of right-wing populism; a wave that has, and will continue to, pose a challenge to all aspects of

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Graphic by Christine Manuel

global health: the control of Covid-19; climate change; international conflict; the plight of refugees; and in many cases, democracy itself.

Bolsonaro [4] dismissing the threat of Covid-19, making rampant the term “fake news”.

A Declining Trust in Medicine A populist is a leader who attempts to appeal to ordinary people, portraying their concerns as disregarded by “the establishment”; more importantly, claiming that they alone represent the people.[2] Donald Trump is the quintessential example.

Boris Johnson, in the United Kingdom, is another. Jair Bolsonaro, president of Brazil; Narendra Modi, of India; Viktor Orban, of Hungary; and Scott Morrison, Australia’s Prime Minister, all fit the mould. While these leaders typically sit on the right side of the political spectrum, Mexico’s Andrés Manuel López Obrador is a populist who lies to the left.

These messages have serious global health consequences. Chief among these is the result of declining trust in medicine.[5] Poor control of the pandemic and a sluggish vaccine rollout can be directly traced to populism; in particular, the sowing of distrust of science and scientists.

Mexico’s government published posters claiming “no es grave”, or “is not serious”;[6] Trump, for months, assured the US that the virus would disappear; Britain’s “Eat out to help out” scheme, giving diners a discount on their food, contributed to the United Kingdom’s second wave.[7] By many metrics, countries led by populists that dismissed the threat of Covid-19 suffered the most serious consequences.[8] Of countries with over one million inhabitants, Hungary has the second highest percapita death rate in the world; the United Kingdom is eight, with the highest of any large country. The United States were languishing in a wave that was claiming over four thousand deaths per day prior to Joe Biden’s inauguration; Brazil is almost there now, at the time of writing, recording the highest death toll to date in the pandemic, with most intensive care units overrun, and shortages of everything from oxygen to sedatives used for intubation.[8,10]

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While appealing to “ordinary people” is, in many ways, a hallmark of a functioning democracy, issues arise when this is coupled with fermenting distrust of the establishment and socalled elites. It varies, who is this establishment and who are these elites.

Sometimes, particularly in the case of left-wing populists, it is formed around socio-economic grievances and inequality.[2] For others it is around nationality, race, and immigration: typical of Modi’s India, and playing a role in Trump’s America.

Sometimes it is big businesses, or the political elites.

Other times it is science and the media – think Trump [3] and

Consequences of poorly controlling Covid-19 or ineffectively rolling out 7

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the vaccine go beyond the morbidity and mortality of the disease. The first wave of Covid-19 devastated Brazil; the city of Manaus was hit particularly hard. An October 2020 seroprevalence study of blood donors suggested that 76% (95% confidence interval 67-98) of the city had been infected with Sars-CoV-2.[9] Yet 2021 brought with it a worse, second wave, corresponding with the detection of the P1 variant of Sars-CoV-2. More transmissible and more lethal than the original,[10] the P1 variant also evade some inherited immunity offered from a previous infection; vaccines may not provide adequate protection. The longer the virus can spread in a community, the more mutations may develop; mutations that may have a better ability to evade the immunity conferred by either vaccination or past infection.

exposed to a heatwave in 2018, a new record.

Then there are the downstream effects. The exacerbation of poverty; displacement; violent conflict; and mental illness.

Not only have populist leaders, in recent years, been slow to act on climate change, they have often dismissed the threat and acted in ways to exacerbate its harmful effects.

Mr Bolsonaro has overseen rampant deforestation [13] in the Amazon, to a 12-year high. Mr Trump withdrew [14] from the Paris agreement and reversed a host of Environmental Protection Agency regulations on carbon emissions. Mr Morrison promised a “gas-led” recovery;[15] the International Monetary Fund estimates Australia offers $30 billion in subsidies to fossil fuels,[16] with sparse if any going to renewable energy. Mr Orban and Hungary, too, have rolled back climate policies.[11]

Populism and Climate Inaction The global health consequences of populism go beyond those attributable to Covid-19. Countries governed by populist leaders have been dragging their feet on climate change,[11] the biggest global health threat the world faces.

The effects of climate change on health are profound.[12] Yields are decreasing for all major crops, threatening food security. Dengue Fever is enjoying year after year of its most favourable conditions for transmission. Air pollution damages each and every organ; in 2016, the number of deaths attributable to global air pollution hit seven million.

Some 220 million people were

A Refugee Crisis Further consider the plight of refugees. There are 26 million people worldwide seeking safety.[17] Persecution and war and, increasingly, the effects of climate change, are leading reasons that people flee their home country. Each is associated with populist politics.

On the right, populism is commonly associated with nationalist and antiimmigration ideas. People not from the country become “the other”. This gives motive not just to deny people refuge, but to expand defence spending, protecting against “the other”, whomever that may be.

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Mr Trump built a wall to Mexico. Mr Orban, during the so-called European Migrant Crisis, built a barbed-wire fence at the border with Croatia and Serbia,[18] preventing refugees escaping Syria, Afghanistan and Iraq in the Middle East, and Kosovo and Albania in Europe – seeking asylum in Europe. He has also nearly doubled [19] the country’s defence spending over the last five years. Closer to home, “Stop the boats” has been a core feature of the Coalition government policy for years.[20]

ground for the rise of extremism.

“The risk of radicalisation is heightened where refuges find themselves in protracted situations: marginalized, disenfranchised, and excluded”. These conditions are a core feature of populist, nationalist policy.

A Threat to Democracy Beyond the threats of Covid-19, climate change and refugee health, democracy itself is at stake. This is possibly the greatest threat of all.

Often has populism slid into autocracy, or attempts to claim autocracy. Hungary and India are sliding towards authoritarianism in recent years. Donald Trump spent an entire election cycle attempting to undermine the democratic system and the free nature of the USA’s elections. Australia, too, has backslid in its democratic openness. There are fears that Mr Bolsonaro will seek to return Brazil to the military dictatorship it was between 1964 and 1985. Hungary and India have both experienced “democratic backsliding” under their current leaders.

A 2019 study published in The Lancet [23] concluded that democracy is good for public health. The transition from autocracy to democracy improved, after 10 years, life expectancy by 3%. The link between income and health as long been known; this effect is outweighed by the power of “the democratic experience”, which explains a greater degree of variation than GDP between countries for outcomes including cardiovascular disease,

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Failure to provide safe havens for refugees has consequences. Some are very clearly evident. People in refugee camps tend to have poorer health than those in the countries they fled from, attesting to the health consequences of the journey.

Communicable diseases including diarrheal diseases, malaria, sexually transmitted infections and measles are rampant. One study found that 63% of health problems in a refugee camp in Calais, France, were associated with living in the camp.

There are also challenges to managing non-communicable diseases, with medications in short supply.[21] Recipient countries are not spared the harms of their own policies. “The arrival of large refugee populations, when not properly handled, increases the risk of attacks in recipient countries”.[22] Emphasis on “when not properly handled”. Over-crowded and underfunded camps plus a lack of education or work provides fertile 9

tuberculosis, transport injuries, cancers, cirrhosis, and noncommunicable diseases in general.

These contribute a quarter of death and disability in individuals younger than 70 in low- and middle-income countries.

Democracy is good, and populism bad, for health. Particularly global health. Covid-19 has unmasked harms associated with populist leaders, from undermining trust with science and leaving Covid-19 to spread unchecked; to failure to act on climate change; to blocking the safe haven of refugees; to threatening democracy itself. These challenges have serious consequences.

About the Author Michael is completing the MD/PhD pathway at Monash University and a freelance writer, who covers the interaction between politics, public policy, the media and health.

Conflicts of Interest None

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Correspondence michael.tanner@monash.edu Acknowledgements None References 1.Mackenbach JP. Politics is nothing but medicine at a larger scale: reflections on public health's biggest idea. Journal of epidemiology and community health. 2009;63(3):181-4.

2. Bryant O & Moffit B. What actually

is populism? And why does it have a bad reputation?

[Internet].

The Conversation. 2019. Available from: https://theconversation.com/whatactually-is-populism-and-why-doesit-have-a-bad-reputation-109874 3. Shear, M & Stolberg, SG. With Winter Coming and Trump Still in Charge, Virus Experts Fear the Worst [Internet]. The New York Times.

2019. Available from: 4. Anderson, JL. Brazil’s Covid-19 Crisis and Jair Bolsonaro’s Presidential Chaos [Internet]. The New Yorker. 2021. Available from: https://www.newyorker.com/news/da ily-comment/brazils-covid-19-crisisand-jair-bolsonaros-presidentialchaos 5. Funk C & Kennedy, B. Public Confidence in Scientists has Remained Stable for Decades [Internet]. Pew Research Centre.

2020.

Available from: https://www.pewresearch.org/facttank/2020/08/27/public-confidencein-scientists-has-remained-stable-fordecades/ 6. Leonhardt D and Leatherby L. Where the Virus is Growing Most: Countries With ‘Illiberal Populist’ Leaders [Internet]. 2020. The New York Times Available from: https://www.nytimes.com/2020/06/0 2/briefing/coronavirus-populistleaders.html 7. Macaskill, A. 'Eat out to help out' offer contributed to UK second COVID wave: study [Internet].

Reuters.

2020.

Available from: https://www.reuters.com/article/ushealth-coronavirus-britain-vouchersidUKKBN27F1IR 10

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8.Dong E, Du H, Gardner L. An interactive web-based dashboard to track COVID-19 in real time. Lancet Infect Dis; published online Feb 19.

9. Sabino EC, Buss LF, Carvalho MPS, Prete CA, Jr., Crispim MAE, Fraiji NA, et al. Resurgence of COVID-19 in Manaus, Brazil, despite high seroprevalence.

The Lancet.

2021;397(10273):452-5.

10. Coutinho RM, Marquitti FMD, Ferreira LS, Borges ME, da Silva RLP, Canton O, et al. Model-based evaluation of transmissibility and reinfection for the P.1 variant of the SARS-CoV-2. medRxiv.

2021:2021.03.03.21252706.

11. Kashdan A. The Rise of Populism and the Fall of Climate Action [Internet]. Yale School of Forestry & Environmental Studies.

2020.

Available from: https://www.arcgis.com/apps/Cascade /index.html? appid=14c033aa48e14976831104d98cd 608a7 12. Watts N, Amann M, Arnell N, Ayeb-Karlsson S, Belesova K, Boykoff M, et al. The 2019 report of The Lancet Countdown on health and climate change: ensuring that the health of a child born today is not defined by a changing climate. The Lancet. 2019;394(10211):1836-78.

13. Phillips, T. Amazon deforestation surges to 12-year high under Bolsonaro [Internet]. The Guardian.

2020.

Available from: https://www.theguardian.com/enviro nment/2020/dec/01/amazondeforestation-surges-to-12-year-highunder-bolsonaro 14. Gross, S. What is the Trump

administration’s track record on the environment?

[Internet].

The Brookings Institute. 2020. Available from: https://www.brookings.edu/policy202 0/votervital/what-is-the-trumpadministrations-track-record-on-theenvironment/ 15. Morton, A. Scott Morrison’s ‘gasled recovery’: what is it and will it really make energy cheaper?

[Internet]. The Guardian. 2020.

Available from: https://www.theguardian.com/enviro nment/2020/sep/17/scott-morrisonsgas-led-recovery-what-is-it-and-willit-really-make-energy-cheaper 16. Coady D, Parry I, Nghia-Piotr L, Baoping S. Global Fossil Fuel Subsidies Remain Large: An Update Based on Country-Level Estimates.

The International Monetary Fund.

2019.

17.

Amnesty International.

The world's refugees in numbers [Internet]. Amnestry International 2021.

Available from: https://www.amnesty.org/en/whatwe-do/refugees-asylum-seekers-andmigrants/global-refugee-crisisstatistics-and-facts/ 18. Berend N. Hungary, the Barbed Wire Fence of Europe [Internet]. EInternational Relations.

