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The Health Wrap: a global focus on Indigenous knowledges, polio, the opium trade and climate, plus the Paralympics and brilliant women

In her latest edition of The Health Wrap, Associate Professor Lesley Russell covers wide-ranging global health concerns, as well as exploring the wider impacts of the Paralympic Games.

She also shares some (much-needed) good news on climate action, and links to a series of articles profiling women who’ve been at the forefront of vaccine science over the past 100 years or more.


Lesley Russell writes:

In Australia we have learned how important community control is for Aboriginal and Torres Strait Islander communities in managing the pandemic – and in places like Walgett in northwestern NSW we are now seeing both how easily infection can come to these communities, and how imperative it is that they are provided with the resources to manage this.

Back in March, my Croakey colleague Alison Barrett did a great summary for the COVID-19 Wrap about the pandemic’s impact on Indigenous communities, both in Australia and globally.

A recent paper in Nature Medicine looks at Indigenous communities that, to date, have been missing from global perspectives on the pandemic – those who live in Arctic regions. The lessons echo those learned here in Australia.

The Arctic covers a vast area in the Northern Hemisphere encompassing parts of Canada, Denmark (Greenland and the Faroe Islands), Finland, Iceland, Norway, Sweden, Russia and the United States (Alaska).  These areas are sparsely populated by a total of some seven million people.

These Arctic populations generally have high rates of health conditions that make COVID-19 more dangerous (particularly true for the Indigenous populations) and their remote settlements have limited access to healthcare and possess few healthcare resources with which to fight the disease.

Despite this, in most cases, Arctic regions have fared better in the COVID-19 pandemic than have temperate areas south of the Arctic in the same countries. (You can track cases by region with this dashboard, set up by the Arctic Center at the University of Northern Iowa.)

The blessing of remoteness is that some communities were able to implement strong isolation measures in the early stages of the pandemic. The curse of remoteness is that when, inevitably, SARS-CoV-2 arrived, managing infections has been very difficult.  

The pandemic’s “second wave” observed in the Arctic between September 2020 and January 2021 was severe in terms of COVID-19 infections and fatalities, with particularly strong impacts in mining and industrial settlements in Alaska, Northern Russia and Northern Sweden.

In contrast, a number of Arctic regions with large Indigenous populations, such as Greenland and northern Canada, have seen limited spread of SARS-CoV-2.

The authors of the Nature Medicine paper collected Indigenous community testimonies that show strict preventive measures that combined public health and Indigenous knowledge approaches were able to curtail the spread of COVID-19 in these regions and provide physical, emotional, and mental support.

In addition to remoteness, cultural memory of devastating past epidemics, such as the 1918 influenza pandemic, in Indigenous-dominant regions may have contributed to protection efforts.

Alaska has been able to put an effective vaccination campaign in place, reaching out into remote villages. Alaska’s rural and Indigenous residents are vaccinated at levels that meet or even exceed those in Alaska’s cities.

Again, institutional memory may have helped drive this. Each year the Iditarod race celebrates how, in 1925, the small Alaskan town of Nome was saved from a diphtheria epidemic when in the middle of winter, 20 teams of sled dogs transported the needed vaccines over 1,085 kilometres in just six days.

The Arctic COVID-19 website has informational materials in Arctic languages, testimonies from Indigenous peoples, and lots of up-to-date data.


What does the fall of Afghanistan mean for polio control?

Afghanistan is one of the few countries now classified by the International Health Regulations as a state infected with Wild Type Polio Virus 1 (WTPV1) (the only wild type still circulating)  and Circulating Vaccine Derived Polio Virus 2 (cVDPV2) (generated when the attenuated vaccine virus circulates in populations with low immunisation levels) – with the potential risk of international spread.

Afghanistan and Pakistan are now the only countries where wild type polio virus is found; Africa was declared free of wild polio in August 2020.

With millions of refugees now on the move in both countries, and an unstable political situation, what are the consequences for polio control and elimination – targets that are at once so close and so threatened?The progress made is highlighted in the statement of the Emergency Committee on the international spread of poliovirus, which was convened by the WHO Director-General on 4 August 2021.

It found that wild polio virus transmission continues to fall, with no new case since January 2021 when two cases occurred, one each from Pakistan and Afghanistan. This compares to 94 cases during the same time period in 2020. In Afghanistan cVDPV2 cases, all of which occurred in inaccessible areas, are also down in 2021.

Now the takeover of Afghanistan by the Taliban, combined with the coronavirus pandemic, puts all the hard work done to date in jeopardy.

In the last edition of The Health Wrap I wrote about the precarious situation for the healthcare system in Afghanistan, which is almost totally reliant on foreign aid.

