AJGH Volume 16 Issue 1

AJGH AMSA Journal of Global Health

Vol 16

Issue 01

July 2022 01 '22

Glass Glass Glass Glass

Ceilings Ceilings Ceilings Ceilings

This issue is proudly sponsored by :

AJGH 2022 Volume 16 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 PEER REVIEWERS Dr Biswajit Banik Dr Isabella Huang Dr Claire Henderson–Wilson Dr Richard Bradbury Dr Jennifer Ayton EDITOR-IN-CHIEF Lawrence Lin SENIOR EDITORS Shani Nguyen Jessica Xue

ASSOCIATE EDITORS Shayan Abbas Nanditha Hareesh Steven Huang Dawn Lee PROMOTIONS DIRECTORS Simra Azher Benyamin Zargar PODCAST PRODUCERS Meghna Prasannan Ponganam Kevin Huang PUBLICATIONS DESIGNERS Amani Azlan Anna Duan Design and Layout © 2022, AJGH Australian Medical Students’ Association Ltd, Level 1, 39 Brisbane Avenue, Barton, ACT 2600 ajgh@amsa.org.au journal@globalhealth.amsa.org.au Content © 2022, The Authors Cover Design by Amani Azlan AJGH is the official student-run, peerreviewed 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.

01 '22

Glass Ceilings

Despite the advancements and developments in the world of global health, glass ceilings continue to enmesh marginalised demographics in conspicuous and underhanded ways. We hope this Issue will help shed light on these invisible barriers.

The AJGH Team.

This Issue's Contents 01 '22

01

Neglecting the most neglected Written by Anna Duan, Peer reviewed by Dr Richard Bradbury

08

The evolution of Globalisation and its impacts on public health Written by Aatif Syed, Peer reviewed by Dr Isabella Huang

13

The time is now: What can Australia learn from social prescribing programs in the United Kingdom?

Written by Grace Newman, Peer reviewed by Dr Biswajit Banik

20

Aborting Our Autonomy: Abortion Access During COVID-19 in Australia and America Written by Melody Ahfock, Peer reviewed by Dr. Jennifer Ayton

28

Utilising a Health Promotion Approach to Climate Action Written by Jasmine Davis, Peer reviewed by Dr Claire Henderson–Wilson

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Neglecting the Most Neglected Feature Article by Anna Duan

Of the 20 Neglected Tropical Diseases (NTDs) deemed by the World Health Organisation as requiring exigent national and global attention, one disease has been described as being the ‘most neglected’ of the NTDs – Strongyloidiasis.

Strongyloidiasis poses a major public health burden for remote Aboriginal communities in Australia, and yet, there is a distinct lack of public health attention its control and eradication. Existing strategies explored have been limited to the clinician-patient interface, with no evidence of any concerted transdisciplinary approach encompassing veterinary, environmental, and human medicine disciplines. While the link between environmental conditions and strongyloidiasis has been well-established, the zoonotic link has been a subject of debate. OneHealth is defined as an approach recognizing the close connection between human health and the health of animals and the environment. This article provides an overview of the key issues and challenges in the control of strongyloidiasis. Reflecting on existing barriers, the article advocates a need for OneHealth approaches to strongyloidiasis elimination and control endeavours. As future doctors and clinicians, understanding the importance of transdisciplinary and more holistic approaches to health is critical to closing the gap in health equity. The reflection on OneHealth was completed in close consultation with the Indigenous Environmental Health Officer (QLD Health), Mr. Frank Mills.

Neglecting the Most Neglected

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Reflecting on the endemicity of S. Stercoralis in Australian Aboriginal communities and the need for OneHealth approaches The word ‘Neglect’ in medicine is particularly pertinent to a group of 20 diseases deemed by the World Health Organisation as the ‘Neglected Tropical Diseases’ (NTDs) [1], endemic to tropical and subtropical regions of the world, over 149 countries [1]. They are deemed so due to their substantial impact upon the wellbeing of under-served tropical populations [1]. The NTDs have long been overlooked in our global and public health agenda – intimately being linked to impoverishment and social disadvantage.

Australia is home to several NTDs – Chikungunya, Dengue, Leprosy, Rabies, SoilTransmitted Helminths (STHs), Echinococcosis, and Trachoma [2]. The disproportionate burden of trachoma and leprosy on Australian Aboriginal communities has long been noted and researched, attracting public health response, interventions, and attention over the years [3,4]. However, one disease has remained overlooked despite its endemicity in Australia – Strongyloidiasis. Strongyloides stercoralis is a soil-transmitted helminth (STH), causing the infectious disease, strongyloidiasis [5].

Clinically, strongyloidiasis can cause acute and chronic infection, especially for immunocompromised individuals [5].

Strongyloidiasis is estimated to affect an estimated figure up to 613.9 million people worldwide and has been proposed as one of the most neglected tropical diseases [6].

Strongyloidiasis is hyper-endemic in remote regions of Australia [7], with high prevalence in remote Aboriginal communities [8-10]. As medical students, building an early awareness of the endemicity and severity of diseases which pose especially high burdens to under-served populations is crucial.

Strongyloidiasis – lack of diagnostic capacity or recognition?

In Australia, significant morbidity and preventable deaths are associated with strongyloidiasis infection in remote Aboriginal communities [8]. Rather than a lack of diagnostic capability, preventable deaths from strongyloidiasis most often occur due to under-recognition of the disease, and subsequent poor clinical management [8]. Clinical manifestations may range from asymptomatic to acute GI, respiratory or cutaneous syndromes, the most severe being disseminated disease and subsequent fatality [8].

Chronic strongyloidiasis is underdiagnosed in Australia, with accompanying non-specific symptoms often overlooked in clinical practice, unless explicitly considered by the physician. This condition may lead to hyperinfection or disseminated strongyloidiasis if the auto-infective cycle becomes amplified, resulting in fatality rates up to 87% [6].

Literature has highlighted frequent and problematic end-of-life diagnoses with “unknown aetiology” [11]. As aptly noted by Page and colleagues, strongyloidiasis – being a non-overt disease: ‘if you don’t look for [strongyloidiasis] – you won’t find it’ [12].

Interventions targeted at increasing the capacity of practitioners to recognize strongyloidiasis are likely to be effective in minimizing the burden of strongyloidiasisassociated morbidity. In an intervention study investigating testing for chronic strongyloidiasis, integration of S. stercoralis serology testing within the Indigenous adult preventative health assessment system increased the number and proportion of people tested in endemic communities [11].

The authors noted the potential for prevention of life-threatening complications due to earlier detection and treatment of strongyloidiasis, particularly for high-risk populations [11].

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Public health interventions – impossible in a landscape of convoluted incidence A 2005 review identified strongyloidiasis as particularly common in Aboriginal communities in Northern Australia, with a positive test for Strongyloides ranging from 060% [8]. Rurality and Indigeneity have been found to be both positively correlated with risk of strongyloidiasis [7]. Among Aboriginal Australian populations, high rates of strongyloidiasis may also partly reflect the incidence of human T-cell lymphotropic virus type 1 (HTLV-1), a risk factor for parasite proliferation and transmission [13, 14]. This was noted as being particularly prevalent in Central Australian Aboriginal communities [15]. A 2018 review concurred with the endemicity for strongyloidiasis in the Indigenous Australian population, particularly in QLD, NT, WA, Northern SA and NSW [16]. Another review on strongyloidiasis in Central Australia found all seropositive patients to be Indigenous Australian [17]. However, it was identified that true incidence in Australia is currently unknown as a result of under-diagnosis and the absence of surveillance data – negatively impacting on public health attempts to institute effective elimination and control measures [16,18]. This limitation is well noted by Australia’s lack of inclusion of strongyloidiasis on the Australian Notifiable Disease Register [16], in spite of recent literature pushing for the inclusion of strongyloidiasis on the notifiable diseases register in Australia [16,19].

The social determinants of health – how relevant are they?

Despite interventions targeting the capacitybuilding of practitioners, strategies aiming to curb S. stercoralis transmission will be unsuccessful if they do not act on the upstream social determinants of health, namely, social disadvantage, environmental, housing factors [20]. A lack of primary

community or environmental interventions to eliminate S. stercoralis was noted by a literature review on strongyloidiasis control [8]. A general gap in public health approaches to the control of strongyloidiasis was highlighted [8]. A more recent systematic review on STHs in minority indigenous populations likewise identified a lack of systematic action plans to address strongyloidiasis [18].

Ultimately, the social determinants of health are crucial factors to consider in the control of strongyloidiasis. A 2014 systematic review identified three key barriers to the control of strongyloidiasis in Australian Indigenous communities: health status, socioeconomic status and health care literacy and procedures [19]. Firstly, comorbidities (Chronic Liver Disease, Chronic Lung Disease, Acute Rheumatic Fever, HTLV-1, Hepatitis B, immunocompromised) and rates of concurrent infections (meningitis, pneumonia) tend to be higher with strongyloidiasis, leading to the complication of both diagnosis and clinical management [19]. Secondly, racial disparities, social cohesion, housing, and socioeconomic conditions have large environmental implications, as well as the ability of patients to seek healthcare for non-specific symptoms associated with strongyloidiasis. Thirdly, limited health literacy and procedural factors such as clinician competency, lack of communication/follow-up, or nonadherence to treatment, contributed to increased Page 03

morbidity and strongyloidiasis [19].

mortality

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It is evident that approaches to elimination of S. stercoralis require more than action at a clinician-patient interface, as broader determinants including structural and socioeconomic disadvantage remain large upstream barriers to effective disease control. Yet, consideration of the upper stream determinants of health cannot be done from an isolated point of view by policymakers.

Community-based interventions for strongyloidiasis have been found to be more likely to be successful, especially when combined with principles of community codesign and ownership [21]. A 2018 interventional study highlighted the importance of local Aboriginal leadership and governance alongside mass Ivermectin administration to address strongyloidiasis [21]. The study illustrated how communitydirected and led strongyloidiasis control programs have increasing significance in halting strongyloidiasis outbreaks [21]. As training medical professionals, understanding the more complex and upstream determinants health is critical to our future efforts in closing the gap in health.

A potential need for OneHealth approach to strongyloidiasis?

As aforementioned, strongyloidiasis has not yet been proven to be zoonotically transmitted, however, literature has pointed toward this direction. Further research is required to determine if a OneHealth approach is necessary. S. stercoralis is a species complex with at least three genetically distinct species [22]. More cryptic species of Strongyloides have been found in dogs in remote Aboriginal communities – however further research is required to understand if there is cross transmission between dogs and human hosts [23].

