tag:theconversation.com,2011:/au/topics/essays-on-health-32828/articlesEssays on health – The Conversation2020-08-13T20:11:35Ztag:theconversation.com,2011:article/1443572020-08-13T20:11:35Z2020-08-13T20:11:35ZPandemic letter from America: how the US handling of COVID-19 provides the starkest warning for us all<figure><img src="https://images.theconversation.com/files/352461/original/file-20200812-16-1on3gsi.jpg?ixlib=rb-1.1.0&rect=0%2C1%2C1000%2C661&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/statue-liberty-wearing-surgical-mask-new-1728185668">Shutterstock</a></span></figcaption></figure><p><em>This is one of our occasional <a href="https://theconversation.com/au/topics/essays-on-health-32828">Essays on Health</a>, this time from an Australian visiting fellow in Washington, DC. Adam Elshaug, professor of health policy, asks how one of the world’s most inequitable health-care systems has coped with COVID-19. The short answer, he says, is that it provides a wake-up call for us all. It’s a long read.</em></p>
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<p>We all hoped for a rapid and effective COVID-19 response. For the United States, that has not occurred. It is now host to <a href="https://covid19.who.int/region/amro/country/us">more documented COVID-19 cases</a> and deaths <a href="https://coronavirus.jhu.edu/map.html">than any other country</a>.</p>
<p>With <a href="https://www.worldometers.info/world-population/us-population/">about 4%</a> of the world’s population, the US accounts for about <a href="https://coronavirus.jhu.edu/map.html">25% of all cases</a> and <a href="https://coronavirus.jhu.edu/map.html">about 20%</a> of all deaths — <a href="https://www.worldometers.info/coronavirus/country/us">more than 169,000</a> deaths so far.</p>
<p>Yes, it’s a large country, but that is <a href="https://ourworldindata.org/grapher/total-covid-deaths-per-million">about 500 deaths per million</a> population, compared with Australia’s <a href="https://ourworldindata.org/grapher/total-covid-deaths-per-million">about 12 per million</a>. </p>
<p>Australia’s state of Victoria is amid its second wave, recording <a href="https://theconversation.com/723-new-covid-19-cases-in-victoria-could-reflect-more-testing-but-behaviour-probably-has-something-to-do-with-it-too-143677">723 new cases and 13 deaths</a> on July 30. The same day, the US recorded <a href="https://www.worldometers.info/coronavirus/country/us/">68,585 new cases and 1,465 deaths</a>.</p>
<p>I write this from my temporary base in Washington, DC.</p>
<p>I have experienced first hand, and since the outset of the pandemic, how deficiencies in the organisation of the US social, political and health-care systems have become more vivid and their consequences intensified.</p>
<p>Given its status as a world superpower, and its stratospheric <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019">per capita health care spend</a>, the situation in the US is <a href="https://www.rollingstone.com/politics/political-commentary/covid-19-end-of-american-era-wade-davis-1038206/">truly alarming</a>. </p>
<p>Entire books will be written on this woeful epoch in US history. But I want to focus on some key observations of the country’s failed COVID-19 response, and the lessons.</p>
<h2>Transitioning to failure</h2>
<p>It would be unfair to blame President Donald Trump and his administration for the systemic failures in the US social and health-care systems. Those have been decades in the making. </p>
<p>But his pre-COVID-19 dismantling of the pandemic preparedness system, disregard for scientists, and hyper-partisanship have clearly worsened the US response.</p>
<p>I agree with the political commentator David Frum, who <a href="https://www.theatlantic.com/ideas/archive/2020/04/americans-are-paying-the-price-for-trumps-failures/609532/">wrote</a>: </p>
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<p>That the pandemic occurred is not Trump’s fault. The utter unpreparedness of the United States for a pandemic is Trump’s fault.</p>
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<p>President Barack Obama left the Trump administration with <a href="https://www.newstatesman.com/world/north-america/2020/03/america-pandemic-response-swine-flu-avian">pandemic-ready infrastructure</a>. This was motivated by outbreaks of Ebola and previous novel coronaviruses (responsible for Middle East Respiratory Syndrome, or MERS, and SARS, severe acute respiratory syndrome), and an appreciation of their ever-present threat. </p>
<p>Then, Trump took critical steps before COVID-19 that weakened its preparedness to the point of catastrophe. Here are just a few.</p>
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Read more:
<a href="https://theconversation.com/explainer-what-donald-trumps-funding-cuts-to-who-mean-for-the-world-136384">Explainer: what Donald Trump's funding cuts to WHO mean for the world</a>
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<p>The Trump administration <a href="https://www.washingtonpost.com/outlook/nsc-pandemic-office-trump-closed/2020/03/13/a70de09c-6491-11ea-acca-80c22bbee96f_story.html">dismantled</a> the (Obama-instituted) White House team in charge of pandemic response, dismissing its leadership and staff in early 2018.