2017.

Available from: https://www.eir.info/2017/06/12/hungary-thebarbed-wire-fence-of-europe/ 19. Inotai E. Hungarian ‘Militarisation’ Under Orban Stirs Concern [Internet]. Reporting Democracy.

2020.

Available from: https://balkaninsight.com/2020/07/2 9/hungarian-militarisation-under11

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orban-stirs-concern/ 20. Boochani B. ‘The boats are coming’ is one of the greatest lies told to the Australian people [Internet].

The Guardian. 2019. Available from: https://www.theguardian.com/comm entisfree/2019/jul/02/the-boats-arecoming-is-one-of-the-greatest-liestold-to-the-australian-people 21. Daynes L. The health impacts of the refugee crisis: a medical charity perspective [Internet]. Clin Med. 2016;16(5):437-40.

22. Mbiyozo AN. Fleeing terror, fighting terror: the truth about refugees and violent extremism[Internet].

Relief Web. 2018.

23. Bollyky TJ, Templin T, Cohen M, Schoder D, Dieleman JL, Wigley S. The relationships between democratic experience, adult health, and cause-specific mortality in 170 countries between 1980 and 2016: an observational analysis. The Lancet.

2019;393(10181):1628-40

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MIDAS TOUCH A WORLD WITHOUT TOUCH

IS A WORLD WITHOUT CONNECTION

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Erica Longhurst The congratulatory pat on the back from your soccer coach after you score a goal. The leap into a loved one’s arms after an awaited reunion.

The shaking of a doctor’s hand after they tell you that they will be the one taking you into surgery. Touch has been integral for humans since the beginning of time. We cannot explain touch purely in terms of the proprioceptors that receive and the dorsal root ganglia that transmits its impulse. It is about forming an interpersonal connection. Touch has been an important aspect of human interaction for eons, and the lack of it

has come to the forefront with the increased number of people affected by a lack of it during COVID19. So going forward, what will a world post COVID19 look like? Will we continue to, subconsciously or consciously, social distance?

The importance of touch is seen in all aspects of medicine. Babies that are held experience better health outcomes, socially and neurodevelopmentally than those who are shown little affection. In neonatology, kangaroo care (when a newborn is strapped to the chest of their mother

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or another human) can stabilise newborn heart and respiratory rates.

[1] Touch is also the sensory stimulation necessary to reach developmental milestones.[2] In Psychology, pain stimulation studies have shown that when women held their partner’s hands, they experienced less pain than when they were by themselves.[3] Touch starvation, or a long period of time without touch, has been shown to have a corresponding relationship with rates of depression according to Beyond Blue.[8] It’s also increasingly common. Touch is able to reduce stress, lower blood pressure, heart rate and activate the parasympathetic nervous system. That sounds like the profile for a wonder drug as it has no side effects!

There is an electric difference when humans are able to hug a loved one during a stressful or difficult experience – often words are superfluous and not what we are craving. Likewise, it is understandable how much comfort touch is able to provide to support to those scared of undergoing something incredibly stressful, such as surgery. Touch can save us from loneliness. Our mental health is such a beautiful and delicate part of who we are, and it makes sense that the care that we show each other boosts the way we feel.

Substituting COVID-19

Touch

home gardening, with plant nurseries struggling to cope with demand as new gardeners attempt to create oases and vegetable gardens in their backyards.[4] There are many reasons for this: ample free time, an interest in trying something new, life confined to our homes, and the joy of providing ourselves with fresh and nutritious food to enjoy. There is also the theory that we long to touch living things, to feel their vitality between our fingers.

[10] How satisfying is it to knead bread and then watch it rise, as though it is alive?

During our social isolation we have been substituting touch with video calls, meme tagging, gifs and long texts to share our feelings.[9] These are effective ways of communicating but we must recognise them for what they are – substitutes. Nothing can fully replace the value that is derived from connecting physically with each other. The number one thing that Australians were looking forward to doing after social isolation restrictions cease was to hug their loved ones.

COVID-19 has been a period where we test the extremes – what happens when we are dependent on technology for the majority of our interactions with each other? This saturation will help us see how important it is to have a healthy relationship with technology and value it as a flavouring to life rather than the meal.

During

Touch is not solely limited to human contact. We can also seek it in the world around us. 2020 saw a surge in

A Doctor’s Touch Of Aristotle's five senses,[5] touch is perhaps the most important part of being a good doctor. Being a doctor 14

doctor means wearing many hats and one of the most frequently donned is that of the carer. Touch in the time of COVID-19 has become a prominent concern. Telehealth is not yet in focus as a linchpin of healthcare delivery, but with the growing demand for technologically dependent means of communication, it may soon become a mainstay.[6]

by staying 1.5 metres from each other. Heartbreaking stories of families unable to visit their dying loved ones infected with COVID19 have numbed our society. A world without touch means losing one of the most beautiful aspects of who we are. There is so much that we gain through being there for each other.

Whatever happens, we remain a resilient species.

"NOTHING CAN FULLY REPLACE THE VALUE THAT IS DERIVED FROM CONNECTING PHYSICALLY WITH EACH OTHER."

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Telehealth removes one of the most critical aspects of being a good doctor – eliciting clinical signs through examination. With the touch of our fingers, we are guided to the pathologies of diseases; the triad of jaundice, fever and right upper quadrant pain was a diagnostic criterion for cholecystitis long before the advent of CT scans.[7] Many doctors have cited the significance of touch in a healthcare setting, both as a means of clarifying disease and of creating a bond of trust and openness between doctor and patient.[8] There are endless reasons to admire the healing and transformative nature of touch. What will our world look like when social distancing ceases but the fear of transmission persists? Our society has transformed from one which prided itself on its large music concerts, with arm bumping wonderfulness, to one where sterility and ‘cleanliness’ can only be achieved

We won’t let the corrosive nature of fear eat into our connections with each other, we are stronger than that.

We just must not forget the importance of touch and hopefully when we return to ‘normal’ we will value it even more.

About the Author Erica is a final year medical student at the University of New South Wales (UNSW). She has a strong passion for global health and writing. Erica is also part of the AJGH team in her role as a podcast producer for The Global Health Chat.

Correspondence erica.longhurst@amsa.org.au Acknowledgements None Conflicts of Interest None

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References 1. Ardiel, E. L., & Rankin, C. H. 2010.

The importance of touch in development. 15(3), 153–156. Available from https://doi.org/10.1093/pch/15.3.153 2. Kelly, Martina MB BCh BAO, MA; Tink, Wendy MD, BSc, FCFP; Nixon, Lara MD, FCFP Keeping the Human Touch in Medical Practice, Academic Medicine: October 2014 - Volume 89 - Issue 10 - p 1314 Available from doi: 10.1097/ACM.0000000000000454 3. Sorabji, R. (1971). Aristotle on Demarcating the Five Senses. The Philosophical Review, 80(1), 55-79. doi:10.2307/2184311

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5. Kangaroo care for the preterm infant and family. Paediatrics & child health, 17(3), 141–146. https://doi.org/10.1093/pch/17.3.141 6. Harrison M, Milbers K, Hudson M, Bansback N. Do patients and health care providers have discordant preferences about which aspects of treatments

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COVID-19, RACISM AND ENVIRONMENTALISM: WHY INTERSECTIONAL ACTIVISM MATTERS

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Georgia Brown

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Introduction 2020 was a year in which global health was placed on centre stage due to multiple states of crisis. The unprecedented nature of COVID-19 touched the lives of many across the globe, and catalysed increased discussion about healthcare collaboration and health equity.

However, a number of other crises marked 2020 and also involved health injustice – the Black Summer bushfires, the continued violent loss of Black, Aboriginal and Torres Strait Islander lives, and the global climate emergency. While health inequities and societal injustices are not a new experience for people facing oppression under racist and colonial societal structures, the year put a spotlight on those in positions of privilege to heed the necessity of more intersectional global health advocacy.

COVID-19 exacerbates health injustices The COVID-19 pandemic has been characterised previously as “the great equaliser”, since “the virus doesn’t discriminate” and affects all people uniformly. Multiple critiques of these statements have been published and research shows that those who are facing existing social, economic and health vulnerabilities are more likely to be affected by COVID-19.[1-8] Women, children, the elderly, people with disabilities or health comorbidities, ethnic and racial minorities, migrants and refugees, homeless people,[9] and those with a lower income or less education,[1]

face exacerbated disadvantages from the pandemic.

There has been disproportionate death amongst Black, Indigenous, Asian and minority ethnic groups due to social and economic disparities in the UK [10-12] and USA [2,13,14]. In Australia, Aboriginal and Torres Strait Islander communities are particularly vulnerable to COVID-19, due to increased likelihood of crowded housing, chronic disease and socioeconomic disadvantages,[15-17] stemming from structural racism and intergenerational trauma from colonisation.[18-20] Moreover, both here and overseas, Aboriginal, Torres Strait Islander and Black communities continue to face a concomitant and long-standing crisis of violent deaths perpetrated by police officers and correctional officers, a symptom of ongoing structural oppression.[21-29] Research indicates that in times of crisis and global emergency, an increased threat of hate and violence against minority groups is seen.[3032] These compounding threats to the wellbeing of vulnerable people highlight a moral and public health imperative that the roots of injustices, such as systemic racism, be addressed in a crisis to safeguard the health of communities.

Shifting the dialogue about “the Global South” Compounded racism and nationalism in this pandemic has seen as slurs like “China virus”, “Wuhan virus” attached the virus to the Asian diaspora, 18

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stigmatising racial groups and geographical locations which has devastatingly led to xenophobic hate crimes.[30,33] People in Chinese and East Asian populations are being scapegoated for the global pandemic [34]; while colonial and imperial beliefs about the “Global South” have been seen through the expectation of a higher death toll and disease burden in news headlines such as ‘Why don’t Africans have the disease?’,[34-37] questioning of COVID-19 response successes such as in Vietnam,[38,39] and a French doctor’s proposal to test COVID-19 treatments in Africa.[40] These responses to the pandemic in the media starkly reveal the attitude of superiority of the “Global North” and western society over the “Global South”.[34] Western and white settler healthcare structures are used as the reference point, wherefrom conversations about “developing” or “third world” nations focus on healthcare deficits.[41-43] This narrative is countered with the successes of COVID-19 responses in countries in the “Global South”. Case data from Taiwan,[44] Vietnam,[45] the Indian state of Kerala,[46] Senegal and Ghana,[47] and the Inuit community in Nanvut, northern Canada,[48] are a few examples of successful non-western COVID-19 responses overseas.

Moreover, while complex political factors influence healthcare, the large burden of disease toll in the US,[49] UK [50] and parts of Europe,[51,52] demonstrates that Euro-western

healthcare systems being objectively more sophisticated is a falsehood.[53] However, media coverage of these successes in the “Global South” is minimal, highlighting a predisposition of western media to fixate on peoples’ pain and disease, [54-58] thus controlling the narrative around the pandemic and leading to erasure of local perspectives and ethnically diverse voices.[59-62] In Australia, while noted as a vulnerable group, Aboriginal and Torres Strait Islander communities recorded the best COVID-19 result for any Indigenous population in the world and kept infection rates six times lower than the rest of Australia.

[63,64] Many Indigenous communities live in a “post-disaster landscape” having experienced crises stemming from colonisation,[48,65] and community-focused COVID-19 responses were enacted quickly and many local services developed preparedness plans.[66] In Australia, Aboriginal people mobilised communities to distribute information, resources and enact sovereign Country border closures ahead of government directives; Elders were respected, supported and visited with safe practice; increased health training and culturally appropriate, consistent health messaging was seen in Aboriginalcontrolled services; and telehealth was implemented to ensure peoples’ medical conditions were managed.