OneHealth is defined as an approach recognizing the close connection between human health and the health of animals and the environment [24]. A framework for OneHealth in relation to strongyloidiasis is shown in figure 1. In any effort to control strongyloidiasis, action should be multisectoral. Environmental transmission is crucial in the epidemiology of strongyloidiasis, and the possibility of zoonotic links should not be neglected [20].

These are intimately linked to the upper and midstream social determinants of health, including housing infrastructure, access to health hardware, health literacy and hygiene practices. Without consideration to the root causes of strongyloidiasis transmission – namely, zoonotic, and environmental, programs solely aiming to increase clinician competency in diagnosis or management will be ineffective in the long-term.

Zoonotically, Strongyloides spp have the potential to affect canids [20, 25]. A recent 2020 study examined 274 dog faecal samples across 27 remote communities in Northern and Central Australia, found that the prevalence of S. stercoralis was 21.9% [25].

This study points toward potential for zoonotic transmission of strongyloidiasis and suggests the possibility to examine a OneHealth approach to the elimination of strongyloidiasis in Australia. This is particularly important as dogs play an important role in many Aboriginal communities – serving as totems for some clan groups, playing roles in hunting as well as companionship (Frank Mills, oral communication, Environmental Health Officer). Effective means to control strongyloidiasis should therefore consider the zoonotic potential of S. stercoralis.

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determinants for Strongyloides (zoonotic and environmental) [20]. However, it is worth noting that zoonotic aspects, geographical variations, social, cultural and environmental aspects are poorly understood in terms of Strongyloides transmission [6]. Therefore, strategies to control strongyloidiasis require multisectoral integration, more effective surveillance strategies as well as meaningful ways to engage at-risk communities toward primary and secondary disease prevention approaches.

As previously discussed, control of strongyloidiasis is dependent on action towards the social determinants of health.

Persistence of parasitic infections has been attributed to factors including poverty, poor health literacy, inadequate access to sanitation and hygiene- amenities, and poorly coordinated public health campaigns [7]. Public health bodies should work with government bodies to improve welfare, housing and sanitation infrastructure, increase health literacy, and in the long term, improve the socioeconomic gap that exists between burdened communities and the broader Australian population. In a recent review of OneHealth approaches to strongyloidiasis in North America, coordinating medical, veterinary, and environmental expertise represented implementable opportunities for treatment, community engagement and land management to mitigate the impact and transmission of strongyloidiasis [20].

However, it should be noted that the above review has made the assumption that zoonotic transmission is occurring due to the similarities in the rhabditiform larval stages in dogs and humans. There is a lack of literature to confirm zoonotic links in the transmission of strongyloidiasis. Despite this, the authors recommended the OneHealth approach as a systematic and integrated means to target the various

The Queensland Health environmental health officer (EHO) Frank Mills provided other key insights toward the integration of environmental expertise with clinical medicine. Key themes identified were: 1. Professional silos as a barrier to control of strongyloidiasis and transmission of S. stercoralis.

2. Sustainability of health promotion campaigns.

3. Need for knowledge continuity and ‘local champions’ for program continuity.

Mr. Mills identified that professional ‘siloing’ of disciplines was a limitation to greater collaboration and progress on the control of S. stercoralis. He spoke of a ‘we vs. them’ mindset prevalent in the medical profession, and the lack of connection between environmental and medical disciplines as a key barrier to control of disease. The need for specialists that are able to ‘sit in the middle’ and connect clinical and environmental spaces well would be an enabler to greater transdisciplinary action to control transmission of S. stercoralis. In rural and remote Aboriginal communities, environment-related personnel are Environmental Health Workers (EHWs) who play a role in dog health, other animal health, water, sewerage and housing issues, often taking roles in health promotion, education, and community education. As such, Mr Mills believes that EHWs have great Page 05

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capacity to take a large role in S. stercoralis eradication programs (Frank Mills, oral communication, EHO).

Sustainability of eradication programs also need to be considered. Mr Mills identified that an aging workforce and entry of doctors from urban areas result in a lack of knowledge continuity necessary for program coordination. For instance, many doctors that come in were described as having ‘no knowledge of the existence of EHWs’ – and thus facilitating large barriers in professional collaboration and sustainability of programs.

Ensuring that professionals coming into the community possess adequate knowledge, and that local leaders and champions for health promotion are able to pass on knowledge, is critical. (Frank Mills, oral communication, EHO). As medical students, there is often seldom opportunity to engage with other traditionally siloed disciplines like environmental and veterinary fields – perhaps this is an area in need of curricula review.

Where to from here?

Strongyloidiasis remains a major public health burden for Aboriginal communities in remote Australia. Yet, there is limited research on prevention and control strategies, as well as very little known about the capacity of integrated transdisciplinary approaches in control programs. The article welcomes OneHealth as a potential area warranting further research, in particular, looking at the acceptability of OneHealth to key expertise – environmental, human, and veterinary, to strongyloidiasis control.

However, further research is also required to establish a stronger case for zoonotic transmission for strongyloidiasis before it is definitively brought into the scope of strongyloidiasis along with the environmental determinants.

Global inequalities are matters of moral consequence – as training health

professionals, we ought to care about both grave poverty and gross inequity that continues to affect some of our most underserved populations. It is easy as medical students to forget that human medicine forms just one component of the more holistic model of ‘health’ which encompasses not only the social determinants, but also environmental and animal health.

OneHealth aims to integrate these currently siloed disciplines, and in facilitating greater transdisciplinary collaboration, provides a more effective way to control infectious disease that is zoonotic and/or environmentally mediated. As training doctors, being more receptive to teamwork and collaboration may ultimately assist us in finding better solutions to infectious disease control.

Acknowledgements: Professor Maxine Whittaker and Mr. Frank Mills. This review was conducted to aid in the development of a research project relating to OneHealth approaches to S. stercoralis control, supported by the Amuthan Medical Research Bursary from James Cook University. As such, I would like to acknowledge and thank my mentor and supervisor, Professor Maxine Whittaker for her support, extensive insights and input into helping me come up with this project idea. I would like to thank the environmental health officer, Mr. Frank Mills for his time and invaluable insight into OneHealth approaches to strongyloidiasis control.

Correspondence: anna.duan@amsa.org.au Conflicts of interest: None declared.

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References 1. Neglected Tropical Diseases. World Health Organization. Updated 2022. Accessed April 14, 2022. https://www.who.int/news-room/questions-andanswers/item/neglected-tropical-diseases 2. Kurcheid J, Gordon CA, Clarke NE, et al. Neglected tropical diseases in Australia: a narrative review. Med J Aust. 2022;216(10):532-538. doi:10.5694/mja2.51533 3. Couzos S, Murray R, eds. Aboriginal Primary health Care: An evidence-based approach. 3 rd ed. Oxford University Press; 2008.

4. Addressing trachoma. Australian Government Department of Health. Updated 2021 June 30. Accessed April 14, 2022. https://www.health.gov.au/initiativesand-programs/addressing-trachoma 5. Strongyloides. Centers for Disease Control and Prevention. Updated September 2, 2020. Accessed April 17, 2022. https://www.cdc.gov/parasites/strongyloides/gen_info/f aqs.html#where 6. Buonfrate D, Bisanzio D, Giorli G, et al. The Global Prevalence of Strongyloides stercoralis Infection.

Pathogens. 2020;9(6):468. Published 2020 Jun 13. doi:10.3390/pathogens9060468 7. Paltridge M, Smith S, Traves A, McDermott R, Fang X, Blake C, et al. Rapid progress toward elimination of strongyloidiasis in North Queensland, Tropical Australia, 2000-2018. Am J Trop Med. 2020;102(2):33945. doi:10.4269/ajtmh.19-0490 8. Johnston FH, Morris PS, Speare R, McCarthy J, Currie B, Ewald D, et al. Strongyloidiasis: A review of the evidence for Australian practitioners. Aust. J Rural Health. 2005;13(4):247-54. doi: 10.1111/j.14401584.2005.00710.x 9. Hotez PJ. Aboriginal populations and their neglected tropical diseases. PLoS Negl.Trop. Dis. 2014;8(1):1. doi: 10.1371/journal.pntd.0002286 10. Holt DC, McCarthy JS, Carapetis JR. Parasitic diseases of remote Indigenous communities in Australia. Int. J Parasitol. 2010;40(10):1119-26. doi:10.1016/j.ijpara.2010.04.002.

11. Page WA, Juddid JA, Maclaren DJ, Buettner P. Integrating testing for chronic strongyloidiasis within the indigenous adult preventive health assessment system in endemic communities in the Northern territory, Australia: An intervention study. PLoS Negl.

Trop. Dis. 2020;14(5):1-17. doi: 10.1371/journal.pntd.0008232 12. Page W, Speare R. Chronic strongyloidiasis Don't look and you won't find. Aust.

Fam. Physician. 2016;45(1):40-4. Accessed April 12, 2022. https://www.racgp.org.au/afp/2016/januaryfebruary/chronic-strongyloidiasis-don-t-look-and-youwon-t 13. Kline K, McCarthy JS, Pearson M, Loukas A, Hotez PJ. Neglected tropical diseases of Oceania: Review of their prevalence, distribution, and opportunities for Control. PLoS Negl. Trop. Dis. 2013;7(1). doi: 10.1371/journal.pntd.0001755.

14. Einsiedel LJ, Pham H, Woodman RJ, Pepperill C, Taylor KA. The prevalence and clinical associations of HTLV-1 infection in a remote indigenous community.

Med. J. Aust. 2016;205(7):305-9. doi: 10.5694/mja16.00285 15. Einsiedel L, Fernandes L. Strongyloides stercoralis: A cause of morbidity and mortality for indigenous people in Central Australia. Intern. Med. J. 2008;38(9):697-703.

16. Beknazarova M, Whiley H, Judd JA, Shield J, Page W, Miller A, et al. Argument for inclusion of strongyloidiasis in the Australian national notifiable disease list. Tropical Medicine and Infectious Disease.

2018;3(2). doi: 10.1111/j.1445-5994.2008.01775.x 17. Wilson A, Fearon D. Paediatric strongyloidiasis in central Australia. Tropical Medicine and Infectious Disease. 2018;3(2). doi:10.3390/tropicalmed3020064 18. Gilmour B, Alene KA, Clements ACA. The prevalence of soil transmitted helminth infections in minority indigenous populations of south-east asia and the western pacific region: A systematic review and meta-analysis. PLoS Negl. Trop. Dis. 2021;15(11).

19. Miller A, Smith ML, Judd JA, Speare R. Strongyloides stercoralis: Systematic review of barriers to controlling strongyloidiasis for Australian Indigenous communities. PLoS Negl. Trop. Dis. 2014;8(9). doi: 10.1371/journal.pntd.0009890 20. Jariwala S, Redding L, Hewitt D. The severely underrecognized public health risk of strongyloidiasis in North American cities-A One Health approach.