This team had also laid out a detailed dossier for a pandemic response plan. Trump ignored it.</p>
<p>Since coming to office, the Trump administration has also <a href="https://www.snopes.com/fact-check/trump-fire-pandemic-team/">cut funding</a> to key agencies including the <a href="https://www.cdc.gov/">Centers for Disease Control and Prevention</a> (CDC). These cuts directly impacted domestic projects and international collaborations (including with China) on pandemic preparedness.</p>
<h2>Too little, too late</h2>
<p>Even into February as the severity of the pandemic was realised worldwide, Trump was downplaying the threat, openly stating it was like <a href="https://www.washingtonpost.com/politics/2020/03/24/trump-again-downplays-coronavirus-by-comparing-it-seasonal-flu-its-not-fair-comparison/">the common flu</a>.</p>
<p>He called growing concerns about COVID-19 a “<a href="https://www.vox.com/2020/2/29/21159294/trump-coronavirus-hoax-south-carolina-first-death">hoax</a>” and had a “<a href="https://www.theguardian.com/world/2020/mar/05/trump-coronavirus-who-global-death-rate-false-number">hunch</a>” expert assessments of the potential toll were wrong.</p>
<p>As cases and deaths, particularly <a href="https://www.theguardian.com/world/2020/apr/07/new-york-coronavirus-deaths-record-cases">in New York</a> began to rise steeply, the real evidence of unpreparedness became apparent.</p>
<p>Critically, at no point through the pandemic has the US had in place a sincere strategy of public health 101: test, trace, isolate.</p>
<p>Trump has repeatedly <a href="https://www.youtube.com/watch?v=1_XwC9IQKBc">claimed</a> anyone who wants a test can get a test, but this has been a <a href="https://khn.org/news/donald-trumps-wrong-claim-that-anybody-can-get-tested-for-coronavirus/">farce</a>. Shortages of testing supplies and poor coordination have hamstrung containment strategies.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/1_XwC9IQKBc?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">President Donald Trump saying there were enough COVID-19 tests to go round.</span></figcaption>
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<p>Even though testing has increased, it has not kept up with demand. The time to receive results as of July <a href="https://fortune.com/2020/07/14/how-long-do-coronavirus-test-results-take-quest-diagnostics-covid/">ranged from</a> 1 to 14 days, averaging 7 days. </p>
<p>This is inadequate to manage spread via active but undiagnosed cases. That is just the beginning of the current troubles. </p>
<h2>The Disunited States of America</h2>
<p>The <a href="https://www.nejm.org/doi/full/10.1056/NEJMp2006141">limited availability</a> of masks, personal protective equipment (PPE) and ventilators revealed significant cracks in US preparedness. It also put on full display the caustic political divisions that are a modern feature of US politics and society.</p>
<p>Despite the <a href="https://www.kiro7.com/news/local/coronavirus-washington-state-timeline-outbreak/IM65JK66N5BYTIAPZ3FUZSKMUE/">first cases</a> being recorded in Washington state, its deadly potential was initially felt most in the Democratic state of New York. Trump used this to avenge old scores and fuel competition between red (Republican) versus blue (Democratic) states.</p>
<p>When the New York health-care system <a href="https://www.nytimes.com/2020/07/27/podcasts/the-daily/new-york-hospitals-covid.html?searchResultPosition=1">buckled</a> as a result of its fragmented structure (another failing) and enormous caseload, the state’s Democratic governor, Andrew Cuomo, called for urgent assistance, such as supplies from the national stockpile.</p>
<p>Trump <a href="https://www.npr.org/2020/04/20/837737368/trump-often-picks-fights-with-governors-but-americans-like-them-more">tweeted</a> Governor Cuomo “should spend more time ‘doing’ and less time ‘complaining’.”</p>
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<p>The fierce competition between states for limited mask and PPE supplies led to suppliers price-gouging.</p>
<p>Frustration led governors to place clandestine international orders. <a href="https://www.forbes.com/sites/sergeiklebnikov/2020/04/18/illinois-gov-pritzker-secretly-bought-medical-supplies-from-china-and-the-white-house-is-not-happy/#525b01517891">Illinois</a> and <a href="https://www.nytimes.com/2020/04/20/us/larry-hogan-wife-yumi-korea-coronavirus-tests.html">Maryland</a>, for example, <a href="https://www.forbes.com/sites/sergeiklebnikov/2020/04/18/illinois-gov-pritzker-secretly-bought-medical-supplies-from-china-and-the-white-house-is-not-happy/#584bbd387891">received plane-loads of supplies</a> under the cloak of darkness and protected by state police. They <a href="https://www.forbes.com/sites/sergeiklebnikov/2020/04/18/illinois-gov-pritzker-secretly-bought-medical-supplies-from-china-and-the-white-house-is-not-happy/#59c068917891">did this</a> “out of fear the Trump administration would seize the cargo for the federal stockpile”, as occurred <a href="https://www.boston.com/news/politics/2020/03/30/donald-trump-massachusetts-coronavirus-response-supplies">in Massachusetts</a>.</p>
<p>There has also been tension across the country about stay-at-home orders, school closures, schools and retail reopenings, data transparency and sharing – the list goes on.</p>
<p>Wearing a mask has become a <a href="https://www.theguardian.com/world/2020/jun/29/face-masks-us-politics-coronavirus">political act</a>. Now, concerningly, Trump has <a href="https://www.nytimes.com/2020/07/14/us/politics/trump-cdc-coronavirus.html">ordered</a> COVID-related hospital data bypass the CDC and be fed directly to the White House, raising concerns about transparency.</p>
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Read more:
<a href="https://theconversation.com/us-coronavirus-data-will-now-go-straight-to-the-white-house-heres-what-this-means-for-the-world-142814">US coronavirus data will now go straight to the White House. Here's what this means for the world</a>
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<p>Despite Trump <a href="https://www.npr.org/2020/04/20/837737368/trump-often-picks-fights-with-governors-but-americans-like-them-more">threatening</a> his absolute authority over the states, much responsibility rests with state governors (equivalent to Australian premiers). And yet counties (equivalent to local councils) have enacted policies independent of, and often contradicting, state policies. </p>
<p>This could be sensible in reflecting local conditions as the rolling wave moves on. However, it has confused any singular messaging and exemplified the red/blue political divide.</p>
<p>The southern (primarily red) states that were late to institute control measures and early to re-open are now the epicentre of this <a href="https://www.voanews.com/covid-19-pandemic/us-southern-states-worry-about-rising-coronavirus-spread">rolling wave</a>.</p>
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<em>
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Read more:
<a href="https://theconversation.com/coronavirus-is-spreading-through-rural-souths-high-risk-population-reopening-economies-will-make-it-worse-136817">Coronavirus is spreading through rural South’s high-risk population – reopening economies will make it worse</a>
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<h2>Systemic inequality</h2>
<p>Among <a href="https://www.oecd.org/">OECD countries</a>, the level of <a href="https://inequality.stanford.edu/sites/default/files/Pathways_SOTU_2019.pdf">structural inequality</a> in the US is extreme. The collision of three problems — uncontrolled pandemic, recession, uninsured people — is disproportionately impacting the most vulnerable.</p>
<p>Pre-pandemic, about <a href="https://www.kff.org/state-category/health-coverage-uninsured/">32 million Americans</a> (around 10% of population) lacked health insurance. A further <a href="https://www.kff.org/other/state-indicator/rate-by-age-2/?dataView=1&currentTimeframe=0&selectedDistributions=total&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D">150 million</a> (around 50% of the population) held employer-sponsored health insurance.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1233249953511665666"}"></div></p>