[67] This is indicative of the health promotion capacity and strength of Aboriginal and Torres Strait Islander 19

communities with self-determination, and demonstrates a lot to learn for the rest of Australia, and the western world at large, from Indigenous thinking.

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Dual crises: COVID-19 and the climate emergency The global climate emergency is a crisis that intersects with COVID-19.

In Australia, COVID added to existing stressors while communities were still recovering from the devastating Black Summer bushfires.[68] We are fast approaching 50 years of international climate action negotiations since the 1972 United Nations Conference on the Human Environment, however, climate change is no longer a distant “threat” but a reality for many, and requires a response as any other health crisis. The same people who are vulnerable to COVID-19 are the most vulnerable to climate change.

Wealthy, white westerners, are more protected from climate change due to the access to resources to survive extreme weather, an increasing burden of disease, and socioeconomic reparations.[69,70] This zoonotic pandemic has highlighted the immense interconnectedness of humanity and the natural world.[71] However, rhetoric around “humans are the virus” and the argument of overpopulation as a cause of climate change negates how the desecration of the natural environment is carried out predominantly by large corporations and wealthy nations; and how environmental determinants

of health disproportionately impact the world’s already most vulnerable.

[72-74] Climate change is not just an environmental issue, but one of social justice, as those most vulnerable are responsible for the least global emissions while the richest 10% are responsible for 50%.[75] Thus, environmentalism needs to be intersectional, to address and dismantle systems that perpetuate health injustices and predispose communities to the impacts of climate change.[76,77] Intersectional environmentalism Intersectional frameworks call for acknowledging how different aspects of a person’s social and political identity combine to create different levels of discrimination and privilege that inform an individual’s lived experience.[78] “Intersectional Environmentalism,” coined by Black environmentalist Leah Thomas, “advocates for both the protection of people and the planet. It identifies the ways in which injustices happening to marginalised communities and the earth are interconnected...it does not minimise or silence social inequality”.

[79] Intersectional environmental justice necessitates racial justice as those who profit off the planet’s resources also profit off Black, First Nations, Asian and Latinx people.

[79,80] Homogenising the experience of climate change obliterates the nuances and complexities of this global problem, negates accountability of those in power for systemic injustices and invalidates marginalised groups’ struggles.[81,82] 20

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Interestingly, while Greta Thunberg is a household hero for climate action (and rightly so) there has been minimal media recognition of more diverse environmental advocates.

[83,84] Black and First Nations peoples have historically driven movements for social change and using an intersectional approach, but environmentalist accolades and spaces are historically white.[85,86] Other young people have been driving advocacy and grassroots change across the world in their diverse communities, responding to the climate crisis while dismantling systems of oppression that enable it.

[87-89] For example, Vanessa Nakate is a 24 year old Ugandan activist who founded the organisations Youth for Future Africa and Rise Up Movement for social justice and empowerment of young Africans. She has advocated for national action on climate change, as well as conservation of the Congolian rainforests.

Helena Gualinga is a 19 year old spokeswoman from the Kichwa Sarayaku Indigenous community in Pastaza, Ecuador who advocates against oil extraction on Indigenous land in the Ecuadorian Amazon. She also started the Polluters Out movement, a global coalition of grassroots activists and organisations that demands fossil fuel divestment from governments, banks, universities and United Nations Climate Change Conference as well as for polluting corporations to pay climate reparations. John Paul Jose is a 23 year old Indian activist who

advocates against the Yettinahole project, an irrigation scheme requiring acquisition of rural farmers’ land, forest clearance and water diversion away from the sensitive and unique Western Ghats ecosystem. He also conducts environmental justice webinars and collaborates with a number of organisations such as Greenpeace, The Energy Research Institute in India, the High Seas Alliance, and multiple United Nations portfolios.[90] These people are not widely recognised, or are called “the Greta Thunberg” of their respective nation.

[83] This facilitates erasure of different experiences and perspectives,[83] and ignorance of demands of local communities who are disproportionately affected by the complex issue they are advocating on.

[79,80] After all, as the climate crisis operates on multiple axes of oppression including racism, ableism, classism and misogyny, collective work and collaborative, intersectional organising is required to adequately address this many facets of this complex and global emergency.[84] Lessons from the COVID-19 crisis response for planetary health and a green recovery The pandemic has triggered fundamental changes in how global health is discussed, but has also led to demonstrations of international collaboration, solidarity, healthcare innovations and respect of science.

[77] WHO Director-General Dr Tedros Adhanom Ghebreyesus stated 21

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in his address to the 73rd World Health Assembly that “The world cannot afford repeated disasters on the scale of COVID-19, whether they are triggered by the next pandemic, or from mounting environmental damage and climate change. Going back to “normal” is not good enough”.

[91] Many lessons from the COVID-19 response can be utilised in the climate emergency response. Building strong, resilient health systems is essential for climate action,[91] as called for by 40 million health professionals.[92] The pandemic response required pragmatic and immediate action and policy change informed by scientific evidence, which is also required in the climate crisis. Climate change is already claiming lives, but there have been ongoing barriers to implementing action, despite a scientific consensus warning of the impacts of environmental change for decades.[93] Moreover, the successes of COVID-19 containment could not have been achieved without global communities and governmental bodies working together and this level of international commitment to public health is crucial for climate action.[94] It remains imperative that nations actively work towards their IPCC commitments and unite in action on climate change, as this global health issue requires international corporation.[93] WHO also calls for a healthy and green recovery from COVID-19 including investment in frontline and equitable healthcare services, a rapid clean

energy transition, and the removal of all fossil fuel subsidies.[94] Moreover, the connectedness of people and Country in health promotion and crisis mitigation has been practices in Australia by Aboriginal and Torres Strait Islander peoples, the world’s longest continuing culture, since time immemorial, pandemic successes can be attributed to this philosophy.[48] While cultural Lore provided insight about responding to crises by connecting communities and protecting Country,[95] interdisciplinary, pragmatic and community-focused response strategies safeguarded health.[67] It is thus crucial that climate action is led

by First Nations communities, with the wealth of Indigenous planetary health thinking integrated into health sector preparedness and crisis mitigation strategies.[96] The COVID-19 pandemic has provided a key opportunity for rethinking global public health. Bold and transparent planetary health leadership; a sustainable crisis recovery; and intersectional, community-focused public health promotion have been shown to be key in combatting existing and future health inequities in this time of concurrent crises.[77,97] Conclusion COVID-19 has exacerbated health inequity, and demonstrated that a one-size fits all response to global crises does not sufficiently address 22

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the needs of diverse populations,[98] hence, recovery efforts and climate action need to be intersectional.

Health interventions that do not engage with local communities, perpetuate systems of oppression or continue a transactional international aid arrangement, will fail.[34,99].

Success stories of local crisis responses in the “Global South”, and driven by First Nations peoples show the strength, resilience and capacity of Black, Asian, Latinx and First Nations communities, and the need to dismantle systems of oppression and attitudes of superiority to facilitate learning and reciprocity.

[34,98] Learning from the pandemic, the unique international crisis of climate change also necessitates courageous, coordinated and intersectional action both to respond to this health emergency and promote health equity.

Author Statement Georgia Brown is a final year undergraduate medical student at the University of Newcastle, Australia.

She acknowledges that she works on unceded Awabakal Country and writes from a position of privilege and as an ally, as a white Australian medical student. Georgia is passionate about systems-change for environmental justice and public health equity and advocates for climate action. She is a current Ambassador with the Planetary Health Alliance.

First Nations’ lead environmental organisations in Australia and the Pacific include Seed Indigenous

Youth Climate Network, Firesticks Alliance Indigenous Corporation, and Pacific Climate Warriors. Global collectives include Wretched of the Earth, Indigenous Environmental Network, Grassroots Global Justice Alliance and Climate Justice Alliance.

However, many more grassroots Black or First Nations-led organisations than mentioned here exist.

Intersectional environmentalism resources can be found through the organisation The Intersectional Environmentalist, an online platform created by Leah Thomas.

Further information: https://docs.google.com/document/d /1NUuRwvpgWK1bMYQTOgsfPo6gK XP5tk4eoqkvxZpSQ9U/edit? usp=sharing Correspondence C3258274@uon.edu.au Acknowledgements The ideas presented in this article are not new or ‘radical’. Intersectional justice campaigns have been led by ethnically diverse groups throughout history, while First Nations peoples have safeguarded planetary health since time immemorial.

Funding None Conflicts of interests None Ethical approval Not required 23

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48. Clement, M. Roundtable: How Indigenous communities respond to disasters. 2020 [cited 01/04/ 2021]; Available from:

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Covid-19: Pandemic Shatters More Records in U.S., as States and Cities Tighten Restrictions, in New York Times. 2020: Online.

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51. Rudan, I., A cascade of causes that led to the COVID-19 tragedy in Italy and in other European Union countries. Journal of global health, 2020. 10(1): p. 010335-010335.

52. Horton, R., Offline: Europe and COVID-19—struggling with tragedy.

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53. Freed, J.S., et al., Which Country is Truly Developed? COVID-19 has Answered the Question. Annals of global health, 2020. 86(1): p. 51-51.

54. Braithwaite, P. Black Joy Isn’t Frivolous—It’s Necessary. 2020 [cited 04/04/ 2021]; Available from: https://www.self.com/story/black-joy.

55. Willoughby, V. Representation Matters: Black Joy Is an Act of Resistance. 2020 [cited 04/04/ 2021]; Available from: https://www.slj.com/? detailStory=representation-mattersblack-joy-act-resistance-publishingdisparities.

56. Yancy, G., Whiteness and the Return of the Black Body. The Journal of Speculative Philosophy, 2005. 19(4): p. 215-241.

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Muhammad, M. Getting Off: What Black Trauma Porn Is and Why We Hate It. 2019 [cited 04/04/ 2021]; Available from: 26

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https://medium.com/@smartbrainiac 101/getting-off-what-black-traumaporn-is-and-why-we-hate-ite2dc12b5b0e.

58. Nkumane, Z. No Longer Will I Partake in Black Trauma Porn. 2016 [cited 04/04/ 2021]; Available from: https://www.okayafrica.com/blacktrauma-porn-black-lives-matter/.

59.

Sihlongonyane, M.F., The challenges of theorising about the Global South-a view from an African perspective. Africa insight, 2015. 45(2): p. 59-74.

60. Abimbola, S., The foreign gaze: authorship in academic global health.

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61. Bertram, K., N. Erondu, and M. Pai, Silenced voices in global health.

2020, ThinkGlobalHealth.

62. Pai, M., Global health needs to be global & diverse. Forbes, 2020.

63. Crooks, K., D. Casey, and J.S. Ward, First Nations people leading the way in COVID-19 pandemic planning, response and management.

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64. Power, J., The outstanding health outcome Indigenous communities have produced, in The Sydney Morning Herald. 2021.

65. Lucashenko, M., It’s no accident that Blak Australia has survived the pandemic so well. Survival is what we do. 2020, The Guardian Australia.

66. Barrett, A., COVID-19 wrap: the pandemic and Indigenous communities, locally and globally, in Croakey. 2021.

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Power, J., When it came to COVID-19, Indigenous Australians sent it packing, in The Sydney

Morning Herald. 2020.

68. Zhang, Y., et al., The 2020 special report of the MJA–Lancet Countdown on health and climate change: lessons learnt from Australia’s “Black Summer”. Medical Journal of Australia, 2020.

69. Norgaard, K.M., Climate Denial and the Construction of Innocence: Reproducing Transnational Environmental Privilege in the Face of Climate Change. Race, Gender & Class, 2012. 19(1/2): p. 80-103.

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71. De Paula, N.W., Liz. COVID-19 and Planetary Health: How a Pandemic Could Pave the Way for a Green Recovery. 2021.

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Dyett, J. and C. Thomas, Overpopulation Discourse: Patriarchy, Racism, and the Specter of Ecofascism. Perspectives on Global Development and Technology, 2019.