Zoonoses Public Health. 2017;64(8):579-88. doi: 10.1111/zph.12371 21. Miller A, Young EL, Tye V, Cody R, Muscat M, Saunders V, et al. A community- directed integrated strongyloides control program in Queensland, Australia. Trop Med Infect Dis. 2018;3(2). doi: 10.3390/tropicalmed3020048 22. Bradbury RS, Pafčo B, Nosková E, Hasegawa H. Strongyloides genotyping: a review of methods and application in public health and population genetics.

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2021;51(13-14):1153-1166. doi:10.1016/j.ijpara.2021.10.001 23. Beknazarova M, Barratt JL, Bradbury RS, Lane M, Whiley H, Ross K. Detection of classic and cryptic Strongyloides genotypes by deep amplicon sequencing: a preliminary survey of dog and human specimens collected from remote Australian communities. PLoS Negl. Trop. Dis. 2019; 20;13(8):e0007241.

24. One Health. Centers for Disease Control and Prevention. Updated Feburary 7, 2022. Accessed April 17,2022. https://www.cdc.gov/onehealth/basics/index.html 25. Beknazarova M, Whiley H, Traub R, Ross K. Opportunistic Mapping of Strongyloides stercoralis and Hookworm in Dogs in Remote Australian Communities.

Pathogens. 2020;9(5). doi:10.3390/tropicalmed3020061

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The Evolution of Globalisation and its Impacts on Public Health

By Aatif Syed

From the onset of the 20th century, globalisation has been the defining economic and social process that has fundamentally shaped our lives. In broad terms, globalisation is defined as a set of processes that makes the world a single entity through increased interconnection and exchange of ideas, cultures and innovation (1). However, the impact of globalisation especially in relation to global health in general and its cognitive aspects in particular have been highly contested due to the myriad of sometimes conflicting factors which makeup overall health and wellbeing.

Hence it is vital that the evolution of modern globalisation be explored to better understand both the detriments and advantages that these factors bring towards public health.

The forces at play in globalisation have always had a fundamental and sometimes damaging impact on global health, such as the bubonic plague that affected much of Eurasia in the 14th century or the spread of smallpox to the New World in the 16th century (2). However, the first modern phase of globalisation has its roots in the 19th century during the rise of democracy and a burgeoning scientific and industrial revolution. Such advancements allowed for the development and spread of the first public health initiatives such as sanitation and medical advancements that lead to incremental improvements in life expectancy (3). The second wave occurred post World War II, where shifts towards commercialisation and deregulation led to the growth of new economic markets and greater social cohesion (4). As a result, developing nations have undergone rapid modernisation of their health infrastructure which has allowed for the global eradication of diseases such as smallpox through successful vaccination campaigns (5). Such actions have been greatly bolstered through rapid advancements in communication and information technology which has expedited medical research yet has promoted an obesity and diabetic epidemic (6).

Globalisation is a process which transcends across multiple spheres and boundaries which has had profound impacts on health outcomes on a public health level. Lee (7) has defined globalisation as a set of processes contributing to intensified human interaction in a wide range of economic, political, social and environmental spheres.

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Moreover, he adds that it occurs across three types of boundaries—spatial, temporal, and cognitive, which has had significant negative and positive impacts on human behaviour and public health responses over the past three decades. The spatial element refers to the erosion of physical boundaries with the fast-scale movement of people, information and capital (8). Whilst such elements have led to the rapid spread of communicable diseases as seen in the COVID-19 pandemic it has also resulted in decisive international humanitarian responses such as in the 2010 Haiti earthquake with the provision of thousands of medical staff and billions of dollars of aid (9). The temporal dimension refers to our perception of time, with modern communication technologies revolutionising the speed and frequency of transmissions thus allowing for greater collaboration in directing public health responses and in medical innovation (10). Lastly, the cognitive aspect concerns our perception about the world and ourselves. Forces such as free web spaces, educational institutions, tourism and mass-media have led to an influx in information and knowledge (10) which has had the dual function of challenging archaic medical practices and cultural identities but has also led to the spread of misinformation that has been the bedrock behind rising vaccine hesitancy (11). As such, the interconnection that globalisation brings has resulted in both profound innovation and challenge in global health.

Globalisation has developed higher levels of accessibility and ability for transnational media to influence people. Cultural shifts brought by the upheaval of mass advertising and marketing of Western food consumer goods have facilitated the spread of non-communicable diseases (NCD).

According to the WHO, NCDs have contributed 41 million deaths annually, accounting for 71% of all deaths globally (12). However, this has had a disproportionate impact on low- and middle-income countries, where 85% of these deaths occur in such regions (12). These trends are highlighted by the diabetes epidemic where the prevalence of diabetes has risen from 151 million in 2000 to 424.9 million in 2017 (13). Of this group, the International Diabetes Federation (IDF) counts 90% of this population to be comprised of people with Type 2 Diabetes Mellitus (T2DM) (13), where risk factors related to insulin resistance such as obesity and the metabolic

syndrome are exacerbated through the popularisation of unhealthy and processed foods around the world. Whilst developed nations such as the United States traditionally have had a greater incidence of T2DM, the disease burden of T2DM has now shifted onto developing nations with some 77% cases being from low- and middle-income countries (13).

When analysed further, the global marketing of tobacco, alcohol and processed foods has had widespread detrimental effects on countries as large as China to those as small as the Solomon Islands.

Marketing of such products is targeted towards developing countries and vulnerable populations, by advertisers taking advantage of weak regulatory environments and using misleading deceptive advertising to reach targets (14). Looking specifically into the tobacco pandemic, tobacco companies have aggressively exploited legal loopholes to mass produce tobacco in developing countries, and mass advertise to young people and women in these regions (15). In Nigeria, attempts to control tobacco by tobacco control NGOs to limit the tobacco industry’s involvement in policy making has been hindered by the British American Tobacco (BAT), a cigarette manufacturing company (16). In 2014, BAT ran a newspaper advert on July issue of The Guardian (Nigerian) by running an aggressive campaign to undermine the efforts of the NGO’s by falsely suggesting that the tobacco industry has aided in stronger tobacco control in the country, and thus be involved in further policy making around issues surrounding tobacco (17). Furthermore, in Sub-Saharan African countries, efforts to expand the industry are marked by tobacco companies offering free cigarettes to young and poor residents, while increasing their marketability through sponsoring youth events in these regions (16).

Another tool used by such companies is via corporate social responsibility (SCR), whereby they secure their presence and investment in programs that are perceived to benefit greater public health, but indirectly expand their products (16). For example, in the Democratic Republic of Congo, companies like BAT have engaged in activities such as donating towards sickle cell anaemia research and diagnostic tools, and sponsoring education in countries such as Uganda, which are perceived by the broader public as advancements in local issues, Page 09

but indirectly are expanding their footprint on younger populations (16). Acutely aware of the characteristics of globalisation, the tobacco industry acts as a global force to influence public research and policy development to exert promotion of its products (18). This is done via investing public research into addiction sciences to best study alteration of chemical nicotine forms to increase smoking rates whilst funding biassed think tanks that question the scientific evidence around the negative health impacts of smoking (18). As a result, this has increased public complacency over the adverse effects of tobacco such as lung cancers; paving way for further industry funded research with skewed findings to confuse the public and delay government intervention (19).

Furthermore, online marketing by major tobacco companies significantly increased in the past few years, with some offering easier access for people in developing nations by offering toll-free numbers for offline orders for tobacco products (20).

Combining their accelerated efforts across multiple streams and influence to target vulnerable populations across the globe, it is estimated that by 2030, 70% of deaths related to tobacco use would occur in developing countries (12).

On the contrary, the cognitive dimensional change brought on by globalisation has led to crucial progress in the advancement of key social issues. At the forefront of this change has been the emergence of the feminist movement which has been one of the most instrumental outcomes of the late twentieth century. Heightened encouragement for the empowerment of women, wherein a process of change which has provided women with greater personal and professional agency. (21). This was primarily characterised by the Peace Review Journal as “intertwined nets of communitarian, associative or transnational interactions that expanded mostly from local to global and reinforced by computers and internet” (22). Just as globalisation has allowed for the exportation of new technologies, the advancement of progressive ideologies through online platforms has heightened global consciousness against the centuries of discrimination and suppression of women’s rights.

As a result, these forces have resulted in shifts in our cultural paradigms on an institutional level by the degradation of practices such as early forced child marriages and female genital mutilation. This commitment has been shown by organisations such as UNICEF in partnership with UN Population Fund (UNFPA) to end both early child marriages and female genital mutilation by 2030 (23). Moreover, governments have taken initiatives to improve women’s health by aiming to adhere towards international initiatives such as the UN’s Global Strategy for Women and Child Health 2010, where progress has been seen in two determinants of women’s health – school enrolment rates for girls and political participation (24). Moreover, the cognitive evolution of globalisation has improved living standards of women worldwide relatively. By increasing their social and economic agency via improving their involvement in diverse employment sectors, improving worker rights, and greater social protection measures such as greater inheritance and maternity rights, women have enjoyed greater autonomy in many facets of life than previously (25).

From a public health perspective, women with greater agency are likely to have greater control over their reproductive rights and have increased autonomy with accessing healthcare services and health resources (26). In Nepal, the rise of globalisation has led to the establishment of various NGOs which have advocated for reducing inequities faced by women, and the advancement of women in society (27). Furthermore, the government of Nepal has been influenced towards progressing with direct policy initiatives towards reducing the discrimination and exclusion of women in society, such as by the legalisation of abortion in 2002 and implementation of gender responsive budgets in governmental organisations (27). Furthermore, globalisation has led to the support of movements that are directed towards abolishing cultural practices that actively repress women’s autonomy, such as the “chhapaudi partha”, whereby young girls and women are isolated from family during their menstrual period (27). Such advancements in Nepal have been reflected in various public health metrics. This is reflected in a study conducted by Pandey, Lama (28), which examined if gender empowerment is associated with increased health service use in Nepal. Results showed that 3 indicators of Page 10

empowerment such as women’s age at birth of first child and their education and knowledge about sexually transmitted diseases significantly increased their willingness and ability to access health services. Consequently, this means that children are more likely to survive and receive better physical and mental health care during childhood (26). This is evident in the substantial progress made towards infant and child mortality rates since 1990, with WHO reporting that the total number of child mortality rates declined from 12.6 million in 1990 to 5.3 million in 2018 (29). Overall, greater empowerment of women due to the cognitive forces of globalisation has improved women's health on a personal and systems level.