<p>Up to July 18, about <a href="https://www.cnbc.com/2020/08/06/weekly-jobless-claims.html">32 million Americans</a> had filed for unemployment as a direct result of the pandemic, pushing the unemployment rate <a href="https://www.brookings.edu/research/the-covid-19-crisis-how-do-u-s-economic-and-health-outcomes-compare-to-other-oecd-countries/">well into teen figures</a>.</p>
<p>This number is rising weekly and millions of those have, or will, lose their employer-sponsored health insurance at a time they may need it most.</p>
<p>The US has the unenviable <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019">first place position</a> for the highest health-care costs in the OECD yet some the <a href="https://www.commonwealthfund.org/publications/issue-briefs/2020/jan/us-health-care-global-perspective-2019">worst health outcomes</a> among similar countries.</p>
<p>COVID-19 has placed millions more Americans further away from accessing needed health care.</p>
<p>The country was already experiencing a <a href="https://www.forbes.com/sites/joshuacohen/2019/12/01/dying-young-decline-in-us-life-expectancy-for-third-straight-year-signals-alarming-trend/#2bc0f5e56621">decline in life expectancy</a> and the fear now is this will be exacerbated further.</p>
<h2>A stark warning</h2>
<p>There is a political rallying cry in the US that the country represents a shining light on the hill, a “beacon of hope” for the world.</p>
<p>We must admit the US population size and current political climate make its pandemic response more complex than countries like Australia’s. But that doesn’t mean we can be apathetic.</p>
<p>The US, through COVID-19, offers the starkest of warnings. Underlying gross structural inequality, under-investment and unpreparedness in public health, and socio-political tensions have met in a dizzying, tragic outcome for the richest country in the world.</p>
<p>All Americans have suffered but their most vulnerable have, and will continue to, suffer disproportionately.</p>
<p>It is a shining light for what we must avoid, what we must stand up for and protect against.</p>
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<p><em>This is a co-publication with <a href="https://pursuit.unimelb.edu.au/">Pursuit</a>.</em></p><img src="https://counter.theconversation.com/content/144357/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Adam Elshaug will join the University of Melbourne as Professor of Health Policy and Director, Centre for Health Policy, Melbourne School of Population and Global Health and Melbourne Medical School. Adam Elshaug's spouse is Chief Medical Officer for a US ventilator manufacturer that is responding to the pandemic.</span></em></p>Underlying inequality, an under-resourced public health system and socio-political tensions have met in a dizzying, tragic outcome for the richest country in the world.Adam Elshaug, Visiting Fellow, Brookings Institution, Washington, DC, Professor of Health Policy and Co-Director, Menzies Centre for Health Policy, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1280612020-02-05T19:02:20Z2020-02-05T19:02:20Z‘I want to stare death in the eye’: why dying inspires so many writers and artists<figure><img src="https://images.theconversation.com/files/312728/original/file-20200130-41503-1sawtra.jpg?ixlib=rb-1.1.0&rect=11%2C2%2C1000%2C827&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/close-image-typewriter-paper-sheet-phrase-381699667">from www.shutterstock.com</a></span></figcaption></figure><p><em>This is one of our occasional <a href="https://theconversation.com/au/topics/essays-on-health-32828">Essays on Health</a>. It’s a long read.</em></p>
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<p>It may seem paradoxical, but dying can be a deeply creative process.</p>
<p>Public figures, authors, artists and journalists have long written about their experience of dying. But why do they do it and what do we gain?</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/on-poetry-and-pain-80273">On poetry and pain</a>
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<p>Many stories of dying are written to bring an issue or disease to public attention.</p>
<p>For instance, English editor and journalist Ruth Picardie’s description of terminal breast cancer, so poignantly described in <a href="https://www.goodreads.com/en/book/show/424646.Before_I_Say_Goodbye">Before I say Goodbye</a>, drew attention to the impact of medical negligence, and particularly misdiagnosis, on patients and their families.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=892&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=892&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=892&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1121&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1121&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312716/original/file-20200130-41481-6o52kl.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1121&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
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<span class="caption">English editor and journalist Ruth Picardie’s description of terminal breast cancer drew attention to the impact of medical negligence and misdiagnosis.</span>
<span class="attribution"><span class="source">Penguin Books</span></span>
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</figure>
<p>American tennis player and social activist Arthur Ashe wrote about his heart disease and subsequent diagnosis and death from AIDS in <a href="https://www.goodreads.com/book/show/698054.Days_of_Grace">Days of Grace: A Memoir</a>. </p>
<p>His autobiographical account brought public and political attention to the risks of blood transfusion (he acquired HIV from an infected blood transfusion following heart bypass surgery). </p>
<p>Other accounts of terminal illness lay bare how people navigate uncertainty and healthcare systems, as surgeon Paul Kalanithi did so beautifully in <a href="https://www.goodreads.com/book/show/25899336-when-breath-becomes-air">When Breath Becomes Air</a>, his account of dying from lung cancer.</p>
<p>But, perhaps most commonly, for artists, poets, writers, musicians and journalists, dying can provide <a href="https://www.goodreads.com/book/show/25733900-the-violet-hour">one last opportunity for creativity</a>.</p>
<p>American writer and illustrator Maurice Sendak drew people he loved as they were dying; founder of psychoanalysis Sigmund Freud, while in great pain, refused pain medication so he could be lucid enough to think clearly about his dying; and author Christopher Hitchens <a href="https://books.google.com.au/books/about/Hitch_22.html?id=H6nbV6nLcWcC&redir_esc=y">wrote about</a> dying from <a href="https://www.cancer.org.au/about-cancer/types-of-cancer/oesophageal-cancer.html">oesophageal cancer</a> despite increasing symptoms:</p>
<blockquote>
<p>I want to stare death in the eye. </p>
</blockquote>
<p>Faced with terminal cancer, renowned neurologist Oliver Sacks wrote, if possible, more prolifically than before.</p>
<p>And Australian author Clive James found dying a mine of new material:</p>
<blockquote>
<p>Few people read</p>
<p>Poetry any more but I still wish</p>
<p>To write its seedlings down, if only for the lull</p>
<p>Of gathering: no less a harvest season</p>
<p>For being the last time.</p>
</blockquote>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/vale-clive-james-a-marvellous-low-voice-whose-gracious-good-humour-let-others-shine-127992">Vale Clive James – a marvellous low voice whose gracious good humour let others shine</a>
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<p>Research shows what dying artists have told us for centuries – creative self-expression is core to their sense of self. So, creativity has <a href="https://www.headspace.com/blog/2017/04/18/grief-creativity-together/">therapeutic and existential benefits</a> for the dying and their grieving families.</p>