The situation is even more complicated for the internationally-run polio vaccination campaign (it’s run by the Global Polio Eradication Initiative, a coalition of the WHO, the Centers for Disease Control and Prevention, the Gates Foundation, and Rotary International).

The Taliban’s attitude toward eradication activities has varied.

In the 1990s, the Taliban allowed the campaign to begin to operate in Afghanistan. But in 2018, it forced a pause in areas it controlled, banning teams of vaccinators from going house to house, and then disallowed mass vaccinations at public buildings such as mosques. More recently the Taliban has been held responsible for the killings of a number of female vaccination workers.

Those bans and the intimidating violence, and similar problems in Pakistan as political parties jockeyed for power, were responsible for a recent spike in polio case counts: from a total of 33 cases in the two countries in 2018 to 117 in 2019.

Long-lasting interruptions to polio vaccination programs are critical blows because it takes several rounds of the oral vaccine to immunise a child. It is estimated that there are several million children in Afghanistan and Pakistan who are now incompletely vaccinated.

The sudden drop in cases seen in 2021 may be due to the mask wearing, social distancing and travel restricts required by the pandemic. However, with many people now displaced and refugees living in camps, the situation can only worsen.

Last week, the Global Polio Eradication Initiative issued a statement that it is “currently assessing immediate disruptions to polio eradication efforts and the delivery of other essential health services, to ensure continuity of surveillance and immunization activities while prioritizing the safety and security of staff and frontline health workers”.

You can read more about this in an article in Wired here and an article in Science here. There was an interview last week on ABC RN Breakfast with the acting Health Minister of Afghanistan which was very sobering. You can access the audio here.


Afghanistan and the opium trade

International experts are fearful that Afghanistan, already the world’s top opium producer, will boost its opium trade to support its collapsed economy.

According to recently released United Nations data, Afghanistan accounted for 85 percent of the opium produced worldwide last year, far outpacing rival producers such as Myanmar and Mexico. The country is also accused of playing a major role in the global supply of cannabis and methamphetamines.

Opium production previously flourished under Taliban rule and during the international occupation of Afghanistan, production continued to rise in Taliban-controlled areas. This is despite American-backed eradication efforts estimated to have cost US$9 billion over 20 years.

But since they assumed power in Kabul earlier this month, their spokesman Zabihullah Mujahid has repeatedly said the Taliban would not allow the production of opium or other narcotics within its state.

That may not be an easy task – and these statements may just be window-dressing for the international media.

The United Nations Office on Drugs and Crime (UNDOC) estimated that in 2018 opium production contributed up to 11 percent of the country’s economy and it is a major source of employment. In 2019, opium harvesting provided almost 120,000 jobs, according to a UNDOC survey.

The Taliban has profited through taxes on the opium crop and indirectly through processing and trafficking. A 10 percent cultivation tax is reportedly collected from opium farmers.

Last year an expert from the Washington-based Brookings Institute testified about the harmful outcome of international eradication efforts at an inquiry in the UK House of Lords into drugs, security, and counternarcotics policies in Afghanistan.

The key points made were:

  • The illicit drug economy is a vital lifeline for many Afghans.
  • Most counternarcotics measures have been ineffective or outright counter-productive both economically and politically.
  • The poorest and most socially marginalised communities have suffered most from eradication efforts and bans on opium poppy cultivation, and this has generated extensive political capital for the Taliban.

You can read the full testimony here.

While poor Afghan farmers may rely on opium farming for their livelihood, opioid addiction has taken a huge toll on Afghan society. A 2015 survey concluded that there were between 2.9 million and 3.6 million drug users in Afghanistan, with opioids being the drug of choice — an exceptionally high level of per capita drug usage.

Husbands often addict wives, and mothers often addict children by using opium while pregnant, by exposing the children to second-hand opium smoke and by using a pinch of opium to calm them when they are fussing.

There is little or no help available for drug addiction. The Afghan Government estimated that 99 percent of Afghan addicts do not receive treatment and the quality of treatment is often poor. The previous Government was opposed to methadone maintenance and blocked methadone from entering the country. Prevention efforts have been even more inadequate.


One more crisis for Afghanistan – climate change

A recent article in The New York Times highlights how Afghanistan, like Somalia, Syria and Mali, embodies a new sort of international crisis, where the hazards of war collide with the hazards of climate change to create a dreadful feedback loop that punishes some of the world’s most vulnerable people.

Parts of Afghanistan have warmed twice as much as the global average. Over the past 60 years, average temperatures have risen sharply, by 1.8 degrees Celsius since 1950 in the country as a whole and by more than 2 degrees Celsius in the south. Spring rains have declined, most worryingly in some of the country’s most important farming and grazing areas in the north. Droughts are more frequent in many parts of the country.