Moving forward, it is important to acknowledge that the multi-dimensional nature of globalisation means that its implications on public health are diverse and complex. To mitigate the adverse consequences of globalisation on population health such as the rise of non-communicable diseases in developing nations, structural changes are needed.

This includes political willingness for governments and international organisations to implement legislations and heavy regulations for trans-national giants like tobacco and alcohol industries to restrict their reach on production and advertising in lowincome countries (20). Finally, the general public should better exercise their rights and use their globalised web platforms effectively to pressure governments to prioritise people’s health over political and economic gains. This will ensure we are striving towards universal net-health benefits as the process of globalisation only further increases in scale and intensity.

References 1. Bettcher D, Lee K. Globalisation and public health. Journal of Epidemiology & Community Health. 2002;56(1):8-17.

2. Piret J, Boivin G. Pandemics Throughout History. Front Microbiol. 2021;11:631736.

Published 2021 Jan 15. doi:10.3389 Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7874133/ 3. Jackson T. What the Industrial Revolution Did for Us: Modern Medicine. BMJ. 2003;327(7422):1056.

Available from: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC261680/ 4. Baru RV, Mohan M. Globalisation and neoliberalism as structural drivers of health inequities. Health Research Policy and Systems. 2018;16(1):91.

5. Greenwood B. The contribution of vaccination to global health: past, present and future. Philos Trans R Soc Lond B Biol Sci. 2014;369(1645):20130433. Published 2014 May 12. doi:10.1098/rstb.2013.0433.

Available from: https://pubmed.ncbi.nlm.nih.gov/24821919/ 6. Hu FB. Globalization of diabetes: the role of diet, lifestyle, and genes. Diabetes Care.

2011;34(6):1249-1257. doi:10.2337/dc11-0442.

Available from: https://pubmed.ncbi.nlm.nih.gov/21617109/ 7. Lee K. Globalization and health: an introduction: Springer; 2003.

8. Robertson R. Globalization: Social theory and global culture: Sage; 1992.

9. The Guardian. Haiti Earthquake Aid Pledged by Country [Internet]. The Guardian 2010 [Updated 2010 Jan 14].

Available from: https://www.theguardian.com/news/datablog/2010/jan/14/haiti-quake-aidpledges-country-donations 10. Lee K. Globalisation: what is it and how does it affect health? Medical Journal of Australia. 2004;180(4):156-8.

11. Garett R, Young SD. Online misinformation and vaccine hesitancy. Transl Behav Med. 2021;11(12):2194-2199. doi:10.1093/tbm/ibab128.

Available from: https://pubmed.ncbi.nlm.nih.gov/34529080/ 12. World Health Organisation. Noncommunicable Diseases 2018. Available from: https://www.who.int/news-room/fact-sheets/detail/noncommunicable-diseases 13. Standl E, Khunti K, Hansen TB, Schnell O. The global epidemics of diabetes in the 21st century: Current situation and perspectives. Eur J Prev Cardiol.

2019;26(2_suppl):7-14. doi:10.1177/2047487319881021.

Available from: https://pubmed.ncbi.nlm.nih.gov/31766915/ 14. Beaglehole R, Yach D. Globalisation and the prevention and control of noncommunicable disease: the neglected chronic diseases of adults. Lancet.

2003;362(9387):903-8.

15. Brands A, Yach D. Women and the rapid rise of noncommunicable diseases.

NMH reader. 2002(1).

16. Gilmore AB, Fooks G, Drope J, Bialous SA, Jackson RR. Exposing and addressing tobacco industry conduct in low-income and middle-income countries.

Lancet. 2015;385(9972):1029-43.

17. Messanvi F. Increasing Aggressive Propaganda Against the Tobacco Industry: The Guardian (Nigeria); 2014. Available from: http://ntcang.org/wpcontent/uploads/2014/08/BAT-advert.pdf.

18. Yach D, Bettcher D. Globalisation of tobacco industry influence and new global responses. Tobacco control. 2000;9(2):206-16.

19. Saleeby Jr R. Review of directory of ongoing research in smoking and health.

Bates; 1971.

20. Yach D, Bialous SA. Junking science to promote tobacco. American journal of public health. 2001;91(11):1745-8.

21. Kabeer N. Gender equality and women's empowerment: A critical analysis of the third millennium development goal 1. Gender & Development. 2005;13(1):13-24.

22. Inácia d'Avila M, Nazareth J. Globalisation and Women's Employment. Peace Review. 2005;17(2-3):215-20.

23. Nations U. New UN initiative aims to protect millions of girls from child marriage: United Nations; 2016.

Available from: https://www.un.org/youthenvoy/2016/03/new-un-initiative-aims-to-protectmillions-of-girls-from-child-marriage/.

24. World Health Organisation. Women and health: 20 years of the Beijing Declaration and Platform for Action 2014.

Available from: https://apps.who.int/gb/ebwha/pdf_files/EB136/B136_18-en.pdf.

25. Acharya I. Globalization-A Gateway to Women Empowerment. Journal of Humanities and Social Science.21(8).

26. Bloom SS, Wypij D, Gupta MD. Dimensions of women’s autonomy and the influence on maternal health care utilization in a north Indian city. Demography.

2001;38(1):67-78.

27. Sharma M. Process and Impact of Globalization in Nepalese Women. Dhaulagiri Journal of Sociology and Anthropology. 2015;9:128.

28. Pandey S, Lama G, Lee H. Effect of women’s empowerment on their utilization of health services: A case of Nepal. International Social Work. 2012;55(4):554-73.

29. World Health Organisation. Children: reducing mortality 2019. Available from: https://www.who.int/news-room/fact-sheets/detail/children-reducing-mortality.

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AMSA Journal of Global Health

BY GRACE NEWMAN

The time is now: What can Australia learn from social prescribing programs in the United Kingdom?

Keep reading!

Volume 16 | Issue 1 | July 2022

The time is now: What can Australia learn from social prescribing programs in the United Kingdom?

Despite the World Health Organisation defining health as a state of complete physical, social, and mental wellbeing, the holistic nature of health is often overlooked by the predominantly biomedical focus of the Australian healthcare system.(1) In recent years social prescribing has emerged as a novel approach to patient centred healthcare, involving linking patients to non-medical community supports to holistically address their health and its upstream social determinants.(2-4) Social prescribing is an innovative approach to healthcare which empowers people to take control over their own health, uses a multisectoral approach to improving health, and a focus on primordial and primary prevention.(5,6) Social prescribing also provides an opportunity to make significant progress towards the United Nations Sustainable Development Goal three, which seeks to ensure healthy lives and promote wellbeing for all.(7) It is wellestablished in the United Kingdom (UK), with a growing presence in countries such as Canada, Spain, and the Netherlands.(2,8) While there are a number of pilot programs in Australia it is not yet integrated into the healthcare system. Social prescribing is an innovative model of healthcare which has the potential to drastically improve the health of our communities and its role in the future of Australian healthcare needs to be appropriately considered.

to help determine with the patient which community supports are most suitable.(2,3) A key focus is asking “what matters to me”, allowing the patient control over how the prescription is developed.(10) As such, the services offered under the prescription, including arts, physical activity, formal education opportunities, or housing and legal support, can be specifically tailored to each patient.(4) Groups who are especially thought to benefit are the elderly, those with poor mental health or chronic conditions, and people experiencing social isolation or socio-economic stress.(8) A number of reviews have found significant benefits resulting from social prescribing programs including improvements in mental wellbeing (2,4,11), physical activity (2), social connectedness (3,8), self-esteem (4) and mood (4,8). There have also been increases in employment (11) and decreased levels of anxiety and depression (3). While the evidence base for social prescribing continues to develop there is a growing consensus it can offer significant benefits to patients and the wider community.

What is social prescribing?

Social prescribing was first described in the 1990s with a number of formalised programs emerging soon after, however its principles have been used in healthcare for decades.(9) Programs typically involve a referral from a health professional, commonly a general practitioner (GP), to a link worker or navigator Page 14

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How social prescribing can address the social determinants of health By reorienting health services.

Social prescribing programs reorient the health service to place social determinants of health at the forefront of patient care, developing partnerships between health services and local community organisations. For example, a social prescription for an elderly person with mild depression may involve services addressing their social isolation such as a community art class rather than medication.(4) Health services are traditionally extensively siloed, with challenging referrals outside the streamlined pathways from primary to secondary and tertiary healthcare. Social prescribing aims to integrate these silos, making it easier to capitalise on the strengths in the community to support wellbeing. A number of social prescribing programs in the UK have demonstrated a reduction in presentations to GPs and emergency departments for those involved in the program, with Polley and Pilkington reporting an average 28% reduction in demand for GP services and emergency attendance decreased by an average of 24%.

(11) Social prescribing offers an opportunity to better connect our communities and decrease reliance on the increasingly strained healthcare system.

placed to address them.(2) Spending time with a link worker allows patients a greater understanding of their health and what determines it. Furthermore, many of the prescriptions themselves upskill patients by providing further education and social support.

By strengthening community action.

Empowering communities and developing social connection is another pillar of social prescribing. It aims to mobilise a community’s power to protect and promote the health of its members.(9, 12) For example a community member may be suffering poor health as a result of diet or insufficient physical activity. Rather than only treating the resulting health conditions such as diabetes or high blood pressure, social prescribing aims to mobilise community support to address the contributing social factors causing these health concerns. This could include financial support to allow healthier choices, or referral to a local walking group or sporting team to promote safe physical activity and develop social connection.

Empowering communities is at the heart of social prescribing and offers a legitimate strategy to address the social determinants of health.

What lessons can Australia learn from how the United Kingdom implemented their program?

By developing personal skills.

Social prescribing empowers the patient and builds their capacity to manage and contribute to their own healthcare, having an active co-design role in determining which needs are most important and which services are best

Strong, healthy public policy is essential.

Central to the UK’s successful nationwide social prescribing programs is strong policy and governance. There is a significant political commitment to social prescribing, with its inclusion in the NHS Long Term Plan, along with a commitment from the current UK Secretary of State for Health and Social Care to provide social prescribing services in every GP practice by 2024.(9,13) Political support established both funding and resource provisions for social prescribing across the UK, Page 15

Volume 16 | Issue 1 | July 2022

allowing link workers to become a formalised paid role with appropriate training across most primary care networks, as well as establishing referral pathways. Funding streams meant pilot programs could be scaled up to service entire communities and ensured their sustainability. Funding for the National Academy of Social Prescribing further demonstrated the commitment to social prescribing and improving the quality of research available to better understand how to develop the programs.(9) The UK established this strong policy foundation by capitalising on a policy window which emerged over the last decade. A policy window occurs when a problem reaches a critical point at the same time as growing political interest and the availability of experts to develop appropriate policy.(14) A number of key reports were published around 2010 (15-17), each highlighting the importance of social supports in managing health, and raising concerns about the sustainability of the current healthcare model. There was also a growing emphasis on mental health and wellbeing in public discourse, placing increasing pressure on politicians.(4) The culmination of these events resulted in an opportunity to make changes to the structure of primary healthcare in the UK and social prescribing emerged.