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73. Wilkinson, R. Humanity isn’t a disease – but ecofascism is. 2020 [cited 04/04/ 2021]; Available from: https://www.globaljustice.org.uk/202 0/04/humanity-isnt-diseaseecofascism/.

74. Thomas, C. and E. Gosink, At the Intersection of Eco-Crises, EcoAnxiety, and Political Turbulence: A Primer on Twenty-First Century Ecofascism. Perspectives on Global Development and Technology, 2021.

20(1-2): p. 30-54.

75. Gore, T., Confronting Carbon Inequality: Putting climate justice at the heart of the COVID-19 recovery.

2020.

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76. Klenert, D., et al., Five Lessons from COVID-19 for Advancing Climate Change Mitigation.

Environmental and Resource Economics, 2020. 76(4): p. 751-778.

77. Threlfall, M. Applying Lessons from COVID-19 to Tackle the Climate Crisis. 2021 [cited 04/04/ 2021]; Available from: https://thepalladiumgroup.com/news /Applying-Lessons-from-COVID-19to-Tackle-the-Climate-Crisis.

78. Crenshaw, K., Demarginalizing the intersection of race and sex: A black feminist critique of antidiscrimination doctrine, feminist theory and antiracist politics. u. Chi. Legal f., 1989: p. 139.

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82. Lakhani, N., 'Racism dictates who gets dumped on': how environmental injustice divides the world, in The Guardian. 2019.

83. Bastida, X. My name is not Greta Thunberg: Why diverse voices matter in the climate movement. 2020 [cited 01/04/ 2021]; Available from: https://theelders.org/news/my-namenot-greta-thunberg-why-diverse-

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Frazer-Carroll, M. On environmentalism, whiteness and activist superstars. 2019 [cited 01/04/ 2021]; Available from: https://galdem.com/on-individualismwhiteness-and-activist-superstars/? fbclid=IwAR2nZWGp9zqK04FGukcF Iddz1HTLoQEWG5bDUPStAxwTIw MFG_18yl6TTRQ. 85.

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88. Burton, N., Meet the young activists of color who are leading the charge against climate disaster. 2019, Vox. 89. 19 youth climate activists you should be following on social media.

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90. Ohene, A., Abelvik-Lawson, H., Meet the young people of colour fighting for our planet. 2020; Available from: https://www.greenpeace.org.uk/news/ 28

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young-climate-activists-of-colourprofiles/.

91.

Ghebreyesus, T.A., WHO Director-General's opening remarks at the World Health Assembly. World Health Organization. May, 2020. 18.

92. Iacobucci, G., Covid-19: Public health must be “at the core” of global recovery plans, say doctors. BMJ, 2020.

369: p. m2077.

93. Watts, N., et al., The 2020 report of The Lancet Countdown on health and climate change: responding to converging crises. The Lancet, 2021. 397(10269): p.

129-170.

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World Health Organization., WHO Manifesto for a Healthy Recovery from COVID-19.

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95.

Smith, A.S., et al., Creation, destruction, and COVID-19: Heeding the call of country, bringing things into balance. Geographical Research, 2020.

96. Etchart, L., The role of indigenous peoples in combating climate change.

Palgrave Communications, 2017. 3(1): p. 17085.

97. DiBianca, S. 5 things COVID-19 has taught us about fighting climate change. 2020 [cited 01/04/ 2021]; Available from: https://www.weforum.org/agenda/20 20/09/5-things-covid-19-has-taughtus-about-curbing-climate-change/.

98.

The Lancet Global Health., Decolonising COVID-19. The Lancet Global Health, 2020. 8(5): p. e612.

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Affun-Adegbulu, C. and O. Adegbulu, Decolonising Global (Public) Health: from Western universalism to Global pluriversalities. BMJ Global Health, 2020. 5(8): p. e002947.

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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://ajgh.amsa.org.au/index.php/ajgh/blog

30

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Learn. Apply. Retain.

Study medicine from anywhere.

https://www.lecturio.com

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Which vaccination path should we follow?

Nitika Govind 32

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There have been over 160 million cases of COVID-19 worldwide since it was first reported in December 2019, with 222 countries affected today.[1] With a huge health burden and no cure in sight, the best option was to develop vaccines – and fast. Within one year of vaccine development and trials, the first Pfizer COVID-19 vaccine was given to a UK woman in December 2020.[2] Since then, there are approximately 346 million fully vaccinated individuals.[3] The global vaccination rollout may be the light at the end of the tunnel for this pandemic. However, as each country has taken its own approach in inoculating their population, this poses the question: what does the evidence say about each approach?

What is the best approach?

inoculating their population, with four approaches analysed. The reasons for inclusion are outlined: · Australia is most relevant to the readership · India’s COVID-19 situation has collapsed since 10th February · Indonesia’s approach is unique in targeting the working-class population · United Kingdom (UK) has one of the highest vaccination rates Four different approaches

The World Health Organisation (WHO) states that only priority groups should receive the vaccine in the first phase to protect health systems and reduce disease burden in all countries. WHO defines these groups as: frontline health workers, people over 65 years and those with serious health conditions.[4] This approach was suggested because it decreases the death rate in the elderly and immunocompromised – groups most likely to suffer severe consequences from COVID-19.

Additionally, WHO’s recommendations enable equitable access to vaccines as it accounts for vulnerable populations.

Australia Currently, Australia has vaccinated approximately 6% of its population.[3] Australia’s three-phased approach is advantageous as the first phase targets the bulk of citizens at highest risk of COVID-19, which includes the elderly and Indigenous population.[5] However, this strategy’s effectiveness is impeded by growing concerns that the vaccine is not sufficiently effective and safe. The unforeseen side effect of thrombosis with thrombocytopenia following the AstraZeneca vaccine has sparked much hesitancy.[6] Additionally, there is a lack of longterm research about vaccine safety in vulnerable groups such as the elderly and pregnant. In current vaccine trials, these two groups are understudied.[7] Thus, Australia’s strategy is effective, but must involve educating citizens to prevent vaccine hesitancy – especially in groups not represented in vaccine trials.

Despite WHO’s guidelines, every country has its own approach to

India India is facing a devastating second 33

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wave of COVID-19 with acute shortages of oxygen and hospital beds leading to high mortality rates.[8] There is approximately 300,000 daily cases and only 11.5% of the population has been fully vaccinated.

[9] For phase one, India aimed to vaccinate healthcare and frontline workers, those over 50 years old and those under 50 years old with comorbidities.[10] The advantage of India’s strategy is that the first phase would inoculate a large proportion of the population, thus reducing disease transmission and conferring herd immunity to the unvaccinated.

However, with a population of almost 1.4 billion, difficulties arise in distributing vaccines to such a large number of people. This strategy has had little success as there is now a shortage of vaccines. Moreover, rural Indians have increasing difficulty with equitable access to healthcare services providing vaccines.[10] However, potential solutions to tackle these challenges include mobile vans which travel to isolated communities and creating vaccination clinics in rural areas to provide equitable access.

Indonesia Unlike Australia and India, Indonesia has a very different approach by targeting the young working-class (1859 years) after health care workers.[11] To date, around 3.3% of the population has been vaccinated through this schedule.[3] This strategy was developed after infection patterns showed that young people

were more likely to be unknown COVID-19 carriers and epidemiological data highlighted that most of the elderly population live in intergenerational households.[11] Thus, the “youth-first strategy” is beneficial by creating herd immunity for the elderly. Also, the strategy is beneficial by boosting the workforce and economy, as the country fell into recession after massive job losses and over 1.1 million infections to date.[11] Despite this strategy, global vaccine nationalism has delayed Indonesia’s vaccination schedule. With wealthier countries keeping vaccines for themselves, it will likely result in the pandemic continuing for longer in countries such as Indonesia which do not have access to sufficient numbers of vaccines.

UK The UK was the first country to commence COVID-19 vaccinations and their strategy involves vaccinating nine groups of priority in the first phase, which includes aged care residents and frontline health workers.

[12] According to the UK government, these nine groups can prevent approximately 99% of COVID-19 mortality. However, an issue with this strategy is that the UK had sped up its vaccination approval process, resulting in concerns of final safety checks being overlooked.[13] However, with this approach, around 30% of the population has been fully vaccinated.[3] Although this high proportion of inoculated individuals may be beneficial to the UK, this 34

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country is one of the culprits of vaccine nationalism and thus contributing to the deficiency of vaccines worldwide. The problem with vaccine nationalism is that with the emergence of new COVID-19 strains, such as the Indian and South African strains, this creates doubts about whether current vaccines can effectively immunise against newer mutations. [13] Thus, it is still essential for those who have received the vaccines to comply with pre-existing safety measures that reduce infection risk and for countries such as the UK to ensure that developing countries have equitable access to these vaccines.

Conclusion Australia’s, India’s, Indonesia’s and the UK’s vaccination schedules are examples of different approaches to vaccine distribution to tackle the COVID-19 pandemic. One strategy cannot be the best for all countries, as each approach should be based on a country’s epidemiology and risk profile. However, all countries face the struggle of physically implementing vaccination programs, educating the public on vaccine safety and achieving herd immunity.

Currently, vaccine nationalism poses a risk to global solidarity and immunity, and this must be resolved.

Ultimately, the different vaccination strategies try to achieve the universal goal of ridding this world of COVID19.

About the Author Nitika Govind is a fourth-year

medical student from Bond University, Gold Coast. She is extremely passionate about Global Health after living and volunteering in developing countries such as Mongolia, Fiji and Papua New Guinea.

She has been the Vice-President of the Global Health Group and the Psychiatry Association at Bond University. She hopes to join the World Health Organization one day.

Conflicts of Interest None Correspondence govindnitika@gmail.com Acknowledgements None References 1. World Health Organisation. WHO Coronavirus (COVID-19) Dashboard [Internet]. Geneva: World Health Organisation; 2021 [cited 2021 Feb 7].

Available from: https://covid19.who.int/ 2. Ellis P. Coronavirus vaccine developed by Pfizer/BioNTech administered to first patient in the United Kingdom [Internet]. ABC News; 2020 [cited 2021 Feb 7].

Available from: https://www.abc.net.au/news/202012-08/uk-hospital-injects-firstpatients-with-covid-vaccine/12960052 3. Ritchie H, Ortiz-Ospina E, Beltekian D, Mathieu E, Hasell J, Macdonald B, et al.

Coronavirus (COVID-19) Vaccinations [Internet]. Global Change Data Lab; 2021 [cited 2021 Feb 7].

Available from: 35

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https://ourworldindata.org/covidvaccinations?countr %20y=~AUS 4. World Health Organisation. Access and allocation: how will there be fair and equitable allocation of limited supplies? [Internet]. Geneva: World Health Organisation; 2021 [cited 2021 Feb 7].

Available from: https://www.who.int/newsroom/feature-stories/detail/accessand-allocation-how-will-there-befair-and-equitable-allocation-oflimited-supplies 5.

Australian Government Department of Health. Who will get the vaccines [Internet]. Australian Government Department of Health; 2021 [cited 2021 Feb 8]. Available from: https://www.health.gov.au/initiativesand-programs/covid-19vaccines/getting-vaccinated-forcovid-19/who-will-get-the-vaccines 6. Christmass P. Seven new blood clot cases reported after AstraZeneca vaccine, TGA confirms [Internet].

ABC News; 2021 [ cited 2021 May 13].

Available from: https://7news.com.au/news/publichealth/seven-new-blood-clot-casesreported-after-astrazeneca-vaccinetga-confirms-c-2831000 7. Laine C, Cotton D, Moyer DV. COVID-19 Vaccine: Promoting vaccine acceptance. Ann Intern Med. 2021; 174(2):252-253.