<p>Creativity <a href="https://onlinelibrary.wiley.com/doi/abs/10.1002/jocb.171">provides</a> a buffer against anxiety and negative emotions about death.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=708&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=708&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=708&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=890&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=890&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312717/original/file-20200130-41554-1ntw9r6.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=890&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Cartoonist Miriam Engelberg chose a graphic novel to communicate her experience of cancer.</span>
<span class="attribution"><span class="source">Harper Perennial</span></span>
</figcaption>
</figure>
<p>It may help us make sense of events and experiences, tragedy and misfortune, as a graphic novel did for cartoonist Miriam Engelberg in <a href="https://www.harpercollins.com/9780060789732/cancer-made-me-a-shallower-person/">Cancer Made Me A Shallower Person</a>, and as <a href="https://books.google.com.au/books?hl=en&lr=&id=MkcGiLeATe8C&oi=fnd&pg=PP2&dq=%5BCarla+Sofka+and+Illene+Cupit+(eds)++Dying,+Death,+and+Grief+in+an+Online+Universe:+For+Counselors+and+Educators,+Springer+2012&ots=vdXYa_3cvU&sig=Od3eQ4A7_hadLwgIn4liIEoyo5c&redir_esc=y#v=onepage&q=%5BCarla%20Sofka%20and%20Illene%20Cupit%20(eds)%20%20Dying%2C%20Death%2C%20and%20Grief%20in%20an%20Online%20Universe%3A%20For%20Counselors%20and%20Educators%2C%20Springer%202012&f=false">blogging and online writing</a> does for so many.</p>
<p>Creativity may give voice to our experiences and provide some resilience as we face disintegration. It may also provide agency (an ability to act independently and make our own choices), and a sense of normality.</p>
<p>French doctor Benoit Burucoa <a href="https://www.cairn.info/article.php?ID_ARTICLE=INKA_181_0005">wrote</a> art in palliative care allows people to feel physical and emotional relief from dying, and:</p>
<blockquote>
<p>[…] to be looked at again and again like someone alive (without which one feels dead before having disappeared).</p>
</blockquote>
<h2>A way of communicating to loved ones and the public</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=982&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=982&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=982&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1234&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1234&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312718/original/file-20200130-41481-b1213u.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1234&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">American tennis player and social activist Arthur Ashe wrote about his heart disease and subsequent diagnosis and death from AIDS.</span>
<span class="attribution"><span class="source">Ballantine Books</span></span>
</figcaption>
</figure>
<p>When someone who is dying creates a work of art or writes a story, this can open up otherwise difficult conversations with people close to them.</p>
<p>But where these works become public, this conversation is also with those they do not know, whose only contact is through that person’s writing, poetry or art. </p>
<p>This public discourse is a means of living while dying, making connections with others, and ultimately, increasing the public’s “<a href="https://www.ncbi.nlm.nih.gov/pubmed/29402101">death literacy</a>”.</p>
<p>In this way, our <a href="https://www.thegroundswellproject.com/">conversations about death</a> become <a href="https://www.penguin.com.au/books/the-end-9781742752051">more normal, more accessible</a> and much richer.</p>
<p>There is no evidence reading literary works about death and dying fosters <a href="https://en.wikipedia.org/wiki/Rumination_(psychology)">rumination</a> (an unhelpful way of dwelling on distressing thoughts) or other forms of psychological harm.</p>
<p>In fact, the evidence we have suggests the opposite is true. There is plenty of <a href="http://www.artshealthandwellbeing.org.uk/appg/arts-and-palliative-care-dying-and-bereavement">evidence</a> for the positive impacts of both making and consuming art (of all kinds) at the <a href="http://www.artshealthandwellbeing.org.uk/appg-inquiry/Briefings/WWCW.pdf">end of life</a>, and specifically <a href="https://spcare.bmj.com/content/7/3/A369.2">surrounding palliative care</a>.</p>
<h2>Why do we buy these books?</h2>
<p>Some people read narratives of dying to gain insight into this mysterious experience, and empathy for those amidst it. Some read it to <a href="https://www.nytimes.com/2012/03/18/opinion/sunday/the-neuroscience-of-your-brain-on-fiction.html">rehearse</a> their own journeys to come.</p>
<p>But these purpose-oriented explanations miss what is perhaps the most important and unique feature of literature – its delicate, multifaceted capacity to help us become what philosopher <a href="https://www.newyorker.com/magazine/2016/07/25/martha-nussbaums-moral-philosophies">Martha Nussbaum</a> <a href="https://www.jstor.org/stable/pdf/2026358.pdf?seq=1">described as</a>:</p>
<blockquote>
<p>[…] finely aware and richly responsible. </p>
</blockquote>
<p>Literature can capture the <a href="https://www.theguardian.com/books/2003/apr/01/londonreviewofbooks">tragedy</a> in ordinary lives; its depictions of <a href="https://partiallyexaminedlife.com/2016/08/12/martha-nussbaum-on-emotions-ethics-and-literature/">grief, anger and fear</a> help us fine-tune what’s important to us; and it can show the <a href="https://books.google.com.au/books/about/Love_s_Knowledge.html?id=oq3POR8FhtgC">value of a unique person</a> across their whole life’s trajectory.</p>
<h2>Not everyone can be creative towards the end</h2>
<p>Not everyone, however, has the opportunity for creative self-expression at the end of life. In part, this is because increasingly we die in hospices, hospitals or nursing homes. These are often far removed from the resources, people and spaces that may inspire creative expression.</p>
<p>And in part it is because many people cannot communicate after a stroke or dementia diagnosis, or are <a href="https://www.theatlantic.com/family/archive/2019/01/how-do-people-communicate-before-death/580303/">delirious</a>, so are incapable of “<a href="https://press.princeton.edu/books/hardcover/9780691628554/last-words">last words</a>” <a href="https://www.amazon.com/Final-Gifts-Understanding-Awareness-Communications/dp/1451667256">when they die</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/what-is-palliative-care-a-patients-journey-through-the-system-82246">What is palliative care? A patient's journey through the system</a>
</strong>
</em>
</p>
<hr>
<p>Perhaps most obviously, it is also because most of us are not artists, musicians, writers, poets or philosophers. We will not come up with elegant prose in our final days and weeks, and lack the skill to paint inspiring or intensely beautiful pictures.</p>
<p>But this does not mean we cannot tell a story, using whatever genre we wish, that captures or at least provides a glimpse of our experience of dying – our fears, goals, hopes and preferences. </p>
<p>Clive James <a href="https://www.theguardian.com/books/2018/sep/01/clive-james-poem-story-mind-heading-obivion">reminded us</a>:</p>
<blockquote>
<p>[…] there will still be epic poems, because every human life contains one. It comes out of nowhere and goes somewhere on its way to everywhere – which is nowhere all over again, but leaves a trail of memories. There won’t be many future poets who don’t dip their spoons into all that, even if nobody buys the book.</p>