Arguably this policy window is open in Australia. The Royal Commission into Victoria’s Mental Health System specifically called for social prescribing trials to be established to support mental health and wellbeing in local communities.(18) In 2019 the RACGP and Consumer Health Forum (CHF) conducted a roundtable to discuss the feasibility of social prescribing in Australia.

(19) Furthermore, Australia’s recently released Long Term National Health Plan and Primary Health Care 10 Year Plan included supporting public health networks to develop social prescribing programs in

the next 1-3 years.(20,21) The occurrence of these key reports, in addition to the strain COVID-19 has placed on an overwhelmed public and mental health system creates an important opportunity to ensure a strong policy foundation for social prescribing.

A program cannot run without partnerships.

As mentioned, the formation of strong, trusted partnerships between health services and multidisciplinary local community organisations is imperative to a successful social prescribing program.(4,13) In their rapid literature review Zurynski et al found poor quality partnerships were a major barrier to the success of a social prescribing program and impacted the benefits reported by patients.(8) The Wellbeing Exeter program in England has designated Community Builders, who map community assets and work with communities to develop relationships between the health sector and link workers.(22) They also are responsible for enabling and developing increased community activity, especially in areas identified to be deficient during mapping.

(22) Australia has a number of programs which fulfil a similar purpose as asset mapping.

Websites such as HealthPathways (23) and Ask Izzy (24) provide a searchable database of local community organisations. While the services listed on these websites are extensive, Australia is struggling to integrate this into a structured referral program. Furthermore, the databases do not require health services to develop a partnership with local community groups, making it challenging to determine which service is most suitable for a specific patient.

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A social prescribing program needs to be co-designed.

Programs must be co-designed with all stakeholders to ensure it is user friendly and will achieve its aims, given the unique integrated and multisectoral components.

This also encourages communities to take ownership of the program and increases the likelihood of investment and participation. Co-design is a feature of many programs in the UK, including the Well London project and the Bromley by Bow Centre.(25) Well London utilises a process which includes: Asset mapping Door to door surveys of residents Community meetings to identify local needs Community action workshops to collate information to begin planning of the local social prescribing program. (25) The Bromley by Bow Centre similarly trains local residents to participate in design and research as they expand their programs.

(26) Co-design is a key feature of a pilot social prescribing program currently under development in Victoria. The Connecting Communities to Care pilot program focuses on co-design of the program, starting with workshops for health professionals, the elderly and those with chronic conditions, community organisations, and healthcare students.(27) The pilot aims to develop a sustainable model of social prescribing which can be translated to other areas of Australia.

Expansion of social prescribing is challenging without high quality evaluation.

One area lacking in the UK’s implementation of social prescribing is the presence of robust, high-quality analysis.

Multiple reviews highlighted the lack of quantitative data on outcomes, short follow up times and absence of peer-review

articles, with many published in grey literature.(4,8,11) Quantitative measures are not well suited to capture the more abstract aims of social prescribing such as community connectedness and increases in confidence.(8) As a result most studies use often unreliable self-reported data.(4) Reliable methods for analysis need to be part of program planning, as high quality data is essential to ensure future programs continue to build on lessons learnt and maximise benefit for patients and communities, as well as providing evidence required to secure sustainable funding.

Conclusion The emerging practice of social prescribing offers a promising approach to healthcare placing a focus on social determinants of health and empowering the patient. The UK has led the way on social prescribing, with well-established policy and structures to support large scale programs. Key features such as strong policy, quality partnerships and co-design from the outset of a program have all contributed to the UK’s success.

However, it is important to acknowledge there are unique challenges in Australia.

Access is a larger issue in Australia, with many rural and remote communities unable to access sufficient healthcare services and limited community organisations available. Further research is needed to assess feasibility of alternative models in rural locations, such as telehealth. Attention should be paid to Canada as their social prescribing programs develop with similar geographical access concerns. Additionally, given Australia’s fee-for-service funding model, compared to the UK’s capitation model, funding avenues such as billing item numbers would need to be established.(28) The feasibility of social prescribing is further complicated by the differing responsibilities of state and federal governments in healthcare and funding in Australia, compared the UK.(28) Page 17

Despite these challenges Australia currently has a unique opportunity to revolutionise our primary healthcare system. Social prescribing is a rapidly growing movement addressing the social determinants of health and empowering communities to take control of their healthcare, offering a promising solution to the unsustainable and increasing reliance on traditional healthcare models.

Volume 16 | Issue 1 | July 2022

References 1. Constitution Geneva [Internet]. Geneva: World Health Organisation; 2021 [cited 2022 Mar 28]. Available from: https://www.who.int/about/governance/constitution.

2. Bhatti S, Rayner J, Pinto AD, Mulligan K, Cole DC. Using self-determination theory to understand the social prescribing process: a qualitative study. BJGP Open.

2021;5(2).

3. Woodall J, Trigwell J, Bunyan AM, Raine G, Eaton V, Davis J, et al. Understanding the effectiveness and mechanisms of a social prescribing service: a mixed method analysis. BMC Health Serv Res. 2018;18(1):604.

4. Chatterjee HJ, Camic PM, Lockyer B, Thomson LJM. Non-clinical community interventions: a systematised review of social prescribing schemes. Arts & Health.

2018;10(2):97-123.

5. Kumar S, Preetha G. Health promotion: an effective tool for global health. Indian J Community Med. 2012;37(1):5-12.

6. Naidoo J, Wills J. Foundations for Health Promotion E-Book. St. Louis, United Kingdom: Elsevier Health Sciences; 2009.

7. 3 - Ensure healthy lives and promote well-being for all at all ages [Internet]. Geneva: United Nations; 2021 [cited 2022 Mar 28].

Available from: https://sdgs.un.org/goals/goal3.

8. Zurynski Y VA, Smith K. Social prescribing: a rapid literature review to inform primary care policy in Australia. NSW: Consumers' Health Forum of Australia; 2020.

9.

Buck D, Ewbank L. What is social prescribing?

[Internet]. London: The King’s Fund; 2020 [updated 2020 Nov 04; cited 2022 Mar 23]. Available from: https://www.kingsfund.org.uk/publications/socialprescribing.

10. Social prescribing [Internet]. London: NHS UK; 2021 [cited 2022 Mar 25].

Available from: https://www.england.nhs.uk/personalisedcare/socialprescribing/.

11. Polley MJ, Pilkington K. A review of the evidence assessing impact of social prescribing on healthcare demand and cost implications. University of Westminster; 2017.

12. WHO Guidelines Approved by the Guidelines Review Committee. In: Khasnabis C, Heinicke Motsch K, Achu K, Al Jubah K, Brodtkorb S, Chervin P, et al., editors.

Community-Based Rehabilitation: CBR Guidelines.

Geneva: World Health Organization. 2010.

13. Husk K, Blockley K, Lovell R, Bethel A, Lang I, Byng R, et al. What approaches to social prescribing work, for whom, and in what circumstances? A realist review.

Health Soc Care Community. 2020;28(2):309-24.

14. Béland D, Howlett M. The Role and Impact of the Multiple-Streams Approach in Comparative Policy Analysis. Journal of Comparative Policy Analysis: Research and Practice. 2016;18(3):221-7.

15. Marmot M, Bell R. Fair society, healthy lives. Public Health. 2012;126:S4-S10.

16.

Kirkwood T, Bond J, May C, McKeith I, Teh M-M. Foresight Mental Capital and Wellbeing Project. 2014. p.

1-90.

17.

Older People & Dementia Team. Prime Minister’s Challenge on Dementia - Delivering major improvements in dementia care and research by 2015. London Department of Health; 2012.

18. Armytage P AM, Fels A, Cockram A, McSherry B. The Royal Commission into Victoria’s Mental Health System Final Report. Melbourne: State of Victoria 2021.

19.

Social Prescribing Roundtable, November 2019: Report. The Royal Australian College of General Practitioners, Consumer Health Forum Australia; 2020.

20. Consultation opens on draft Primary Health Care 10 Year Plan [Internet]. Canberra: Commonwealth of Australia Department of Health; 2021 [cited 2022 Mar 27].

Available from: https://www.health.gov.au/ministers/the-hon-greghunt-mp/media/consultationopens-on-draft-primaryhealth-care-10-year-plan.

21.

Commonwealth of Australia. Future focused primary health care: Australia’s Primary Health Care 10 Year Plan 2022-2032. Canberra: Department of Health; 2022.

22. Community Building [Internet]. Exeter: Wellbeing Exeter; 2021 [cited 2022 Apr 1]. Available from: https://www.wellbeingexeter.co.uk/communitybuilding-2/.

23. HealthPathways Melbourne [Internet]. Melbourne: PHN Eastern Melbourne and PHN North Western Melbourne; 2021 [cited 2022 Mar 27]. Available from: https://melbourne.healthpathways.org.au/LoginFiles/Lo gon.aspx?ReturnUrl=%2f.

24. AskIzzy [Internet]. Melbourne; Infoxchange. 2021 [cited 2022 Mar 27].

Available from: https://askizzy.org.au/.

25. CEAD [Internet]. London : Well London; 2021 [cited 2022 Mar 27].

Available from: http://www.welllondon.org.uk/33/cead.html.

26. Bromley by Bow Community Engagement and Citizen Science [Internet]. London: Bromley by Bow Centre; 2021 [cited 2022 Mar 27].

Available from: https://www.bbbc.org.uk/insights/research-andevaluation/research-and-evaluationbromley-by-bowcommunity-engagement-and-citizen-science/.

27.

Lowthian J. Connecting Communities to Care Melbourne: Monash University; 2021 Available from: https://supervisorconnect.med.monash.edu/projects/co nnecting-communities-care.