8. World Health Organisation. Novel Coronavirus Disease (COVID-19) Situation Update Report -67. India; World Health Organisation; 2021 [cited 2021 May 15]. Available from: https://cdn.who.int/media/docs/defa ult-source/wrindia/situation-

report/india-situation-report-67.pdf? sfvrsn=f73932b4_4 9. Peerzada A. India coronavirus: Over-18s vaccination drive hit by shortages [Internet] BBC News [cited 2021 May 12]. Available from: https://www.bbc.com/news/worldasia-india-56345591 10. Ministry of Health and Family Welfare. COVID-19 vaccines operational guidelines [Internet].

India: Government of India; Dec 2020 [cited 2021 Feb 8]. Available from: https://www.mohfw.gov.in/pdf/COVI D19VaccineOG111Chapter16.pdf 11. Henschke R, Anugrah P. Indonesia coronavirus: The vaccination drive targeting younger people [Internet].

BBC News [cited 2021 Feb 8].

Available from: https://www.bbc.com/news/worldasia-55620356 12. Public Health England. COVID-19 vaccination programme information for healthcare practitioners [Internet].

London: Department of Health and Social Care (DHSC), 2021 [cited 2021 Feb 9].Available from: https://assets.publishing.service.gov.u k/govern ment/uploads/system/uploads/attach ment_data/file/9 58015/CO VID19_vacc ination_programme_guidance_for_h ealthcare_workers_3_February_2021 _v3.2.pdf 13. Bollinger R, Ray S. New variants of coronavirus: what you should know [Internet]. John Hopkins Medicine; 2021 [cited 2021 Feb 9]. Available from: https://www.hopkinsmedicine.org/hea lth/conditions-and36

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diseases/coronavirus/a-new-strainof-coronavirus-what-you-shouldknow

37

NATIONALISM

& VACCINE

SECURITY

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Mansimran Loyal

38

Graphic by Christine Manuel

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Introduction The COVID-19 pandemic has highlighted the need for a unified global approach to equitable vaccine security and distribution. Vaccine security refers to the timely, sustained and uninterrupted supply of affordable, quality vaccines.[1] However, this has been threatened by the nationalistic actions of wealthy countries such as the US, Britain and Japan, who have acquired deals for more than two billion doses of coronavirus vaccine.[2] As a result, 16% of the worlds’ population have purchased 60% of all vaccines, which poses a significant threat to global efforts combatting COVID-19.[3] To equitably distribute vaccines to all countries, the COVAX scheme was founded by the Global Alliance for Vaccines and Immunisation (GAVI), Coalition for Epidemic Preparedness Innovations (CEPI) and the World Health Organisation (WHO).[4] It intends to serve as a representative for 90 percent of the global population, involved in the buying and distributing of vaccines fairly and equitably.[5] However, even if COVAX meets its targets, it will fall short of achieving herd immunity, or vaccinating 70% of the world’s population [4], prompting countries to prioritise high risk groups when distributing vaccines.

A brief introduction to COVID-19 vaccines As of April 2021, there are ten COVID-19 vaccines authorised for use by national governments, though only the Pfizer, AstraZeneca and

Johnson & Johnson vaccines have been approved by the WHO.[6] AstraZeneca is approved in the largest number of countries and has the largest target vaccine reserve, followed by Pfizer.[7] Other vaccines such as BBIBP-CorV, made by China, and Covaxin, developed by India, are mostly distributed locally, though some are exported to trade partners. However, there is scepticism surrounding the safety of some vaccines given the lack of evidence produced during phase III trials.[8] There have also been concerns expressed about the ethics of trials for Covaxin, as well as the data produced.[9] Participant testimonies from Covaxin trials state that trial staff breached the tenet of voluntary participation by misleading participants and preying on those with extreme economic vulnerability.

[9] Crisis Nationalism and Vaccine stockpiling: Benefits and Woes To adequately prevent the spread of COVID-19 and protect vulnerable populations, enough people must be vaccinated to attain herd immunity.

Herd immunity is the inability of infected individuals to propagate an epidemic outbreak due to lack of contact with sufficient numbers of susceptible individuals.[10] Most estimates for COVID-19 herd immunity suggest a threshold of 6070% is required [11], and given the harms of infection-acquired immunity, it is crucial that vaccines are effective in reducing transmission 39

and producible in large quantities.[11] While target manufacturing capacity for COVID-19 vaccines globally is 6 billion courses by the end of 2021, predictions state that the world may only produce 2 billion.[5] This leaves a significant shortfall, which is likely to hurt poorer countries harder.

Global herd immunity – not merely at the national level – is crucial for the world’s recovery. Thus, vaccine security and equitable distribution is integral in overcoming the COVID-19 pandemic.

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Many wealthy countries struck deals directly with pharmaceutical companies to secure initial vaccine batches. A ‘my country first’ approach to vaccine security has economic and social benefits for countries.[12] Fasttracking vaccination ahead of other nations allows for quicker economic rebound, though this is only possible for richer countries. However, there are risks associated with a siloed nationalistic approach to vaccine deployment.

There is concern that if herd immunity is not achieved quickly, new variants of SARS-CoV-2 resistant to existing immunity will arise. This was seen recently in Manaus, Brazil, where herd immunity to an early strain of SARS-CoV-2 was calculated at 60% following a devastating peak in incidence in May 2020.[13] However, a second wave caused by the P.1 variant saw a huge resurgence in cases in January this year despite high communal levels of immunity.[13] Mutations in the viral spike protein

are thought to alter the conformation of SARS-CoV-2, making it easier for newer variants to spread.[14] Securing enough vaccines to confer population may see some economic boost within a country but ignoring COVID-19 in other countries and in particular trade partners will restrict business and trade, especially for industries such as travel and tourism.

[12] Some economic models predict significant economic downturn for wealthy nations to the tune of between $49bn and $230bn a year if low-income countries are denied vaccines early on.[15] High-income countries could see returns of between $1.9 and $12.6 for every dollar invested in vaccines for lowincome countries due to increase in international trade and dropping of borders.[15] Sourcing vaccines exclusively from patented national distributors, as is the case for Russia and China, could cause a spike in vaccine prices due to lack of competition.[6] Unequal distribution of vaccines amongst the rich and poor in countries without socialised healthcare would reduce the impact of securing bilateral vaccine deals.[16] This would result in over-allocation of vaccines to low-risk groups and an increase in preventable deaths due to Covid. Furthermore, limited transparency from countries with bilateral vaccination deals, such as the US, fuels speculation of extreme nationalism and may see other nations follow suit, hindering widespread vaccine access.[7] 40

Hoarding by high-income countries would also greatly disadvantage lowincome countries that lack resources to procure vaccines for their citizens.

[17] This is a worry for countries that lack the resources to manufacture medical supplies such as vaccines and depend on imports from economic partners.[18] This results in people who need vaccines the most receiving them last, such as health workers and the elderly in countries with high incidence of COVID-19.[19] As a result, resource-poor nations experiencing basic health deficits are further deprived by the actions of more privileged countries.[20]

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In summary, there is legitimate fear that vaccine nationalism may only perpetuate the pandemic and prolong global recovery, an outcome that benefits nobody.[12] What is being done to ensure equitable vaccine distribution?

Vaccine nationalism has left underdeveloped countries in a situation where they must obtain vaccines without compromising national interest. [21. This dilemma can be solved through vaccine diplomacy, a form of international diplomacy reliant on the delivery of vaccine services.[22] This can be achieved at either a national or multilateral level to serve the geopolitical interests of nations.

At a national level, Russia have made targeted offers to Eastern Europe and the Balkan States for the production and delivery of the Sputnik-V vaccine

with the intention of highlighting Russia’s support for countries under the EU’s enlargement and neighbourhood policies.[23] Similar programs have been set up by the US, China and India, and have been criticised for their focus on foreignpolicy propaganda over the equitable distribution of vaccines to countries in need.[23] Therefore, a multilateral effort is required to ensure equitable vaccine distribution for low and middleincome countries (LMICS). Currently, the largest global vaccine coalition is COVAX, a joint fund spearheaded by Gavi in partnership with CEPI and WHO.[17] COVAX aims to secure 2 billion vaccines by 2022, with 1 billion reserved for LMICS and the other 1 billion for partnered wealthier nations.[2] Vaccines under this program will be distributed to partner countries equally based on their population, rather than disease burden.[17] The hope is that by vaccinating the most vulnerable 20% of the global population, disease propagation can be delayed so enough vaccines are produced to achieve herd immunity.[16] COVAX aims to combat nationalism by acting as a representative negotiation body for a host of countries. At present, there are over 172 nations who have become COVAX members, and over 100 countries have received vaccines through COVAX.[24] COVAX aims to pool the financial and scientific resources of nation members to 41

insure countries against the failure of any individual vaccine.[12] This will also make the initial batch of vaccines more cost-effective as less independent bilateral vaccine deals will limit price hiking, in turn enticing high-income countries to sign up.

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Shortcomings of COVAX and their solutions COVAX isn’t a perfect solution however, as equal distribution of vaccines to all member nations fails to fully address the issue of global health equity and harm limitation.[17] Vaccine distribution based on the needs of individuals is more likely to reduce preventable hospitalisations and deaths.

For example, an individual in Brazil is more likely to die from COVID-19 than someone in Australia or South Korea, so it is justifiable to prioritise them for vaccination.[25] Therefore, a global coalition that is closer aligned with WHO’s Strategic Advisory Group of Experts (SAGE) principles of prioritising disadvantaged populations would be more effective in distributing vaccines fairly.[17] Another reason COVAX may fail to be as effective as possible is its funding mechanism, which allows high-income countries to both delegate funds to COVAX and secure independent vaccine agreements.[26] The lack of transparency surrounding these agreements may price out COVAX from securing sufficient vaccine resources, undermining their goal to prevent richer countries

monopolising vaccines. In an attempt to prevent this, COVAX have implemented a scheme where wealthier nations donate surplus vaccines to LMICS. The issue is, vaccine donations will only be effective if countries donate immediately, which is unlikely as countries will seek to protect their own citizens before assisting others.

[26] To avoid this conundrum, COVAX policies need to be enforceable, which is only possible if there is international consensus on how agreements and proposed policies are enforced.[15] Conclusion Vaccine nationalism is currently one of the most pressing global health issues and threatens to derail attempts to curb the COVID-19 pandemic by exploiting existing disparities in the wealth and stability of nations. The COVAX facility has been set up as a temporary solution to vaccine distribution. It ensures that low, middle and high-income countries to have equal access to vaccines.

However, COVAX is not perfect and more can be done to address equitable access to vaccines.

Therefore, it is vital that a long-term global framework is developed that guarantees equitable allocation of medical assistance in the case of another health crisis.

About the Author Mansimran is a second year medical student at the University of New South Wales. He has a keen interest in writing and is passionate about health 42

policy and research.

Correspondence mansimran.s.loyal@gmail.com Conflicts of Interest None

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Acknowledgements None References 1.World Health Organisation. Vaccine Security. 2021. [Online]. Accessed April 2021 .

Available from: https://www.who.int/southeastasia/ac tivities/vaccine-security 2. Callaway, E. The unequal scramble for coronavirus vaccines – by the numbers. 2020. Nature 584, 506-507.

Doi: https://doi.org/10.1038/d41586020-02450-x 3.Ghebreyesus, T.A. Vaccine Nationalism Harms Everyone and Protects No One. 2021. Foreign Policy. [Online]. Accessed April 2021.

Available from: https://foreignpolicy.com/2021/02/0 2/vaccine-nationalism-harmseveryone-and-protects-no-one/ 4. The Lancet. Access to COVID-19 vaccines: looking beyond COVAX. 2021. The Lancet, Vol 397. Doi: https://doi.org/10.1016/S01406736(21)00617-6 5. Lancet Commission on COVID-19 Vaccines and Therapeutics Task Force Members. Operation Warp Speed: implications for global vaccine security. 2021. Lancet Global Health.