</blockquote><img src="https://counter.theconversation.com/content/128061/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Public figures, authors, artists and journalists have long written about their experience of dying. But why do they do it? And what do we gain?Claire Hooker, Senior Lecturer and Coordinator, Health and Medical Humanities, University of SydneyIan Kerridge, Professor of Bioethics & Medicine, Sydney Health Ethics, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1270202019-12-19T19:06:42Z2019-12-19T19:06:42ZHow a rethink of emergency care is closing the gap, one person at a time<figure><img src="https://images.theconversation.com/files/307569/original/file-20191218-11919-1epy5bl.JPG?ixlib=rb-1.1.0&rect=2%2C10%2C987%2C722&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Walpiri Transient Camp, Katherine: Western medicine can't be expected to work for disadvantaged Indigenous Australians unless housing and social disadvantage are also addressed.</span> <span class="attribution"><span class="license">Author provided</span></span></figcaption></figure><p><em>This is one of our occasional <a href="https://theconversation.com/au/topics/essays-on-health-32828">Essays on Health</a>, about one community’s attempt at closing the gap between Indigenous and non-Indigenous health in the Northern Territory. It’s a long read.</em></p>
<p>You can see <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/BriefingBook44p/ClosingGap">the gap</a> driving through the main street of Katherine in the Northern Territory.</p>
<p>The broken shop windows, the dust, the wheelchairs and crutches and bandaged bodies sing out poor health and inequity.</p>
<p>Overcrowding and homelessness are pervasive, and there is very little reprieve from the oppressive heat.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1204986670711558144"}"></div></p>
<p>Like many towns of its size, Katherine has its own hospital. Here, social and environmental determinants drive hospital attendance. </p>
<p>For instance, the town has <a href="https://www.katherinetimes.com.au/story/6419712/in-the-top-league-of-homelessness-rates-katherine-needs-a-plan/">some of the highest rates of homelessness</a> in Australia, in a jurisdiction with the <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4517.0%7E2018%7EMain%20Features%7ENorthern%20Territory%7E27">highest incarceration rates</a>, <a href="https://digitallibrary.health.nt.gov.au/prodjspui/bitstream/10137/572/1/Mortality_in_the_NT_1967_2006_web.pdf">lowest life expectancy</a> and the <a href="https://nap.edu.au/docs/default-source/resources/2018-naplan-national-report.pdf?sfvrsn=2">poorest educational outcomes</a>. The gap in Katherine is a chasm.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/three-reasons-why-the-gaps-between-indigenous-and-non-indigenous-australians-arent-closing-91561">Three reasons why the gaps between Indigenous and non-Indigenous Australians aren't closing</a>
</strong>
</em>
</p>
<hr>
<h2>Who’s who in the emergency department?</h2>
<p>The hospital is a busy place, made even more so by the <a href="https://www.mja.com.au/journal/2008/189/10/frequent-attenders-emergency-departments-linked-data-population-study-adult">emergency department frequent attenders</a> who come and go through a constantly revolving door of admission and discharge. </p>
<p>Frequent attenders fall into two broad categories.</p>
<p>Roughly one-third are very sick, wracked by illness or chronic conditions, almost all underpinned by great social challenges. Despite stereotypes, this is a group that rarely drinks alcohol. </p>
<p>By contrast, grog is a driving force for the other two-thirds, often as a direct result of alcohol and its complications. Once again, illness and social exclusion are pervasive.</p>
<p>Most frequent attenders <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern#tbox1">are Indigenous</a>. They come from <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">around 30 different tribal nations</a>, each with unique language. Most are just three or four generations away from the first wave of colonisation.</p>
<p>Just over two-thirds are homeless, a situation shaped by subtle and ongoing forces of colonisation and subsequent displacement.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/making-space-how-designing-hospitals-for-indigenous-people-might-benefit-everyone-122550">Making space: how designing hospitals for Indigenous people might benefit everyone</a>
</strong>
</em>
</p>
<hr>
<p>Only one-fifth of frequent attenders have access to a car in a town with no public transport (other than school buses). This affects people’s health in the tropics where it’s a long, hot walk from where most Indigenous people live to the pharmacy. </p>
<p>It is really no wonder more than half of frequent attenders have not taken their medicines, contributing to their presentation to the emergency department.</p>
<p>For frequent presenters to Katherine Hospital, poverty and illness go hand in hand. When you are living in an over-crowded house, and the <a href="https://www.jacanaenergy.com.au/residential/metering/prepaid_meters">A$20 power card</a> feeding the air conditioner expires on a 43°C tropical day, when your heart, lungs and kidneys are chronically malfunctioning and the insulin in the fridge slowly warms, the only free number you can call for help is “000” for an ambulance trip to hospital.</p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1206693515377467392"}"></div></p>
<p>These are some of the real-world challenges of closing the gap in Indigenous health. But these challenges can be overcome. </p>
<h2>Here’s what worked</h2>
<p>We have <a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">recently published evidence</a> of how a locally driven program can make a difference.</p>
<p>When some of the town’s most vulnerable people attend the emergency department, the program connects them to primary care and other supports. It also tackles underlying drivers of hospitalisation such as homelessness or inadequate housing.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=797&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=797&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=797&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1001&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1001&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307574/original/file-20191218-11909-8s9b4l.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1001&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">At the emergency department, people are supported to move away from inadequate housing, as well as being treated for their physical or mental illness.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>The referral point taps into a critical moment when people choose to turn up to hospital, asking for help.</p>
<p>This is an opportunity to do things differently. As such, the program re-defines “help” beyond the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5750953/">biomedical paradigm</a>, to both improve health and use limited resources more efficiently. </p>
<p>This contrasts with past approaches grounded in <a href="https://www.abc.net.au/news/2017-04-21/nt-mandatory-alcohol-rehab-has-little-health-impact-report-finds/8459998">discipline and law</a> that have failed to meaningfully help people who suffer the combined disharmony of sickness, homelessness and alcohol. </p>
<p>Among the 109 people supported in the first ten months of the program, there was a 23% reduction in emergency department presentations.</p>
<h2>More GP visits</h2>
<p>A <a href="https://grattan.edu.au/wp-content/uploads/2018/07/906-Mapping-primary-care.pdf">Grattan Institute report</a> found the most disadvantaged people living in the remotest areas are the least likely to see or have access to a GP.</p>
<p>In Katherine, many of the people presenting frequently to the emergency department with chronic diseases would benefit from being managed by their GP or other primary care provider.</p>
<p>As a result of the program, there was a 90% increase in GP attendance.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/why-the-housing-shortage-exacerbates-scabies-in-indigenous-communities-71337">Why the housing shortage exacerbates scabies in Indigenous communities</a>
</strong>
</em>
</p>
<hr>
<h2>Community support is vital</h2>