28. Australian Institute of Health Welfare. Health system overview. Canberra: AIHW; 2020.

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Aborting Our Autonomy: Abortion Access During COVID-19 in Australia and America Melody Ahfock

Aborting Our Autonomy: Abortion Access During COVID19 in Australia and America

Volume 16 | Issue 1 | July 2022

Melody Ahfock Summary: Whilst COVID-19 highlighted the world of infectious diseases, other health spaces were also profoundly impacted. One area that saw undeniable change was the provision of abortion. Abortion services were not able to operate in their usual manner due to reduced access to healthcare, reduced staffing, and resource shortages during the pandemic [1,2]. As a result, different strategies were adopted to respond to these challenges, which require evaluation to determine their effect on individuals who sought out abortion services during the pandemic. In this piece, Australian and American approaches to abortion care before and during the pandemic will be explored and compared, with a specific focus on abortion legality and accessibility.

Why Does Access to Abortion Matter?

Abortion, or termination, is defined by the Australian Government Department of health as the medical process of ending a pregnancy so it does not result in the birth of a baby [3]. There are two types of abortion available: surgical and medical.

Surgical abortions are the most common type in Australia and are most often performed before 14 weeks gestation [3].

Medical abortions are performed using a combination of two medications, mifepristone and misoprostol and are most often performed before 9 weeks gestation, sometimes referred to as ‘early medical abortions’ [3]. These options are also available in the US [4].

Globally, abortion remains a topic of intense public scrutiny, acutely emphasised by the recent overturning of Roe v Wade in the United States.

Distilled down, the major reasons for restricting abortion access historically included the danger associated with abortion procedures, for religious and/or moral reasons, or to protect foetal life, which was often considered more important than the pregnant woman’s [5].

Since modern abortion procedures are safe, the latter two reasons are the principal points of contention. However, in direct opposition to the ‘sanctity of life’ argument often used to justify restrictive abortion laws, restrictive legislation is responsible for deaths and millions of injuries to people who cannot afford or access a safe illegal abortion procedure [5].

It is well established that unsafe abortions are a major cause of maternal mortality and psychological distress, as well as economic consequences to the local health system [6].

Whilst the number of unsafe abortions is negligible in Australia and North America currently, there is substantial evidence to show that most abortions are safe in regions where the procedure is legally permitted under a certain criteria6. In countries where abortion laws are restrictive (those where the procedure is prohibited or only performed to save the pregnant person’s life), only 25.2% of abortions are safe, compared to 41.2% when mental health or socioeconomic reasons are included, and 87.4% when no restrictions apply [7]. This highlights the importance of legislation that advocates for people’s authority over their bodies, but that is also protective against the risks of unsafe abortions.

Abortion is a time-sensitive treatment.

Delays and refusals lead not only to unsafe procedures, such as when termination is performed by inadequately qualified practitioners, or in an environment that falls below medical standards, or both [8].

Poor medical treatment due to such factors has further negative psychological ramifications for people seeking abortions [9,10].

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The Turnaway Study was conducted in the US from 2008-2010, interviewing nearly 1,000 women, some who were provided with an abortion, and others who were ‘turned away’ as they did not meet the criteria for the procedure. The study found no evidence that abortion itself caused negative mental health or poor well-being. Conversely, denial of abortion was correlated with anxiety, lower self-esteem, and stress, until 6-12 months later, when both groups returned to having similar mental health [11,12]. In the study, over 95% of women felt that an abortion was the right decision for them five years later. These findings are supported by other large-scale research, which found that the main factors contributing to negative mental health outcomes post-abortion are societal stigma and the difficulty in choosing to have an abortion [13].

For example, in the Northern Territory, abortions can be performed if a doctor approves for up to 14 weeks gestation, and up to 23 weeks if a second doctor approves.

However, in New South Wales, abortion can be requested for up to 22 weeks, and after this counselling and a second opinion must be obtained to proceed [15]. Such legal nuances are present across every state and territory.

Abortion in Australia: Pre-Pandemic

In Australia, it is evident that whilst many legal barriers have been overcome, many other obstacles remain. Access to these services is heavily influenced by location, with some regions having no local access to medical abortion services, including South Australia, most of which has no GP or pharmacist able to prescribe or dispense combination mifepristone/misoprostol [17].

These regions are often rural and are therefore coupled with reduced access to surgical abortion services, as many public hospitals do not provide it, or only under circumstances where there is a foetal abnormality [17]. Private clinics are predominantly located in major cities, resulting in rurality being a significant barrier to access [17].

Abortion in Australia is no longer a criminal offence, as a result of the landmark Menhennit ruling. The Menhennit ruling in Victoria established that abortion is lawful if the accused held an honest belief on reasonable grounds that the abortion was both 'necessary' and 'proportionate' [14]. In this context, necessary means that the abortion is being performed to preserve the pregnant woman’s physical or mental health14. Moreover, proportionate means that the abortion is a commensurate response to the danger that would be imposed by continuing the pregnancy [14].

This ruling influenced the subsequent Levine (New South Wales) and McGuire (Queensland) rulings as well [14].

Whilst abortion is now regulated under health law as opposed to criminal law in every state, restrictions apply, aside from in the Australian Capital Territory. Differing gestational limits apply in each state or territory with restrictions.

The total number of abortions in Australia during 2017-18 was 17.3 per 1000 women aged 15-44 years [16]. The number of surgical abortions declined between 2014-15 and 2017-18, at a mean annual rate of 5.1%.

Conversely, the number of medical abortions increased from 3220 in 2014-15 to 20 741 in 2017-18, attributed to the Pharmaceutical Benefits Scheme listing of combination mifepristone/misoprostol [16].

Furthermore, recognition of social stigma is also paramount, particularly in rural areas, where some practitioners are reluctant to provide abortion services owing to the risk of personal attacks and reputational damage [2]. This also affects those seeking abortions, with an interview-based study of women in rural New South Wales reporting stigma and shame as a barrier to accessing abortion [18].

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TSome states have ‘safe zones’ around abortion clinics to prevent protesters from harassing people outside abortion services [15], however, this does not address all of the stigmas that abortion seekers are subject to, in the forms of confusion about legality, concerns about judgement from providers, and fears about whether their reason for seeking an abortion ‘checks all the right boxes’ [19].

These geographical and structural barriers associated with rurality provide further insight into why many people, even in Australia, must travel to receive an abortion [2]. Increased need to travel to access care further increases the cost, which is another consequential barrier. Discrepancies in the public provision of abortion have led to the private system providing most terminations [2,17], with major cost discrepancies between providers [2]. This cost often increases with gestational age, which then may coincide with the requirement to travel interstate due to legality, potentially leaving the abortion seeker in a financially difficult position, as well as desperate and vulnerable [2].

It is important to also acknowledge the intersectionality of rurality and financial constraints with many other barriers associated with lessened abortion access.

Indigenous women often present later and have to travel further for abortions, which may further exacerbate issues if they are from a rural locality [2]. It would be remiss not to mention the dark history of reproductive control exerted on Indigenous peoples of Australia, which combine to further discourage access to these services [2]. Other communities who already experience barriers to healthcare are affected in a similar manner, including migrants and refugees, LGBTQIA+ people, and those with disabilities [2].

Abortion in the United States: Pre-Pandemic The way that abortion is accessed in the US varies by state. For example, in Missouri, procedures are banned after 20 weeks unless the woman’s life is endangered, and some surgical abortion techniques, including dilation and evacuation, are banned [20]. This is contrasted with Colorado, where there are no restrictions, aside from with which abortion circumstances public funding will contribute to [20]. Some states also have ‘trigger bans’ which would criminalise abortion if Roe v Wade were overturned [21], which is now a reality. 43 states have gestational limits, with some exceptions provided and 36 states require the abortion to be performed by a licensed physician [20].

Rates of abortions in the US were about 11.4 per 1,000 women in 2019 [22]. As with legislation, these rates vary considerably between the states, with states like Missouri reporting 2.6 per 1,000 women, as opposed to Maine with 68.6 in 2017, which can be attributed to state-specific restrictions or facility scarcity [23].

The United States’ pre-pandemic approach to abortion access can also be considered problematic. Abortion deserts have been identified in the US, with 90% of US counties lacking an abortion provider, forcing many women to travel to obtain reproductive care [24]. Such geographical barriers have been shown to disproportionally affect low socioeconomic status individuals who are subject to both time and financial barriers [25].

Financial constraints are inextricably linked with abortion access, with the rates of unintended pregnancies being the highest in low-income groups, and this group also being the least likely to afford abortions [26, 27].

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In addition to low-income earners, nonHispanic Black people and Hispanic people have unintended pregnancies at higher rates [28]. These rates result in an overrepresentation of Black and Hispanic women seeking abortions [28]. Inequities exist in the outcomes and experiences of these patients when seeking sexual and reproductive healthcare, including the stigma associated with negative stereotypes and the downstream effects of structural racism, such as lack of healthcare services in predominantly black neighbourhoods [29].

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Abortion Seeking During COVID-19 The World Health Organisation (WHO) explicitly included reproductive health care as essential and a high priority within the COVID-19 response, demonstrated by the inclusion of misoprostol/mifepristone in the WHO’s Model of Essential Medicines [30,31]. Despite this foundational medical understanding of the importance of accessible abortion care, there were many unique challenges faced by abortion providers during the pandemic not attributable to anything but politics [2].

Whilst these will not be focused on within this discussion, it adds another layer to the complexity of abortion care that must be acknowledged.

When considering the demand and reasons for seeking abortions during COVID-19, preliminary evidence suggests that COVID19 responses may have led to increased unintended pregnancies, due to reduced contraceptive supply, as well as increased domestic violence and increased income insecurity [9,32, 33]. Several large-scale studies have identified that the proportion of women seeking abortions during the pandemic due to reasons related to worry, social factors, and anxiety increased significantly [34,35,36]. This research highlights the burdensome nature of COVID-19 that particularly affected vulnerable pregnant individuals and affected abortion-seeking behaviour and motivations.

Abortion in Australia During COVID-19 In Australia, the legality of abortion during COVID-19 was not questioned, but this does not mean that legal implications were absent. As explored earlier, there is diversity in the legislation on abortion throughout the states and territories of Australia. This means that some people need to travel to receive essential reproductive care. Due to the travel restrictions enforced by States and Territories in Australia which prohibited interstate travel, doctors and patients were not able to provide and receive services interstate [2]. This exacerbated existing geographical barriers experienced by rural and regional inhabitants, as well as people seeking later-term abortions, who may not be able to receive it locally, due to home state legislation or lack of accessibility [2].

In addition to rural inhabitants, these concerns were particularly relevant for Indigenous people, as well as members of already disadvantaged populations who experience barriers when accessing healthcare, as previously explored [2].

Telehealth services were fundamental to the healthcare strategy within the context of COVID-19. Subsidised access to medical abortion via telehealth enabled access and increased affordability during the pandemic [37]. Medical abortions via telehealth increased by 163% when comparing January – June 2019 to the same period in 2020 [2].