[Online]. Accessed April 2021. Doi: https://doi.org/10.1016/S2214109X(21)00140-6

6.

Craven, J. COVID-19 Vaccine Tracker. 2021. [Online]. Accessed April 2021.

Available from: https://www.raps.org/news-andarticles/news-articles/2020/3/covid19-vaccine-tracker 7.

So, A.D. Woo, J. Reserving coronavirus disease 2019 vaccines for global access: cross sectional analysis.

2020.

BMJ, 371:m4750.

Doi: https://doi.org/10.1136/bmj.m4750 8.

Baraniuk, C. Covid-19: What do we know about Sputnik V and other Russian vaccines? 2021. BMJ, 372: n743.

Doi: https://doi.org/10.1136/bmj.n743 9. BMJ India Correspondent. India: Doctors call for investigation into allegations of ethical abuse in covid19 vaccine trial. 2021. BMJ, 372:n131.

Doi:https://doi.org/10.1136/bmj.n131 10. Omer S.B., Yildirim I., Forman H.P. Herd Immunity and Implications for SARS-CoV-2 Control. 2020. JAMA, 324(20):2095– 2096. Doi: 10.1001/jama.2020.20892 11. Aschwanden, C. Five reasons why COVID herd immunity is probably impossible. 2021. Nature 591, 520-522.

Doi: https://doi.org/10.1038/d41586021-00728-2 12. Abbas, M.Z. Practical Implications of ‘Vaccine Nationalism’: A ShortSighted and Risky Approach in Response to COVID-19. 2020. South Centre, Research Paper 124. [Online].

Accessed April 2021. Available from: https://eprints.qut.edu.au/206694/ 13. Buss, L.F. et. al. Three-quarters attack rate of SARS-CoV-2 in the Brazilian Amazon during a largely unmitigated epidemic. 2021. Science.

43

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Vol. 371, Issue 6526, pp. 288-292.

DOI: 10.1126/science.abe9728 14. Callaway, E. The Coronavirus is mutating – does it matter. 2020.

Nature 585, 174-177.

Doi: https://doi.org/10.1038/d41586-02002544-6 15. Hafner, M., Yerushalmi, E., Fays, C., Dufrense, E., van Stolk, C. COVID19 and the cost of vaccine nationalism. 2020. RAND Europe.

[Online]. Accessed April 2021. Doi: https://doi.org/10.7249/RRA769-1 16. Bogdandy, A.V., Villareal, P.A. The Role of International Law in Vaccinating Against COVID-19: Appraising the COVAX Initiative.

2020. MPIL Research Paper, No. 2020-46. [Online]. Accessed April 2020.

Available from: https://papers.ssrn.com/sol3/papers.c fm?abstract_id=3733454 17. Herzog, L.M., Norheim, O.F., Emanuel, E.J., McCoy, M.S. Covax must go beyond proportional allocation of covid vaccines to ensure fair and equitable access. 2021. BMJ, 372 :m4853. Doi:10.1136/bmj.m4853 18. Vogel, P. Nationalism: the even greater risk of the COVID-19 crisis?.

2021. IMD. [Online]. Accessed April 2021.

Available: https://www.imd.org/researchknowledge/articles/Nationalism-theeven-greater-risk-of-the-COVID-19crisis/ 19. Eaton, L. Covid-19: WHO warns against “vaccine nationalism” or face further virus mutations. 2021. BMJ, 372 :n292. Doi:10.1136/bmj.n292 20. Beaton, E., Gadomski, M., Manson, D., Tan, K. Crisis

Nationalism: To What Degree Is National Partiality Justifiable during a Global Pandemic?. 2021. Ethical and Moral Practice. 24, 285-300. Doi: https://doi.org/10.1007/s10677-02110160-0 21. Krasnyak, O. From vaccine nationalism to vaccine policy Eradicating COVID-19 demands global leadership. 2021. Asia and the Pacific Policy Society. Available: https://www.policyforum.net/fromvaccine-nationalism-to-vaccinediplomacy/ 22. Hotez P. J. "Vaccine diplomacy": historical perspectives and future directions. 2014. PLoS neglected tropical diseases, 8(6), e2808. https://doi.org/10.1371/journal.pntd.0 002808 23. Leigh, M. Vaccine diplomacy: soft power lessons from China and Russia?. 2021. Bruegel, European Macroeconomics and Governance.

Available: https://www.bruegel.org/2021/04/vac cine-diplomacy-soft-power-lessonsfrom-china-and-russia/ 24. World Health Organisation.

COVAX reaches over 100 economies, 42 days after first international delivery. 2021. WHO. [Online].

Accessed April 2021.

Available: https://www.who.int/news/item/0804-2021-covax-reaches-over-100economies-42-days-after-firstinternational-delivery 25. Sharma, S., Kawa., N, Gomber, A. WHO’s allocation framework for COVAX: is it fair?. 2021. J Med Ethics.

0:1–5. Doi:10.1136/medethics-2020107152 44

26. Nature. Why a pioneering plan to distribute COVID vaccines equitably must succeed. 2021. Nature, 589, 170.

Doi: https://doi.org/10.1038/d41586021-00044-9

Listen to our podcast,

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Available on Spotify and

Volume 15 | Issue 1 | June 2021

through our website!

45

Graphic by Christine Manuel

CAN CAN OUR OUR APPROACH APPROACH TO TO SEASONAL SEASONAL INFLUENZA INFLUENZA CHANGE? CHANGE? The impact of pandemic prevention on seasonal influenza

Volume 15 | Issue 1 | June 2021

Anna Postema

46

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Introduction COVID-19 is the first pandemic in a century of this proportion, affecting societies that are more densely populated and entwined than ever before. The COVID pandemic caused the rapid introduction of new policies and laws by governments to prevent further spread of the disease. As these measures have been adopted there has been an unforeseen reduction in seasonal flu cases in the southern hemisphere. Exploring what has been done differently during the COVID pandemic compared to normal flu seasons will be important as we move forward from COVID. Are there strategies that can be permanently introduced to reduce the burden of disease caused by influenza each year?

Flu season and the normal response Influenza type A and B are responsible for outbreaks of influenza each year during the winter months.

[1] Influenza is responsible for an acute respiratory illness causing cough, fever and malaise.[1,2] The severity of these outbreaks vary each year with attack rates of 10 to 20%.

Attack rates reach as high as 40 to 50% during epidemics.[1-3] Epidemics and pandemics of the flu occur regularly with the largest influenza pandemic occurring from 1918 to 1919.[1,2,4] Mortality during this epidemic is estimated at over 50 million deaths.

[2,4] The pulmonary complications of influenza are primarily responsible for the mortality rates each year.[1] However, influenza does not only cause death. There is a significant

burden on the healthcare system. A study in 2008 estimated the sum of costs for hospitalisation and GP consultation for a flu season at 114.9 million in Australia.[5] These estimates are considered low with a large proportion of hospitalisations from influenza going unrecorded.[5] Furthermore, with inflation and the rising cost of healthcare, there will be a greater cost today. The health care costs are not the only impact the flu season has. There is a significant economic impact due to the loss of productivity.[1,5,6] Influenza is most effectively transmitted via the aerosol route.[7] The other mechanisms of transmission are droplet and contact transmission.[2,7] Contact transmission occurs as the virus can remain active on surfaces for up to 48 hours.[2] The continued occurrence of influenza in the community is a result of its effective transmission from person to person and the changes in strain year to year.[2] For this reason each year some measures are taken to prevent epidemics of flu.

Vaccination is the most effective measure to prevent influenza.[1,2] Despite vaccines being recommended, vaccination coverage rates vary each year. In Australia, the highest coverage is amongst adults aged over 65 years with rates estimated between 44 to 84% from 1990 to 2015.[8] Rates are highest amongst this age group as they are more likely to go to GP due to other health conditions and then be recommended the flu vaccine.[8] 47

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Despite this, these rates are still considered relatively low.[8] Rates of coverage are even lower in people aged less than 65years.[8] Influenza vaccination rates are similarly low around the world[9], with people resisting the uptake of vaccine meaning more needs to be done to promote the vaccine and help prevent influenza. Other strategies aimed to prevent the spread of influenza include “limiting contact with others while sick (by staying home for at least 24hrs after flu-like symptoms appear if needed), covering one’s nose and mouth with a tissue while coughing or sneezing…. regular washing with soap and water, avoid touching mouth, nose, eyes and cleaning and disinfecting surfaces”.

[10] Of these strategies, anecdotally, few are adhered to during flu season.

Response to a pandemic COVID-19 first emerged in December 2019 in Wuhan.[11] COVID-19, like influenza, is a respiratory illness that ranges from completely asymptomatic to a severe infection that can cause death. As of 23 October 2020, there have been over 41 million confirmed cases of the virus and over 1.1 million deaths globally.[12,13] Case numbers continue to rise each week as countries struggle to prevent transmission.[13] Like influenza transmission of COVID-19 occurs through droplets and contact transmission, aerosol and fomite transmission.[14] To prevent continued transmission of COVID-19 the effective reproductive number (R) for the virus needs to fall below 1.[15]

The only way to achieve this is to put strategies in place to prevent the virus. Prevention has been a key concern for governments. Several strategies need to be in place to effectively reduce the R number.

Quarantining and isolating cases as they are identified is an essential strategy.[15] However to prevent transmission from fomites or infected individuals, contact tracing needs to take place.[15,16] Contact tracing is a key part of prevention.[14-16] Cases need to be identified, quarantined and traced to identify close contacts within less than three days to keep the R number below 1.[15,16] Contact tracing has been remarkably successful in containing clusters with New South Wales, while deficits in contact tracing were detrimental to Victorian rates.[17] Another key strategy in the prevention of the virus has been social distancing.[14.15] Before the pandemic this concept of social distancing was unheard of.

Today, markers and signs remind the public to remain at distances of at least 1.5 meters from one another.[18] A minimum distance of 1 meter is required to have a significant reduction in transmission.[19] Mass gatherings have been largely banned.

[19] Restrictions on the number of people at venues and gatherings are in place to maintain distance between people.[18] Among the harshest measures to limit contact between people included the lockdowns of cities.

Other public health interventions promoted have been the use of personal protective measures like face masks, and a focus 48

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on hand hygiene.[18] Hand hygiene aims to reduce person to person transmission.[20] As the pandemic emerged sales of hand sanitiser dramatically increased demonstrating the adoption of these population behaviours to prevent transmission.

[20] From contact tracing to social distancing and hand hygiene, these various health measures have been demonstrated to be effective in reducing the spread of COVID-19.

[15,16,19-21] The influenza season during COVID-19 In the Southern hemisphere, the beginning of the influenza season coincided with the introduction and adoption of the various COVID-19 prevention strategies. In Australia there has been a significant reduction in influenza cases in 2020 compared to prior years.[22] In the last ten years, 2010, 2013 and 2018 saw relatively low case numbers[23]; the lowest at 13,459 laboratory-confirmed cases in 2010. The worst flu season recorded was 2019 at over 300,000 confirmed cases.[23] In 2020, only 21,196 cases were recorded across all Australian states and territories.[22] Figure 1 from the Australian National Notifiable Diseases Surveillance system illustrates the low number of influenza cases in 2020 compared to the previous five years. This poses the interesting question as to whether the measures put in place to prevent COVID-19 have reduced influenza case numbers or other factors such as reduced virulence may have contributed. I would argue that the

measures put in place to prevent COVID-19 did have an impact on the flu season and the number of cases.

The number of cases this year is well below that of case numbers in the last five years.[22,23] The number of flu cases recorded in January to March 2020 were very similar to numbers in 2019.[22,23] As 2019 had one of the worst influenza seasons in the last 20 years recorded in Australia, and until the COVID-19 pandemic, the 2020 flu season was not looking to be any different.[22,23] Looking at the trends in case numbers from previous years, the peak in cases occurs in the colder months.[22,23] In 2020 confirmed influenza case numbers rapidly fell during these months.[23] In March 2020 there were 5896 confirmed cases within Australia, and in the following month only 309.[23] Case numbers remained low throughout the rest of flu season.[23] This

reduction coincides with the introduction of pandemic measures.