“Climate change will make it extremely challenging to maintain – let alone increase – any economic and development gains achieved so far in Afghanistan,” warned a 2016 United Nations report.

“Increasingly frequent and severe droughts and floods, accelerated desertification, and decreasing water flows in the country’s glacier-dependent rivers will all directly affect rural livelihoods – and therefore the national economy and the country’s ability to feed itself.”

This year, because of the fighting, many people haven’t been able to plant their crops. Because of the drought, the harvest is certain to be poor. A third of all Afghans face crisis levels of food insecurity.

“The convergence of climate risks and conflict further worsens food and economic insecurity and health disparities, limits access to essential services, while weakening the capacity of governments, institutions and societies to provide support,” the International Committee of the Red Cross warned in a recent report that examined the combined effects of conflict and climate change.

Climate change also stands to complicate the Taliban’s ability to fulfill their promise to eliminate opium poppy cultivation. Poppies require far less water than other crops such as wheat or melons and are far more profitable.

If you are interested in learning about what you can do to help the Afghan people, please read this recent Croakey Health Media article: “The situation in Afghanistan is beyond horrifying: this is what you can do to help.”


Why can’t we have real debates on real issues?

On Croakey Health Media a frequent topic is around misinformation and disinformation, an issue that has risen to prominence during the coronavirus pandemic.

Here are some links to some recent articles:

Linked into this new public health ‘epidemic’ is the growing realisation that our society is more and more incapable of having serious debates around the real issues of the day.

I think there are two key reasons for this:

  • Too often the clash of ideas is viewed as a threat.

I think this is why the Morrison Government has been loathe to countenance debate around when and how and under what targets and guidelines Australia should open up and “learn to live with the virus”.

  • The push to ensure that “both sides” of the issue is heard means that too often false equivalence is given to flawed ideas.

As a recent example of this, when the ABC QandA program explored the impact of the recent report from the Intergovernmental Panel On Climate Change, the only person representing the Federal Government’s position was Queensland Nationals Senator Matt Canavan who is a notorious opponent of climate action.

Recently MedPage Today ran an article on the “Seven Cognitive Distortions Poisoning COVID Debates” (with examples for each distortion). The focus is American (and yes, the misinformation, disinformation and debates are must worse there) but it picked up on some of the things I have been thinking about.

The seven ‘cognitive distortions’ are:

  1. Misusing what is called both-sidesing (My point 2 above)
  2. Doing it for fame and clicks (Taking more extreme positions for attention – maybe that’s what Senator Canavan is doing?)
  3. The burden of proof (To whom does this fall? And beware of confirmational bias)
  4. Look what happened to Tom or Jane (Anecdotes are powerful but they are not evidence)
  5. Ideas are dangerous (Especially if they disagree with my ideas or policy recommendation)
  6. “My colleagues all agree with me” (Being able to hold views that sometimes dovetail with your peers and colleagues, but not always, is the hallmark of independent thinking and appraisal of evidence)
  7. Punishing people for holding ideas (Boycotts and trolling or just silently moving on)

You may or may not agree with this list and the examples cited – but it is thought-provoking.


The Paralympic Games

There has been so much to love about the Paralympic Games – great athleticism and sportsmanship, amazing stories of triumphs over adversity, the complete acceptance of disabilities and differences (or were they just not recognised?), and the surprising number of older athletes performing at incredible levels.

(If you are a Paralympic Games fan then you will enjoy the You Little Ripper podcasts from Paralympic legend Kurt Fearnley and co-host Georgie Tunny.)

Why can’t it always be like this, not just for the elite athletes but for everyone living with a disability? This question leads inevitably to asking if the Paralympic Games make a difference to public perceptions and public policies around disability, and if so, how and why?

Let me say upfront that the short answer to these questions is: there is very little data to interrogate, but it’s pretty obvious not much changes. I suspect people living with disabilities will reinforce that statement.

When cities apply to host the Olympic and Paralympic Games, lots of claims are made about the lasting legacies these will leave.

In the lead-up to the 2016 Paralympic Games in Rio de Janeiro, Sir Philip Craven, then President of the International Paralympic Committee, outlined how previous Games had changed attitudes and even rights in host countries (in particular, he emphasised the changes in China and Russia) and what the Games would mean for Brazil.

But there is little research or data to support these claims. My research shows that most of this work has been done in relation to the London Games in 2012.

In 2021, there are plenty of reasons why the Paralympic Games could drive change. Since their advent in Rome in 1960, the Paralympic Games have grown in to a major international event that is widely broadcast and makes a powerful political statement.

This year there 4,403 participants from 161 countries and a team of refugee athletes. And these Paralympic Games are being used as a catalyst for a new global campaign – We the 15 – aimed at removing discrimination faced by disabled people.