However, changes came into effect in July 2020 to restrict rebates to those provided by general practitioners and require patients to have seen that practitioner at least once in the previous year. This again enhanced geographic issues and potential concerns with practitioner attitudes and training in the provision of abortion [2]. It is also important to note here that teleabortions could only be accessed up to nine weeks gestation, so timely service was critical, and not possible in all situations, such as if a surgical abortion was required.

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Abortion in the United States During COVID-19 In the United States, it is evident that there are significant state-based divides under normal circumstances, and this was no different during the pandemic.

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In March and April 2020, all states in the US declared COVID-19 an emergency and responded to sexual and reproductive healthcare with different strategies. Only 12 states explicitly protected abortion, and 14 acted to suspend abortion completely [38].

Whilst these restrictions were overturned, this did not come without confusion and anxiety for providers and patients alike [1].

Overall, the total number of abortions across the USA fell, though the demand for self-managed medical abortions significantly increased, particularly in states with harsher lockdowns and restrictive abortion laws [39]. This was seen in Texas, where the total number of abortions fell by 38%, out-of-state abortions increased by 500% and medical abortion increased by 41% [39]. Some telemedicine was implemented but again varied by state.

A study of 55 abortion clinics in the US found that telehealth was being used for some part of the abortion process in 74% of the sites during the pandemic, as opposed to 18% pre-pandemic [39]. Despite the appeal attempt by the Trump administration after the decision to lift inperson dispensing protocols of mifepristone and misoprostol, the FDA announced in April 2021 was this requirement would be temporarily ceased, easing some of the difficulties associated with accessing medical abortion [39].

Despite easier access to medical abortion drugs, some practitioners distanced themselves from abortion procedures due to fear of controversy [33]. This left physicians who were willing to provide abortion services during a pandemic particularly vulnerable both legally and in terms of their professional reputation.

Practitioners in ‘red states’ reported legitimate concerns about the legal implications of providing abortions through the pandemic1. In addition to legal concerns, the existing geographical and financial constraints were exacerbated by income restrictions and travel restrictions instigated by the pandemic [40].

Implications of such changes were particularly strongly felt by Black and Hispanic abortion seekers, due to the exacerbation of existing inequities in abortion access.

Lessons from COVID-19: A Perspective on Abortion Access When considering the attitudes and value placed on abortion as a health service throughout the pandemic, the lack of importance placed on sexual and reproductive healthcare illustrates the wider held belief that this realm of healthcare is not vital and frames women’s equality and bodily autonomy as expendable [33,41]. This was demonstrated in some US states where access to abortion was curtailed under the guise of an ongoing pandemic, despite abortion being considered a key right [21,32,38]. It is also widely recognised that in both Australia and the US the pandemic did not only create a new set of accessibility issues, but also exacerbated existing ones, disproportionately affecting already marginalised communities [2,38,40].

In some parts of the US and Australia, COVID-19 fast-tracked the implementation of telemedicine and the easing of restrictions on abortion drugs, demonstrating the potential role of this technology and legislative change in addressing existing issues with abortion access. However, whilst telemedicine was a major step forward, it cannot be the only solution to achieving equitable healthcare for abortion or otherwise [2,32].

The COVID-19 pandemic exacerbated existing inequities with abortion services in Australia and the US.

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While telemedicine and legislative changes to medication contributed to improving access, there were significant deficits in its planning and provision [37]. It also elucidated the pervasive and erroneous principle of considering sexual and reproductive healthcare as ‘non-essential’, despite the large body of evidence suggesting otherwise. Gaps in abortion access during the COVID-19 pandemic have demonstrated that preparation for future pandemics must include planning on how to maintain access to abortion [33,34].

Abortion is healthcare, and therefore should be treated as such.

Author’s note – The author recognises that transgender men and non-binary people may become pregnant and seek abortion care. ‘Women’ is used in this article to reflect how participants are referred to in the studies cited.

References:

8. Haddad LB, Nour NM. Unsafe abortion: unnecessary maternal mortality. Reviews in obstetrics and gynecology. 2009;2(2):122–6.

9. Todd-Gher J, Shah PK. Abortion in the context of COVID-19. Sexual and reproductive health matters.

2020;28(1):28–30.

10. Rocca CH, Moseson H, Gould H, Foster DG, Kimport K. Emotions over five years after denial of abortion in the United States: Contextualizing the effects of abortion denial on women's health and lives. Social science & medicine (1982). 2021;269:113567–113567.

11. Rocca CH, Kimport K, Gould H, Foster DG. Women's Emotions One Week After Receiving or Being Denied an Abortion in the United States. Perspectives on sexual and reproductive health. 2013;45(3):122–31.

12. Advancing New Standards In Reproductive Health.

Introduction to the Turnaway Study [Internet]. San Francisco: University of California; 2020. Available from: https://www.ansirh.org/sites/default/files/publicatio ns/files/turnawaystudyannotatedbibliography.pdf 13. Rocca CH, Samari G, Foster DG, Gould H, Kimport K. Emotions and decision rightness over five years following an abortion: An examination of decision difficulty and abortion stigma. Social science & medicine (1982). 2020;248:112704–8.

1. Joffe C, Schroeder R. COVID‐19, health care, and abortion exceptionalism in the United States.

Perspectives on sexual and reproductive health.

2021;53(1-2):5–12.

14. Cica N. Abortion Law in Australia. Parliament of Australia; 1998.

2. Sifris R, Penovic T. Barriers to abortion access in Australia before and during the COVID-19 pandemic.

Women's studies international forum. 2021;86:102470.

15. Abortion Law Australia | MSI Australia [Internet].

Marie Stopes Australia. 2022 [cited 1 July 2022].

Available from: https://www.mariestopes.org.au/advocacypolicy/abortion-law-in-australia/

3. Abortion [Internet]. Healthdirect.gov.au. 2021 [cited 1 July 2022]. Available from: https://www.healthdirect.gov.au/abortion 4. Attia. What are the different types of abortion?

[Internet]. Planned Parenthood. 2019 [cited 1 July 2022]. Available from: https://www.plannedparenthood.org/learn/askexperts/what-are-the-different-types-of-abortion 5. Berer M. Abortion Law and Policy Around the World.

Health and human rights. 2017;19(1):13–27.

6. Sedgh, Gilda, Dr, Henshaw, Stanley, PhD, Singh, Susheela, PhD, Åhman, Elisabeth, MA, Shah, Iqbal H, PhD. Induced abortion: estimated rates and trends worldwide. The Lancet (British edition).

2007;370(9595):1338–45.

7. Ganatra B, Gerdts C, Rossier C, Johnson BR, Tunçalp Özge, Assifi A, et al. Global, regional, and subregional classification of abortions by safety, 2010–14: estimates from a Bayesian hierarchical model. The Lancet (British edition). 2017;390(10110):2372–81.

16. Keogh LA, Gurrin LC, Moore P. Estimating the abortion rate in Australia from National Hospital Morbidity and Pharmaceutical Benefits Scheme data.

Medical journal of Australia. 2021;215(8):375–6.

17. Subasinghe AK, McGeechan K, Moulton JE, Grzeskowiak LE, Mazza D. Early medical abortion services provided in Australian primary care. Medical journal of Australia. 2021;215(8):366–70.

18. Doran FM, Hornibrook J. Barriers around Access to Abortion Experienced by Rural Women in New South Wales, Australia. Rural and remote health.

2016;16(1):3538–12.

19. Kathryn J LaRoche, L L Wynn, Angel M Foster. “We have to make sure you meet certain criteria”: exploring patient experiences of the criminalisation of abortion in Australia. Public Health Research & Practice. 2021;31(3).

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20. An Overview of Abortion Laws [Internet].

Guttmacher Institute. 2022 [cited 31 May 2022].

Available from: https://www.guttmacher.org/statepolicy/explore/overview-abortion-laws 21. Maxmen, A. Why hundreds of scientists are weighing in on a high-stakes US abortion case [Internet]. 2021 [cited 31 May 2022]. Available from: https://www.nature.com/articles/d41586-021-02834-7 22. Kortsmit K, Mandel MG, Reeves JA, Clark E, Pagano HP, Nguyen A, et al. Abortion Surveillance - United States, 2019. MMWR Surveillance summaries.

2021;70(9):1–29.

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23. Smith MH, Muzyczka Z, Chakraborty P, JohnsWolfe E, Higgins J, Bessett D, et al. Abortion travel within the United States: An observational study of cross-state movement to obtain abortion care in 2017.

The Lancet Regional Health Americas.

2022;10:100214.

24. Cartwright AF, Karunaratne M, Barr-Walker J, Johns NE, Upadhyay UD. Identifying National Availability of Abortion Care and Distance From Major US Cities: Systematic Online Search. Journal of medical Internet research. 2018;20(5):e186–e186.

25. Rodgers Y van der M, Coast E, Lattof SR, Poss C, Moore B. The macroeconomics of abortion: A scoping review and analysis of the costs and outcomes. PloS one. 2021;16(5):e0250692–e0250692.

32. Bateson DJ, Lohr PA, Norman WV, Moreau C, Gemzell-Danielsson K, Blumenthal PD, et al. The impact of COVID-19 on contraception and abortion care policy and practice: experiences from selected countries. BMJ sexual & reproductive health.

2020;46(4):241–3.

33. Bayefsky MJ, Bartz D, Watson KL. Abortion during the Covid-19 Pandemic — Ensuring Access to an Essential Health Service. The New England Journal of medicine. 2020;382(19):E47–e47.

34. Tu P, Li J, Jiang X, Pei K, Gu Y. Impact of the COVID19 pandemic on sexual and reproductive health among women with induced abortion. Scientific reports. 2021;11(1):16310–16310.

35. Salehi L, Rahimzadeh M, Molaei E, Zaheri H, Esmaelzadeh‐Saeieh S. The relationship among fear and anxiety of COVID‐19, pregnancy experience, and mental health disorder in pregnant women: A structural equation model. Brain and Behavior.

2020;10(11):e01835–n/a.

36. Naurin E, Markstedt E, Stolle D, Enstrom D, Wallin A, Andreasson I, et al. Pregnant under the pressure of a pandemic: a large-scale longitudinal survey before and during the COVID-19 outbreak. European Journal of Public Health. 2021;31(1):30–6.

26. Bearak J, Popinchalk A, Ganatra B, Moller A-B, Tunçalp Özge, Beavin C, et al. Unintended pregnancy and abortion by income, region, and the legal status of abortion: estimates from a comprehensive model for 1990–2019.

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27. Boonstra H. Abortion in the Lives of Women Struggling Financially: Why Insurance Coverage Matters [Internet]. Guttmacher Institute. 2016 [cited 31 May 2022].