From this data, it seems clear that the measures in place to prevent 49

COVID-19 had a significant impact on the number of flu cases this year.

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A different way of living moving forward Moving forward from the COVID-19 pandemic, it is important to consider whether more could be done to prevent influenza cases each year; given the aforementioned burden on healthcare systems and economic systems, along with its impacts on mortality rates. Since influenza is an infection that occurs every year, with yearly case numbers in Australia averaging higher than that of the cases of COVID-19 that occurred in Australia as of November 2020[24], why are we not doing more to prevent influenza? Since COVID-19 and influenza are similar viruses in terms of transmission and the illness they cause, what measures introduced to prevent COVID-19 are sustainable in the long run?[25] And which of these measures would be acceptable to society to continue to implement to reduce influenza cases?

Lockdowns have been one strategy to prevent COVID-19. This is an unacceptable measure to continue with to prevent the flu due to impact on people’s lives. Lockdowns first became a method of prevention in Wuhan where the virus emerged.

These measures successfully helped increase the time it took for the virus to continue to spread, and resulted in a reduction in case numbers.[26] Many countries including Australia have adopted lockdowns in various forms allowing the health care

systems to better prepare for the virus. However, the impact on mental health, domestic violence and the economy is far too great to be considered an appropriate strategy in the management of the flu.[27] The true fall out from lockdowns and closure of public spaces will only be clear in the future as data is currently limited, but it is well known that isolation is a risk factor for mental health conditions.[29] Social distancing is another of the effective measures introduced during COVID-19.[14,15] The practice of keeping at least 1.5 meters away was another concept not promoted or talked about amongst the public prior to the pandemic. As mentioned with lockdown measures there are concerns about the impact of this on mental health.[28] Social distancing promotes social isolation and could contribute to symptoms of depression and anxiety.[28] This measure, although important, has also been a source of frustration as large gatherings such as concerts and festivals were cancelled. Perhaps the benefits of social distancing are outweighed by the impact it has on our ability to interact with each other, making it an unsustainable measure for the future.

Contact tracing has been another method of containing outbreaks in COVID-19.[17] However, unlikely COVID-19 (where transmission from pre-symptomatic viral shedding is minimal), the transmission of influenza seems to be driven by the 50

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pre-symptomatic transmission.[25] The success of contact tracing during the pandemic has been timesensitive.[15,16] Since influenza is transmitted before people experience symptoms there may be no benefit to contact tracing as tracing is unlikely to occur in the necessary time frame.

Potentially the measures that are more sustainable for the future are those that are simple and relate to our public health behaviour. Encouraging hand hygiene has been a key practice in Australia during the pandemic.

Hand hygiene reduces the person-toperson transmission of COVID-19 and has always been essential in hospitals to prevent infection spread.

[20,29] However, For the general public, hand hygiene perhaps has not been focused on enough. Only as the pandemic occurred have sanitiser wipes become available at supermarkets to wipe down trolleys.

Hand sanitiser stations are now visible and accessible in public spaces, shops, and the entrance of restaurants; all locations which previously had no means of hand sanitisation. The rigid practise of hand hygiene should continue to prevent outbreaks of any infection, and public health messaging should continue to focus on this in the future to prevent influenza.

Conclusion 2020 has been a year of remarkably low influenza cases across Australia.

This reduction in cases could be attributed to the various measures that were put in place to prevent

COVID-19. Moving forward from the pandemic it will be important to reevaluate how we approach seasonal influenza and what we can do to prevent its transmission. Harsh lockdown measures are not feasible for the future to prevent influenza.

However, simple behavioural changes and public health messages focusing on hand hygiene may be a measure society can continue to implement to reduce influenza transmission.

Author Statement I am a final year medical student at Bond University. From my clinical experiences so far I am most interested in obstetrics and gynaecology. However I am looking forward to making the most of my final clinical year and explore other fields.

Correspondence anna.postema@student.bond.edu.au Conflicts of Interest None Acknowledgements None References 1.Mandell GL, Douglas Jr RG, Bennett JE. Principles and practice of infectious diseases. Volume 2. 7th ed.

Churchill Livingstone/Elsevier; 2010.

2.Paules C , Subbarao K. Influenza.

Lancet. 2017;390(10095):697-708.

3.Nichol KL, Lind A, Margolis KL, et al. The effectiveness of vaccination against influenza in healthy, working adults. N Engl J Med. 51

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1995;333(14):889-893.

4. Biggerstaff M, Cauchemez S, Reed C, Gambhir M, Finelli L. Estimates of the reproduction number for seasonal, pandemic, and zoonotic influenza: a systematic review of the literature.

BMC Infect Dis. 2014;14(1):480-480.

5.Newall AT, Scuffham PA. Influenzarelated disease: The cost to the Australian healthcare system. Vaccine.

2008;26(52):6818-6823.

6.Jamotte A, Chong CF, Manton A, Macabeo B, Toumi M. Impact of quadrivalent influenza vaccine on public health and influenza-related costs in Australia. BMC public health.

2016;16(1):630-630.

7.Fields BN, Knipe DM, Howley PM. Fields’ Virology. 5th ed. Lippincott Williams & Wilkins; 2008.

8.Dyda A, Karki S, Hayen A, et al.

Influenza and pneumococcal vaccination in Australian adults: a systematic review of coverage and factors associated with uptake. BMC Infect Diss. 2016;16(1):515-515.

9.Organisation for Economic Cooperation and Development.

Influenza vaccination rates [Internet].

2020 [cite 26 October 2020] Available from: https://data.oecd.org/healthcare/influ enza-vaccination-rates.htm 10.The Lancet. Preparing for seasonal influenza.

Lancet.

2018;391(10117):180-180.

11.World Health Organization.

Coronavirus disease (COVID-19) [Internet]. 2020 [cited 26 October 2020] Available from https://www.who.int/emergencies/dis eases/novel-coronavirus-

2019/question-and-answers-hub/q-adetail/coronavirus-disease-covid-19 12.World Health Organization.

Weekly operation update on COVID19 - 23 October 2020 [Internet]. 2020 [cited 26 October 2020]. Available from: https://www.who.int/publications/m/i tem/weekly-update-on-covid-19--23-october 13.World Health Organization.

Weekly epidemiological update – 20 October 2020 [Internet]. 2020 [cited 26 October 2020]. Available from: https://www.who.int/publications/m/i tem/weekly-epidemiological-update--20-october-2020 14.World Health Organization.

Transmission of SARS-CoV-2: implications for infection prevention precautions [Internet]. 2020 [cited 26 October 2020]. Available from: https://www.who.int/publications/i/it em/modes-of-transmission-of-viruscausing-covid-19-implications-foripc-precaution-recommendations 15.MacIntyre CR. Case isolation, contact tracing, and physical distancing are pillars of COVID-19 pandemic control, not optional choices.

Lancet Infec Dis. 2020;20(10):1105-1106.

16.Kretzschmar ME, Rozhnova G, Bootsma MCJ, van Boven M, van de Wijgert JHHM, Bonten MJM. Impact of delays on effectiveness of contact tracing strategies for COVID-19: a modelling study. Lancet Public health. 2020;5(8):e452-e459.

17.Stuart RM, Abeysuriya RG, Kerr CC, et al. Robust test and trace stratagies can prevent COVID-19 resurgences: a case study from New 52

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South Wales, Australia. medRxiv.

2020 [preprint] 18.Australian Government.

Framework for national reopening: Framework October 2020 [Internet].

2020 [cited 26 October 2020].

Available from: https://www.australia.gov.au/content/ dam/australia/news-andupdates/framework-nationalreopening.pdf 19.Chu DK, Aki EA, Duda S, Solo K, Yaacoub S, Schunemann Hj. Physical distancing, face masks, and eye protection to prevent person-toperson transmission of SARS-CoV-2 and COVID-19: a systematic review and meta-analysis.

Lancet.

2020;395(10242):1973-1987.

20.Pradhan B. A review of current interventions for COVID-19 prevention.

Arch Med Res. 2020;51(5):363-374.

21.Cowling BJ, Ali ST, Ng TWY, et al.

Impact assessment of nonpharmaceutical interventions against coronavirus disease 2019 and influenza in Hong Kong: an observational study. Lancet Public health. 2020;5(5):e279-e288.

22.Australian Government Department of Health. Australian influenza surveillance report No 14 – 05 October to 19 October 2020 [Internet]. 2020 [ cited 28 October 2020].

Available from: https://www1.health.gov.au/internet/ main/publishing.nsf/Content/cdaozflu-2020.htm 23.Australian Government Department of Health: National Notifiable Disease Surveillance System. Number of notifications of

influenza (laboratory confirmed), Australia, in the period of 1991 to 2019 and year-to-date notifications from 2020 [Internet].

National Disease Surveillance System [cited 3 November 2020]. Available from: http://www9.health.gov.au/cda/sourc e/rpt_3.cfm 24.Australian Government Department of Health Web .

Coronavirus (COVID-19) current situation and case numbers [Internet].

2020 [cited 3 November 2020].

Available from: https://www.health.gov.au/news/healt h-alerts/novel-coronavirus-2019ncov-health-alert/coronavirus-covid19-current-situation-and-casenumbers 25.World Health Organization.

Coronavirus disease (COVID-19): Similarities and differences with influenza [Internet]. 2020 [cited 3 November 2020]. Available from: https://www.who.int/emergencies/dis eases/novel-coronavirus2019/question-and-answers-hub/q-adetail/coronavirus-disease-covid-19similarities-and-differences-withinfluenza.

26.Lau H, Khosrawipour V, Jocbach P, et al. The positive impact of lockdown in Wuhan on containing the COVID19 outbreak in China. J Travel Med. 2020;27(3). doi:10.1093/jtm/taaa037 27.World Health Organisation.

Coronavirus disease (COVID-19): Herd immunity, lockdowns and COVID-19 [Internet]. [cited 3 November 2020]. Available from: https://www.who.int/emergencies/dis eases/novel-coronavirus019/question-and-answers-hub/q-a53

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detail/herd-immunity-lockdownsand-covid-19.

28.Bolon MK. Hand hygiene: an update. Infect Dis Clin North Am. 2016;30(3)591-607 29.Venkatesh A, Edirappuli S. Social distancing in COVID-19: what are the mental health implications. BMJ. 2020369:m1379-m1379

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UNMASKED:

AUTISM IN

WOMEN

Jacqueline Bredhauer

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Graphic by Christine Manuel

Autism presents differently in females compared to males. Research is just beginning to understand that girls and women ‘mask’ their autistic traits, appearing ‘neurotypical’ to the untrained eye, and frequently never receiving their autism diagnosis.[1,2] This carries implications throughout life as females with autism are unable to access the support and understanding they need.

The misdiagnosis of autistic women and girls is a public health issue that needs to be addressed through research and education. Girls and women with autism deserve to be identified and supported.

Autism is a neurological difference characterised by atypical social communication, understandings and approaches, repetitive patterns of behaviour and altered sensory processing (Table One).[3] Understandings of autism have evolved since its identification in the 1940s – from a ‘childhood schizophrenia’ caused by poor parenting, to an epidemic tied to the MMR vaccine, and now, to a distinct neurotype that benefits from understanding and supportive inclusion in society.[4] Today, autistic self-advocates champion the concept of neurodiversity, suggesting that 55

autism is a natural and necessary variation of human neurology; and that autistic people, like neurotypical people, are vastly different.[5] There is recognition now that experiences of autism are diverse. [6] An autistic person can look and act like

and they can be female.