<p>The program has been developed gradually over the past five years, first with an understanding of <a href="https://www.mja.com.au/journal/2016/204/3/factors-contributing-frequent-attendance-emergency-department-remote-northern">who the hospital’s frequent attenders are</a>, and then getting the community on board. </p>
<p>Central to the program’s success is this community support. The four main partners include the hospital, the <a href="https://www.wurli.org.au/">Wurli-wurlinjang</a> local Aboriginal health service, the <a href="http://kalano.org.au/">local Aboriginal housing organisation</a> and <a href="http://www.krahrs.org.au/">Katherine Regional Aboriginal Health and Related Services</a>. </p>
<p>Other partners including the <a href="https://www.shelterme.org.au/katherine-doorways-hub">first ever homeless hub in Katherine</a> (a drop-in centre and community space for homeless people), as well as St John Ambulance, Mission Australia, Red Cross and the territory housing department.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Refugees in their own land: how Indigenous people are still homeless in modern Australia</a>
</strong>
</em>
</p>
<hr>
<h2>The harsh reality of the town camp</h2>
<p>Just off Katherine’s main drag is a patch of thick scrub that shields visitors from seeing the harsh realities of <a href="https://theconversation.com/refugees-in-their-own-land-how-indigenous-people-are-still-homeless-in-modern-australia-55183">Warlpiri Transient Camp</a>. This is where many people who frequently present to the emergency department live.</p>
<p>This <a href="https://dlghcd.nt.gov.au/town-camps/about-town-camps">“temporary” camp</a>, set up over 40 years ago, houses some of the sickest people in what is one of the sickest towns in Australia. </p>
<p>Up to 20 people live in small dwellings bursting at the seams. These structures often provide meagre refuge to people on dialysis, with failing hearts from rheumatic heart disease, and to the elderly and frail.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=640&fit=crop&dpr=1 600w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=640&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=640&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=804&fit=crop&dpr=1 754w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=804&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/307573/original/file-20191218-11924-ux1kcq.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=804&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Up to 20 people live in small dwellings bursting at the seams, some without electricity never mind air-conditioning.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Only a handful of these dwellings are air conditioned; some don’t even have electricity. Often it is sickness that drives people from ancestral lands into bigger towns like Katherine to access health services like kidney dialysis.</p>
<p>But <a href="https://www.katherinetimes.com.au/story/6434194/dialysis-patients-forced-onto-housing-waiting-list/">housing is less available than dialysis</a>. And the camp is not a destination of choice.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/want-to-improve-the-nations-health-start-by-reducing-inequalities-and-improving-living-conditions-64434">Want to improve the nation's health? Start by reducing inequalities and improving living conditions</a>
</strong>
</em>
</p>
<hr>
<p><a href="https://www.mdpi.com/1660-4601/16/22/4306/htm">Our analysis of the program</a> demonstrates some striking features of people who live in the camp and who frequently attend the emergency department.</p>
<p>First, they are very sick. Almost 10% had died before the end of the first year of the program. Participants had an average of 2.8 significant health problems, many fold higher than the <a href="https://www.aihw.gov.au/getmedia/666de2ad-1c92-4db3-9c01-1368ba3c8c98/ah16-3-3-chronic-disease-comorbidities.pdf.aspx">Australian average</a>.</p>
<p>Three out of five didn’t have reliable access to enough affordable, nutritious food. Almost one-third had chronic kidney disease, and 10% were on dialysis. Of the 11 people needing dialysis three times a week, eight met the <a href="https://www.abs.gov.au/websitedbs/censushome.nsf/home/factsheetsh">Australian Bureau of Statistics’ definition of homelessness</a>; three were living in a tent.</p>
<p>Needless to say, nowhere else in Australia is it imaginable that someone sick enough to require dialysis has to live in a tent in temperatures <a href="https://www.katherinetimes.com.au/story/6548992/tuesday-was-australias-hottest-day-ever/?cs=9397">regularly above 40°C</a>.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/explainer-what-is-chronic-kidney-disease-and-why-are-one-in-three-at-risk-of-this-silent-killer-81942">Explainer: what is chronic kidney disease and why are one in three at risk of this silent killer?</a>
</strong>
</em>
</p>
<hr>
<h2>A safe home, a working fridge and a good education</h2>
<p>Modern western medicine is the icing on the cake of a healthy and meaningful life. For people who do not have even the most fundamental building blocks of a normal urban existence, like the vast majority of people in this trial, applying western medicine is like icing a cake that has not yet been baked.</p>
<p>A safe home, a fridge that remains powered and relatively stocked, access to transport, and a good education, are ingredients that need to be slowly and systematically put together over a lifetime for western medicine to be an appropriate first step in resolving an individual health problem. </p>
<p>Applying a biomedical model of emergency care is nothing more than a very expensive band aid. But emergency departments can be structured in innovative ways to make a much bigger difference.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/to-close-the-health-gap-we-need-programs-that-work-here-are-three-of-them-91482">To close the health gap, we need programs that work. Here are three of them</a>
</strong>
</em>
</p>
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<img src="https://counter.theconversation.com/content/127020/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Simon Quilty set up and designed the project mentioned in the article.</span></em></p><p class="fine-print"><em><span>Lisa Wood evaluated the program mentioned in the article.</span></em></p>A safe home, a working fridge and access to transport are all needed before western medicine has a chance of working in the long term. But a new way of providing care can help.Simon Quilty, Senior Staff Specialist, Alice Springs Hospital. Honorary, Australian National UniversityLisa Wood, Associate Professor, School of Population and Global Health, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1257092019-11-10T18:57:09Z2019-11-10T18:57:09ZWe may one day grow babies outside the womb, but there are many things to consider first<figure><img src="https://images.theconversation.com/files/300419/original/file-20191106-88403-1g6r0ys.jpg?ixlib=rb-1.1.0&rect=1%2C4%2C997%2C744&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Researchers are developing artificial wombs as we speak. So we need to talk about the pros and cons before science fiction becomes reality.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-illustration/fetus-tank-54671101">from www.shutterstock.com</a></span></figcaption></figure><p><em>This is one of our occasional Essays on Health. It’s a long read. Enjoy!</em></p>
<p>The idea of growing babies outside the body has inspired <a href="https://daily.jstor.org/on-the-history-of-the-artificial-womb">novels and movies</a> for decades.</p>
<p>Now, research groups around the world are exploring the possibility of artificial gestation. For instance, one group <a href="https://www.nature.com/articles/ncomms15112">successfully grew</a> a lamb in an artificial womb <a href="https://www.huffingtonpost.com.au/2017/04/26/an-artificial-womb-has-successfully-grown-a-lamb-for-four-weeks_a_22055661/">for four weeks</a>. Australian researchers have also experimented with <a href="https://www.gizmodo.com.au/2019/03/artificial-wombs-are-getting-better-and-better/">artificial gestation for lambs</a> and <a href="https://www.wired.com/2011/09/artificial-shark-uterus/">sharks</a>. </p>