Available from: https://www.guttmacher.org/gpr/2016/07/abortionlives-women-struggling-financially-why-insurancecoverage-matters 28. Finer LB, Zolna MR. Declines in Unintended Pregnancy in the United States, 2008–2011. The New England journal of medicine. 2016;374(9):843–52.

29. Thompson T, Young Y, Bass T, Baker S, Njoku O, Norwood J et al. Racism Runs Through It: Examining The Sexual And Reproductive Health Experience Of Black Women In The South. Health Affairs.

2022;41(2):195-202.

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31. World Health Organisation. World Health Organization Model List of Essential Medicines.

Geneva: World Health Organisation; 2021 p. 50.

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Utilising a Health Promotion Approach to Climate Action Jasmine Davis The University of Melbourne

Introduction Climate change is the most significant threat to the health and wellbeing of humanity [1]. It has been known for over a century that the recent changes in our climate are driven by human actions [2]. Although there is scientific consensus that climate change harms health, much of the focus of government policy in Australia has been on the economic and industry impacts of climate change [3]. This essay will argue that health promotion should be used as a tool for climate action in Australia, which can be led by public health practitioners.

The public health problem Climate change is an all-encompassing definition that includes any shift in temperature and weather over long periods. Historically, changes in our climate have been natural, however evidence has shown that modern climate change has been greatly influenced by human behaviours [2]. These behaviours include but are not limited to: fossil fuel burning, deforestation, overconsumption, and the impacts of the manufacturing and transportation industries [4].

Climate action encompasses any action taken to combat climate change and its impacts [5].

Climate change has impacted health in a multitude of ways, and will only continue to impact health more extensively if climate action is not taken. Climate change causes increased deaths and disease from extreme heat, natural disasters and food insecurity [6]. Climate change impacts the patterns of disease and infection by increasing the number of water borne and vector diseases [7]. Alongside this, climate change has been seen to exacerbate already rising rates of mental illness [8].

The impact of climate change on public health is not a future problem. As of 2000, global climate change has been estimated to have caused 150,000 deaths and 5.5 million lost disabilityadjusted life years per year [9]. Australia has already seen the impacts of climate change in droughts, bushfires, coral bleaching, and floods [10]. In the near future, climate change will significantly impact Australia’s agriculture and farming industries, will pose significant risks to our beachside infrastructure, and will impact the most vulnerable Australians such as rural and remote communities, and Aboriginal and Torres Strait Islander peoples [11]. Thus, climate change is a public health problem, that requires a public health solution, led by public health professionals.

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The current approach to climate action in Australia Australia has been criticised internationally due to its inaction on climate change [12]. In a United Nations report Australia was ranked last out of developed countries in its actions taken to reduce greenhouse gas emissions [13]. Much of the focus of Australian climate discussions have been on the economic and industry implications of climate change [3]. Although these are important, and action should be taken in these spaces, the health implications of climate change have been largely ignored by policymakers, and Australia has failed to adequately utilise health promotion strategies to raise awareness of, and take action on climate change [12].

Failure to adequately prepare for the impacts of climate change at a government level have been seen through the failure to prevent and minimise the impacts of the 2019/20 Bushfires.

The Australian government was criticised with poor communication to those on the ground, and failed to adequately prepare health services with adequate training, staff and resources [14].

There is a desperate need for the Australian Government to take action on climate change in a holistic manner, placing the health and wellbeing of Australians at the forefront of the discussion.

Taking a health promotion approach Health promotion has been defined by the Ottawa Charter as “the process of enabling people to increase control over, and to improve, their health”. The three basic strategies for health promotion underpinning the Ottawa Charter are: advocate, enable and mediate (Figure 1) [15].

Health promotion has been utilised as a key public health strategy globally in the prevention of disease. This paper will argue that these three components should underpin the health promotion climate action.

Figure 1: Ottawa Charter for Health Promotion

Climate change, if it hasn’t already, will impact every industry and person in Australia. It has been considered a ‘wicked problem’ due to the intertwined nature of climate change challenges, highlighting that not one issue can be dealt with in isolation from the others [16]. Health promotion and public health more broadly are well placed to tackle wicked problems due to the multidisciplinary nature of the field, and the frequency of strong partnerships [17][18]. These strengths of health promotion draw upon the ‘mediate’ component underpinning the Ottawa Charter, as through collaborations and multidisciplinary measures, climate action is likely to be more successful [18].

Advocacy is an essential component to both the Ottawa Charter and climate action. Health promotion bodies have been essential in climate change advocacy in Australia, in putting pressure on the Australian Government to act and increase their climate action commitments, such as the public pressure on Government to commit to net zero by 2050 [14]. Advocacy collaboration is essential through alliances such as the Climate and Health Alliance that bring together multidisciplinary groups working on climate change, to create a coordinated strategy [20].

The third strategy of the Ottawa Charter for health promotion that can be used to argue why a Page 29

health promotion strategy should be utilised for climate action, is ‘enable’. This strategy emphasises that environments need to be enabled for people to achieve the best health they can, and for societies to reach health equity [18]. Climate change will impact underprivileged and vulnerable groups most substantially, and in Australia we are likely to see climate change exacerbating inequities we see in Aboriginal and Torres Strait Islander health and rural and remote health [21[22]. Taking a health equity approach to health promotion climate action is essential to enable individuals and communities to live healthy and fulfilling lives.

Ottawa Charter ‘action areas’ as tools for climate action Alongside the basic strategies of the enable, advocate and mediate, the Ottawa Charter also includes five action means. These ‘action means’ consider health promotion through the lens of the socioecological model of health, recognising the interrelatedness of health and our lived environment [23]. These action means will be discussed individually to highlight the importance of each component and the current ways in which the means are being used, to argue that health promotion should be used as a tool for climate action in Australia.

Develop personal skills The Ottawa Charter highlights the importance of health promotion strategies that develop personal skills to enable people to exercise more control over their lives and make healthy choices [24].

Significant portions of the action that has been taken on climate change in recent decades has been focused on developing personal skills.

The emphasis placed by governments on individual behavioural actions and developing skills to reduce the impact of climate change have been significant. Many social movements have emerged due to climate change such as veganism, electric vehicles, utilising public transport, reducing food waste, and increasing recycling [25]. The utility of individual action on climate change has been debated, and politicians and large corporations have been criticised for using the

individual action message to deflect from the systemic changes that they need to implement [26]. However, other researchers have argued that individual action is essential to ensure systemic climate action as it is important to empower individuals to feel as though they are able to make a difference [27]. Research has also found that those who undertake individual actions to reduce the impact of climate change, are more likely to put pressure on governments for systematic change, or support others who are doing so [28] [29].

Strengthen community action Community action aims to draw on existing resources and connections to build capacity in communities to tackle health issues, as well as to empower communities to place pressure on governments to take action on issues that are important to them [27]. Community action in Australia is most strong in our rural and First Nations populations. As these groups are incredibly vulnerable to the impacts of climate change, building capacity in these communities climate action is essential.

Rural Australians already have a higher burden of disease, and worse access to healthcare [30].

These inequities are going to further worsen due to climate change, with the impacts of floods, droughts, and extreme heat greatly impacting Australia’s farmers and rural and remote communities [8][31][32]. Despite the lack of funding and support provided to rural communities to deal with the current and future impacts of climate change on their livelihoods and health, rural and regional communities are already adapting to the impacts of climate change [35]. Many farmers have altered the way they sow and harvest crops, and have modified the crops they choose to grow due to climate change [33].

The existing gap in the health and wellbeing of Indigenous and non-Indigenous Australians will widen with climate change. Aboriginal Controlled Community Health Organisations have been essential for First Nations health promotion and have developed culturally safe health promotion strategies on many important health issues facing Indigenous Australians, emphasising the importance of using community strength [34].

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Torres Strait Islander Australians in particular are being already hit by the impacts of climate change. Community action is strong in these groups, with Community leaders from the Torres Strait bringing a class action against the Australian Government for its failure to protect traditional lands from the impacts of climate change [35].

First Nations people in Australia have a unique connection to land, and have deep cultural knowledge of how to care for the land and seas [36]. Community action towards climate change can be strengthened through making space for Indigenous voices and Indigenous knowledge [37].

The utility of this approach has been voiced in the aftermath of the 2019/20 bushfire season, recognising that Indigenous fire management strategies prevented many fires, and should be utilised in future prevention [38].

Create supportive environments and build healthy public policy Creating supportive environments in the Ottawa Charter recognises the socioecological determinants of health, and the way in which our environment and community influences our health [27]. Creating supportive environments cannot be separated from another component of the Ottawa charter: ‘build healthy public policy’.

This component of the charter is where health promotion action influences policy in all sectors, not only health policy [27]. A shift in public policy is essential for our lived environment to be supportive and sustainable and to enable people to reach their full potential with regards to their health and wellbeing.

Under the Paris Agreement, signatories have agreed to limiting global warming to 1.5°C, and to commit to a net-zero emissions future. These are the minimum requirements deemed by scientists to halt the impacts of climate change [39]. Policy is required to transform transport, agriculture and health industries in order to reach these targets and create liveable environments [46].

Examples of good policies to create supportive environments are policies that subsidise electric vehicles such as the Zero Emissions Vehicle subsidy in Victoria, and the investment by South Australia to power

their state by solar power [40][41]. However, federal government commitments to creating supportive environments and healthy public policy have been minimal, with the states taking most of the action on climate.

Reorient health services The Ottawa Charter encourages governments to reorient health services from providing clinical and curative services to health promotion and holistic care [27]. Reorienting health services is essential for climate action, in that climate change already is, and will continue to change the landscape of our health and wellbeing needs. The Australian health sector thus far has been illequipped to handle climate related events such as the 2019/20 bushfires, and the Covid-19 pandemic [16].

The key to improving preparedness of health services for climate change and its impacts is through building climate-resilient health systems. Climate resilient health care facilities are those that are able to monitor, anticipate, manage and adapt to the health risks associated with climate change [42]. The WHO recommends specific health National Adaptation Plans for countries to plan their response to adapt health systems for climate change, to collect data, and to evaluate the effectiveness of interventions [49].

Conclusion Climate change is a complex public health problem, which is already having significant impacts on the health and wellbeing of Australians. A holistic approach is required to combat climate change and its impacts. Health promotion as viewed through the Ottawa Charter can and should be used as a tool for climate action in Australia. Taking a health promotion approach to the issue of climate change in a collaborative, coordinated way, will be essential to ensuring climate change does not exacerbate already existing inequalities.

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AJGH AMSA Journal of Global Health

Glass Ceilings Volume 16 | Issue 1 | July 2022