Autism and Gender Until as recently as 2008, autism was assumed to be male dominated. The gender ratio in autism diagnoses has traditionally been recorded as one

A. Social communication and social interaction deficits 1. Deficits in social-emotional reciprocity – ranging from abnormal social approach and failure of normal back-and-forth conversation; to reduced sharing of interests, emotions or affect; to failure to initiate or respond to social interactions 2. Deficits in nonverbal communicative behaviours – ranging from poorly integrated verbal and nonverbal communication; to abnormalities in eye contact and body language or deficits in understanding and using gestures; to a total lack of facial expressions or nonverbal communication 3. Deficits in developing, maintaining and understanding relationships – ranging from difficulties adjusting behaviour to suit various social contexts; to difficulties in sharing imaginative play or in making friends; to absence of interest in peers B. Restricted, repetitive patterns of behaviour, interests or activities 1. Stereotyped or repetitive motor movements, use of objects, or speech 2. Insistence on sameness, inflexible adherence to routines, or ritualised patterns of verbal and nonverbal behaviour 3. Highly restricted, fixated interests that are abnormal in intensity or focus 4. Hyper- or hyporeactivity to sensory input, or unusual interest in sensory aspects of the environment

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Table One: DSM-V Criteria A and B for Autism Spectrum Disorder [1] Raymond Babbit from Rain Man,[7] or Sheldon Cooper from the Big Bang Theory.[8] However, they can also be creative, artistic, hyper-empathetic, or hyper-verbal. They might not ‘look’, or appear, autistic. They can be culturally and linguistically diverse,

female* for every four males.[9] Autism itself has been postulated as a manifestation of extreme masculinity.

[10] However, the past decade of research has revealed that autism does occur in females, and in higher numbers than previously assumed.[11]

*In this article, the gendered terms ‘females’, ‘women’ and ‘girls’ can be taken to refer broadly to any person assigned female at birth (AFAB).

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The gender ratio in autism appears closer to 1:3, and may be even greater, due to diagnostic bias.[11] Girls develop and manifest autism differently, and as a result, can go years, or even a lifetime, undiagnosed.[2] They often need to display more severe symptoms than boys to be recognised as autistic.

[1,12,13] If females are diagnosed, this occurs later than their male counterparts, with some women only learning of their condition in mid-life after their child is identified as being on the spectrum. [14–16] Without a diagnosis, autistic girls, women, and non-binary individuals cannot access the self-acceptance and support they need.[2] This carries significant implications for identity, mental health, academic performance and employment.[2] Autistic females appear to display a unique phenotype, meaning they express challenges in social communication and rigid, repetitive behaviours in a different manner to the traditional conceptualisation of autism.[2] Females tend to display fewer social difficulties than males, possibly indicating higher levels of social motivation.[17,18] Nevertheless, social competence is superficial and autistic females struggle to make and maintain intimate relationships.[2] Autistic females also appear to exhibit fewer repetitive behaviours than their male counterparts, and they become fixated on more ‘typical’ interests – dolls, fashion or celebrities, rather than numbers or trains.[18,19]

Perhaps due to their higher social motivation, autistic females learn to ‘camouflage’ early, enabling them to blend in with neurotypical peers.[20] They employ conscious or unconscious strategies to ‘mask’ their autistic traits – ranging from mimicking behaviours and facial expressions, to forcing eye contact, or not talking about a special interest.

[21,22] They rely on alternative cognitive strategies to navigate their social environment, learning social behaviours and understandings intellectually, rather than through instinct or intuition.[23] Despite their internal experience of autism, through learning to hide their difficulties, autistic females may go entirely unnoticed.[20] In particular, they tend to suppress autistic traits at school and in other social settings. So whilst they may experience challenges at home, like ‘melt downs’, sensory issues, or communication idiosyncrasies, trained teachers and clinicians may never identify them as autistic.[20] The toll of being undiagnosed – camouflaging, masking and identity Not only are autistic people who camouflage less likely to be diagnosed and access necessary support and accommodations – camouflaging and masking also take a toll on mental health.[24] The conscious or unconscious suppression of autistic traits, and fabrication of neurotypical behaviours, requires significant cognitive effort.[24] Camouflaging itself is a cause of stress, anxiety and depression.[24] Camouflaging also 57

impedes identity – through constantly working to blend in, autistic females confuse their true sense of self with the traits and desires of those who surround them.[21]

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Challenges throughout the lifespan Autistic females need to be diagnosed so they can be supported throughout their lifespan.[25] They face challenges relating to behavioural difficulties and friendships during childhood; identity, independence and romantic relationships during adolescence; and employment, childbirth and parenting in adulthood.[25–28] Whilst autistic females can be socially motivated and learn to ‘mask’, they struggle with social nuance, which can interfere with school, relationships, and interacting at work.[25–27] Despite intelligence and ability, they may not reach their potential in academic and work settings due to their differences in social understanding and sensory experiences.[29] Tragically, poor comprehension of social nuance can render autistic females at high risk of manipulation, and in particular, sexual assault. [25] Future directions – education, research, and acceptance Efforts are urgently needed to improve the identification of autistic women and girls. Further research is required to understand the female autistic phenotype, and the unique challenges of women and girls on the spectrum. Autism diagnostic tests should be re-evaluated to more readily identify autistic females,

taking into account differences such as masking and camouflaging.

Support therapies that specifically target the unique needs of autistic females – for example, the burden of camouflaging and masking, or heightened sensory challenges; should be developed. Awareness should be raised about autism in females so that individuals who are struggling can be identified or can recognise traits in themselves.

It is time to un-mask autism in women and girls.

About the Author Jacqueline is a medical student at Monash University and the Chair of AMSA Global Health. She has broad interests, spanning health equity, human rights, psychology, politics and philosophy. Jacqueline plans to work in the intersection of health and politics to forge a fairer and kinder world.

Correspondence jacqueline.bredhauer@amsa.org.au Conflicts of Interest None Acknowledgements None References 1. Duvekot J, van der Ende J, Verhulst FC, Slappendel G, van Daalen E, Maras A, et al. Factors influencing the probability of a diagnosis of autism spectrum disorder in girls versus boys. Autism Int J Res Pract. 2017 58

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Aug;21(6):646–58.

2. Hull L, Petrides KV, Mandy W. The Female Autism Phenotype and Camouflaging: a Narrative Review.

Rev J Autism Dev Disord. 2020 Dec 1;7(4):306–17.

3. Association AP. Diagnostic and Statistical Manual of Mental Disorders (DSM-5®).

American Psychiatric Pub; 2013. 1520 p.

4. Wolff S. The history of autism. Eur Child Adolesc Psychiatry. 2004 Aug 1;13(4):201–8.

5. Fenton A, Krahn T. Autism, Neurodiversity, and Equality Beyond the “Normal.” J Ethics Ment Health.

2007;2(2):2.

6. Lancet T. Pride in autistic diversity.

The Lancet.

2016 Jun 18;387(10037):2479.

7. Levinson B. Rain Man. United Artists, The Guber-Peters Company, Star Partners II Ltd.; 1988.

8. The Big Bang Theory. Chuck Lorre Productions, Warner Bros.

Television; 2006.

9. AIHW. Autism in Australia [Internet]. Australian Institute of Health and Welfare. 2017 [cited 2021 Apr 21].

Available from: https://www.aihw.gov.au/reports/disa bility/autism-inaustralia/contents/autism 10. Baron-Cohen S. The extreme male brain theory of autism. Trends Cogn Sci. 2002 Jun 1;6(6):248–54.

11. Loomes R, Hull L, Mandy WPL. What Is the Male-to-Female Ratio in Autism Spectrum Disorder?

A Systematic Review and MetaAnalysis. J Am Acad Child Adolesc Psychiatry. 2017 Jun 1;56(6):466–74.

12. Dworzynski K, Ronald A, Bolton P,

Happé F. How different are girls and boys above and below the diagnostic threshold for autism spectrum disorders? J Am Acad Child Adolesc Psychiatry. 2012 Aug;51(8):788–97.

13. Shattuck PT, Durkin M, Maenner M, Newschaffer C, Mandell DS, Wiggins L, et al. Timing of Identification Among Children With an Autism Spectrum Disorder: Findings From a Population-Based Surveillance Study. J Am Acad Child Adolesc Psychiatry.

2009 May 1;48(5):474–83.

14. Begeer S, Mandell D, WijnkerHolmes B, Venderbosch S, Rem D, Stekelenburg F, et al. Sex Differences in the Timing of Identification Among Children and Adults with Autism Spectrum Disorders. J Autism Dev Disord. 2013 May 1;43(5):1151–6.

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Kirkovski M, Enticott PG, Fitzgerald PB. A Review of the Role of Female Gender in Autism Spectrum Disorders. J Autism Dev Disord. 2013 Nov 1;43(11):2584–603.

16.

Rutherford M, McKenzie K, Johnson T, Catchpole C, O’Hare A, McClure I, et al. Gender ratio in a clinical population sample, age of diagnosis and duration of assessment in children and adults with autism spectrum disorder. Autism. 2016 Jul 1;20(5):628–34.

17. Head AM, McGillivray JA, Stokes MA. Gender differences in emotionality and sociability in children with autism spectrum disorders.

Mol Autism.

2014 Dec;5(1):1–9.

18. Hiller RM, Young RL, Weber N. Sex differences in autism spectrum disorder based on DSM-5 criteria: 59

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evidence from clinician and teacher reporting. J Abnorm Child Psychol.

2014 Nov;42(8):1381–93.

19. Gould J, Ashton-Smith J. Missed diagnosis or misdiagnosis? Girls and women on the autism spectrum.

Good Autism Pract GAP. 2011 Jan 1;12.

20. Dean M, Harwood R, Kasari C. The art of camouflage: Gender differences in the social behaviors of girls and boys with autism spectrum disorder. Autism Int J Res Pract. 2017 Aug;21(6):678–89.

21. Hull L, Petrides KV, Allison C, Smith P, Baron-Cohen S, Lai M-C, et al. “Putting on My Best Normal”: Social Camouflaging in Adults with Autism Spectrum Conditions. J Autism Dev Disord. 2017 Aug 1;47(8):2519–34.

22. Lai M-C, Lombardo MV, Pasco G, Ruigrok ANV, Wheelwright SJ, Sadek SA, et al. A Behavioral Comparison of Male and Female Adults with High Functioning Autism Spectrum Conditions. PLOS ONE. 2011 Jun 13;6(6):e20835.

23. Livingston LA, Colvert E, Bolton P, Happé F. Good social skills despite poor theory of mind: exploring compensation in autism spectrum disorder. J Child Psychol Psychiatry.

2019;60(1):102–10.

24. Lai M-C, Lombardo MV, Ruigrok AN, Chakrabarti B, Auyeung B, Szatmari P, et al. Quantifying and exploring camouflaging in men and women with autism. Autism Int J Res Pract. 2017 Aug;21(6):690–702.

25. Bargiela S, Steward R, Mandy W. The Experiences of Late-diagnosed Women with Autism Spectrum Conditions: An Investigation of the

Female Autism Phenotype. J Autism Dev Disord. 2016;46(10):3281–94.

26. Carpenter B, Happé F, Egerton J. Girls and Autism: Educational, Family and Personal Perspectives. Routledge; 2019. 215 p.

27. Kanfiszer L, Davies F, Collins S. ‘I was just so different’: The experiences of women diagnosed with an autism spectrum disorder in adulthood in relation to gender and social relationships. Autism. 2017 Aug 1;21(6):661–9.

28. Rogers C, Lepherd L, Ganguly R, Jacob-Rogers S. Perinatal issues for women with high functioning autism spectrum disorder. Women Birth J Aust Coll Midwives.

2017 Apr;30(2):e89–95.

29. Baldwin S, Costley D. The experiences and needs of female adults with high-functioning autism spectrum disorder. Autism. 2016 May 1;20(4):483–95.

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