<p>And in recent weeks, researchers in The Netherlands <a href="https://www.theguardian.com/society/2019/oct/08/artificial-womb-dutch-researchers-given-29m-to-develop-prototype">have received €2.9m</a> (A$4.66m) to develop a prototype for gestating premature babies.</p>
<p>So it’s important to consider some of the ethical issues this technology might bring.</p>
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<strong>
Read more:
<a href="https://theconversation.com/from-frozen-ovaries-to-lab-grown-babies-the-future-of-childbirth-59912">From frozen ovaries to lab-grown babies: the future of childbirth</a>
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<h2>What is an artificial womb?</h2>
<p>Growing a baby outside the womb is known as ectogenesis (or exogenesis). And we’re already using a form of it. When premature infants are transferred to humidicribs to continue their development in a neonatal unit, that’s partial ectogenesis.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300421/original/file-20191106-88382-e2xvkf.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">When premature infants are transferred to humidicribs to continue their development in a neonatal unit, that’s partial ectogenesis.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/incubator-sick-newborn-baby-neonatal-intensive-1532105090">from www.shutterstock.com</a></span>
</figcaption>
</figure>
<p>But an artificial womb could extend the period a fetus could be gestated outside the body. Eventually we might be able to do away with human wombs altogether.</p>
<p>This may sound far-fetched, but many scientists working in reproductive biotechnology believe that with the necessary scientific and legal support, full ectogenesis is a real possibility for the future.</p>
<h2>What would an artificial womb contain?</h2>
<p>An artificial womb would need an outer shell or chamber. That’s somewhere to implant the embryo and protect it as it grows. So far, animal experiments have used <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/zoo.2042">acrylic tanks</a>, <a href="https://onlinelibrary.wiley.com/doi/pdf/10.1002/zoo.2042">plastics bags</a> and uterine tissues removed from an organism and artificially kept alive.</p>
<p>An artificial womb would also need a synthetic replacement for amniotic fluid, a shock absorber in the womb during natural pregnancy. </p>
<p>Finally, there would have to be a way to exchange oxygen and nutrients (so oxygen and nutrients in and carbon dioxide and waste products out). In other words, researchers would have to build an <a href="https://www.ncbi.nlm.nih.gov/pubmed/811007">artificial placenta</a>. </p>
<p>Animal experiments have used complex <a href="https://www.newscientist.com/article/mg13418180-400-japanese-pioneers-raise-kid-in-rubber-womb">catheter and pump systems</a>. But there are plans to use a mini version of <a href="https://www.mja.com.au/journal/2009/191/3/extracorporeal-membrane-oxygenation">extracorporeal membrane oxygenation</a>, a technique that allows blood to be oxygenated outside the body.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-business-of-ivf-how-human-eggs-went-from-simple-cells-to-a-valuable-commodity-119168">The business of IVF: how human eggs went from simple cells to a valuable commodity</a>
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<p>Once these are in place, artificial gestation could one day <a href="https://www.sciencedaily.com/releases/2018/07/180703084127.htm">become as common as IVF</a> is today, a technique <a href="https://www.theguardian.com/society/2013/jul/12/story-ivf-five-million-babies">considered revolutionary</a> a few decades ago. </p>
<p>And just as in the case of IVF, there are many who are concerned about what this new realm of reproductive medicine might mean for the future of creating a family.</p>
<p>So what are some of the ethical considerations?</p>
<h2>Artificial wombs could help premature babies</h2>
<p>The main discussion about artificial wombs has focused on their potential benefit in increasing the survival rate of extremely premature babies. </p>
<p><a href="https://jme.bmj.com/content/44/11/75">Currently</a>, those born earlier than 22 weeks gestation have little-to-no hope of survival. And those born at 23 weeks are likely to suffer a range of disabilities. </p>
<p>Using a sealed “<a href="https://www.theguardian.com/science/2017/apr/25/artificial-womb-for-premature-babies-successful-in-animal-trials-biobag">biobag</a>”, which mimics the maternal womb might help extremely premature babies survive and improve their quality of life.</p>
<p>A biobag provides oxygen, a type of substitute amniotic fluid, umbilical cord access and all necessary water and nutrients (and medicine, if required). This could potentially allow the gestational period to be prolonged outside the womb until the baby has developed sufficiently to live independently and with good health prospects.</p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/dt7twXzNEsQ?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Premature lambs survived for four weeks in a ‘biobag’ at the Children’s Hospital of Philadelphia (Tech Insider/YouTube).</span></figcaption>
</figure>
<p>An artificial womb might provide an optimum environment for the fetus to grow, providing it with the appropriate balance of hormones and nutrients. It would also avoid exposing the growing fetus to external harms such as infectious diseases. </p>
<p>The technology might also make it easier to <a href="https://academic.oup.com/medlaw/advance-article/doi/10.1093/medlaw/fwz014/5510054?fbclid=IwAR1WMf6ZzWD5YgbQZBWHNDuCznVrNEMnL-a-8mlhrTb7Ar_jhWVBBb2rk5">perform surgery on the fetus</a> if needed.</p>
<p>And it could see the end of long-term hospital stays for premature infants, saving health care dollars in the process. This is particularly noteworthy considering some of the <a href="https://www.medibank.com.au/livebetter/newsroom/post/medibank-reveals-its-most-expensive-claims">largest private insurance payments</a> are currently for neonatal intensive care unit expenses.</p>
<h2>Artificial wombs could help with infertility and fertility</h2>
<p>This emerging reproductive technology may allow women who are infertile, either due to <a href="https://www.theguardian.com/lifeandstyle/2017/sep/04/artifical-womb-women-ectogenesis-baby-fertility">physiological or social reasons</a>, with the chance of having a child. It may also offer opportunities for transgender women and other women born without a uterus, or those who have lost their uterus due to cancer, injury or medical conditions, to have children. </p>
<p>Similarly, it could allow single men and gay male couples to become parents without needing a surrogate.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300423/original/file-20191106-88372-iwxt0d.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Artificial wombs could allow gay men to become parents without needing a surrogate.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/gay-couple-using-laptop-kitchen-522801235">from www.shutterstock.com</a></span>
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</figure>
<p>Will this lead to a broader discussion about <a href="https://www.theguardian.com/commentisfree/2017/may/01/artificial-womb-gender-family-equality-lam">gender roles and equality</a> in reproduction? Will it remove potential risks and expectations of pregnancy and childbirth currently only affecting women? Will this eliminate commercial surrogacy? </p>
<p>Equally, artificial wombs could help fertile women who for health or personal reasons choose not to be pregnant. It would allow those whose career choices, medication or lifestyle might otherwise expose a developing fetus to malformation or abnormality. </p>
<h2>Artificial wombs may harm women, reinforce inequality and lead to discrimination</h2>
<p>The prospect of artificial wombs might offer hope for many, but it also highlights a number of potential hazards.</p>