Certainly things have improved dramatically for Australian Paralympic athletes since the Sydney 2000 Games. They now have more sustained funding, and many are well-recognised sportsmen and women. And it was good to see the Prime Minister announce that medal winners would be financially rewarded on a par with Olympic medalists.

There has also been a major effort to make events open to both sexes. In Tokyo more female athletes competed than ever before. I loved the story about the librarian who became Australia’s first female wheelchair rugby (known, for good reason, as murderball) star after a bet with her brother.

The Paralympic Games are recognised as being inspirational for children with disabilities, improving their self-perception (and it is great that the athletes are well aware of this).

Paralympics Australia has several programs aimed at increasing participation in Paralympic sports. These have been very successful. Some 2.9 million Australians report having a long-term disability or physical impairment and 2.3 million said they did some type of sport or physical activity in the past year. Of these, 755,000, or 26 percent, said they had played at least one of the sports to be staged at Tokyo.

A paper published last year looked at how Paralympics broadcasting influenced British attitudes towards disabilities. It found that audiences internalised “socially progressive ideas towards disability”, including an awareness of emerging cultural citizenship concerning disability rights-based discourses.

However the paper also cites evidence of potentially damaging stigma hierarchies of disability preferences. There is reference to the “celebritisation” through media coverage of technologically-enhanced successful para-athletes.

Other have also written about a hierarchy of impairments with the “super human” image valued over complex and less understood impairments (at last in the sporting arena).

It is very Australian to view success and heroism through a sporting lens. But not every person living with a disability is a Paralympian, and the fact is that many disabled people experience material deprivation and exclusion from education, employment and leisure and sporting activities. An article published last month in the UK edition of The Conversation explores this issue.

This is highlighted in the responses to the Rights and Attitudes issues paper published by the Royal Commission into Violence, Abuse, Neglect and Exploitation of People with Disability.

This revealed that the community lacks awareness of the rights of people with disability which can lead to neglect, exploitation and discrimination. Stigmatising representations in the media and assumptions about capacity and autonomy affect people with disability throughout their lives.


‘Opening up’

Michelle Grattan’s piece in The Conversation effectively sums up for me where Australia is 18 months after the start of the pandemic – the transition to “living with the virus” will be tough and government failings and sniping, at both federal and state and territory levels, are unedifying and unhelpful.

There’s lots of disagreement over what the Doherty Institute modelling says – and not just in National Cabinet.

Here’s the original report, including the executive summary and some corrections and addendums.

Here’s how the Office of Prime Minister and Cabinet presents the report’s findings.

Here is the Economic Impact Analysis: National Plan to Transition to Australia’s National COVID 19 Response prepared by Treasury.

Here is some commentary and analysis from trusted sources:

Australia is not the only country facing this dilemma. A July article in The New York Times looked at the standoffs between politicians who want to open up and scientists who warn of the dangers of doing this too early. Only New Zealand seems intent on sticking with a zero COVID strategy.

The prime concern must be that vulnerable and disadvantaged Australians are not lost in the seemingly mad rush to open up and the use of average statistics for vaccination levels in support of this.

Recent articles in Croakey Health Media make the point that opening up when 80 percent of eligible adults are vaccinated won’t be safe for all Australians, and that Aboriginal and Torres Strait Islander communities must be safe.

There is also concern about alarmingly low vaccination levels in prisons.


Call to action

Continuing the theme of concern about the differential impact of “opening up”, I encourage you to engage with Croakey’s call for creative suggestions for developing a series of health equity memes. Read more here.


In case you missed it

Dr Hilda Bastian has written a wonderful three-part series on women in vaccine science in the 20th century. It’s recommended reading! I hope she updates it into the 21st century soon.

Part 1 covers 1900-1930.

Part 2 covers the 1940s through to the 1960s.

Part 3 covers the 1970s to the 1990s.


The best of Croakey

As we prepare for a surge in COVID cases, it’s important to listen to the perspectives of a range of healthcare workers. Some insights in this article below.


The good news story

More than 300 current and former athletes – a who’s who of Australian sport – have come together to highlight that action is needed on the climate crisis.

The campaign, named The Cool Down, and headed by former Wallabies captain David Pocock, was launched this past week. It has backed scientific calls for the country to cut greenhouse gas emissions at least in half by 2030 and reach net zero emissions before 2050.

The Cool Down website states: “at the moment, if climate action was the Olympics, Australia isn’t winning gold, we’re not making the finals, in fact, we don’t even qualify.”


Croakey thanks and acknowledges Dr Lesley Russell for providing this column as a probono service to our readers. Follow her on Twitter at @LRussellWolpe.

Previous editions of The Health Wrap can be read here.


See Croakey’s archive of stories on healthcare and health reform.

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