<p>For some women, using an artificial womb for gestation to continue might seem like a welcome alternative to terminating a pregnancy. But there are fears that other women thinking about an abortion might be compelled to use an artificial womb to continue gestation.</p>
<p>Whether artificial wombs should be allowed to influence a woman’s right to choose <a href="https://www.ncbi.nlm.nih.gov/pubmed/2904469">is already under debate</a>.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whats-mothers-day-if-youve-been-born-in-a-machine-and-raised-by-robots-58631">What's Mother's Day if you've been born in a machine and raised by robots?</a>
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<p>Artificial wombs might also further increase the gap between rich and poor. Wealthy prospective parents may opt to pay for artificial wombs, while poorer people will rely on women’s bodies to gestate their babies. Existing disparities in nutrition and exposure to pathogens between pregnancies across socio-economic divides could also be exacerbated.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=504&fit=crop&dpr=1 754w, https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=504&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/300425/original/file-20191106-88394-g7i272.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=504&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
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<span class="caption">Artificial wombs might further increase the gap between rich and poor.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/image-gap-between-rich-poor-1108746449">from www.shutterstock.com</a></span>
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</figure>
<p>This raises issues of distribution of access. Will artificial wombs receive government funding? If it does, who should decide who gets subsidised access? Will there be a threshold to meet? </p>
<p>Other issues concern potential discrimination individuals born via an artificial womb may face. How do we prevent discrimination or invasive publicity and ensure individuals’ origin stories are not subject to negative public curiosity or ridicule?</p>
<p>Others might consider artificial wombs to be deeply repugnant and fundamentally against the natural reproductive order.</p>
<h2>Preparing for future wombs</h2>
<p>Currently, there is no prototype of an artificial womb for humans. And the technology is very much in its infancy. Yet we do need to consider ethical and legal issues before rushing headlong into this reproductive technology.</p>
<p>Not only do we need to ensure the technology is safe and works, we need to consider whether it’s the right path to take for different circumstances.</p>
<p>It might be easier to defend using artificial wombs in emergency situations, such as saving the lives of extremely premature neonates. However, using them in other circumstances might need broader social and policy considerations.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-must-develop-techno-wisdom-to-prevent-technology-from-consuming-us-91656">We must develop 'techno-wisdom' to prevent technology from consuming us</a>
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<p>Without first establishing clear regulatory and ethico-legal frameworks, the development and release of artificial wombs could be problematic. We need to clearly outline pregnancy termination rights, parenthood and guardianship issues, limitations to experimentation, and other issues before the technology is fully realised and available. We need to do this soon rather than allowing the law to lag behind the science. </p>
<p>We recommend:</p>
<ul>
<li><p>approved protocols for testing artificial wombs that gradually extend the gestation period </p></li>
<li><p>funding that prevents discrimination on socio-economic grounds. This might be in the form of government funding to ensue a wide range of groups have access to the technology </p></li>
<li><p>clear legal guidelines for the status of ectogenetic embryos and fetuses, including what happens if prospective parents die, divorce or disagree on how to proceed</p></li>
<li><p>guidelines for access that calm public fears about misuse of emerging reproductive technologies.</p></li>
</ul>
<p>It is easy to get carried away with visions of utopian or dystopian societies. As radical and futuristic as artificial wombs might sound, it is important to pause and reflect on the present. </p>
<p>While this technology may solve some existing problems concerning inequality in reproduction, there are many other issues that demand our immediate attention.</p>
<p>Improving maternal health services, equal opportunity in the workplace, and reducing the impact of poor social determinants of health on fetal outcomes are all pressing concerns we must address now before we can consider what the future of reproductive biotechnology might hold.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/where-we-come-from-determines-how-we-fare-the-fetal-origins-of-adult-disease-3581">Where we come from determines how we fare – the fetal origins of adult disease</a>
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<img src="https://counter.theconversation.com/content/125709/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The authors do not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and have disclosed no relevant affiliations beyond their academic appointment.</span></em></p>Yes, there are pros and cons of this new reproductive technology. But there are many other issues about maternal and child health we need to tackle first.Neera Bhatia, Associate Professor in Law, Deakin UniversityEvie Kendal, Lecturer in Bioethics and Health Humanities, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/779432017-09-11T19:41:21Z2017-09-11T19:41:21ZEssays on health: Australia is failing new parents with conflicting advice – it’s urgent we get it right<figure><img src="https://images.theconversation.com/files/181928/original/file-20170814-28487-1h0x1q.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Much of the baby's distress, as well as that of the parents, can be prevented.</span> <span class="attribution"><a class="source" href="https://unsplash.com/search/photos/baby?photo=EpbIXGCrtK0">Janko Ferlič/Unsplash</a></span></figcaption></figure><p>Every year, hundreds of thousands of Australians embark on a disorienting, life changing journey. They have a baby.</p>
<p>What happens after a woman gives birth should be a matter of serious public interest. Screaming babies, breast pain, baby weight-gain worries, breastfeeding issues, wind, colic, reflux, allergies, tongue tie, sleep deprivation, and parental anxiety and depression. These are common concerns at the beginning of the life of every Australian citizen. </p>
<p>In reflecting on these, we’re actually considering the developmental origins of disease. This is so for many reasons, including that the infant gut microbiome <a href="https://www.ncbi.nlm.nih.gov/pubmed/26663826">affects</a> metabolism and immunity even as an adult, and that postnatal depression has <a href="https://www.ncbi.nlm.nih.gov/pubmed/25455250">long-term effects</a> on a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4412485/">child’s cognitive potential and mental health.</a></p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/gut-instinct-how-the-way-youre-born-and-fed-affect-your-immune-system-65104">Gut instinct: how the way you're born and fed affect your immune system</a>
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<p>Throughout the developed world, <a href="https://www.health.gov.au/internet/main/publishing.nsf/Content/AFF3C1C460BA5300CA257BF0001A8D86/$File/NFUCFHS.PDF">non-communicable diseases</a> are now the <a href="http://adc.bmj.com/content/early/2016/08/29/archdischild-2016-310991">major cause of illness</a> and death in children, mirroring trends in adults. Among these, immune, gut, developmental disorders and mental illness feature prominently. All are shaped by environmental factors in very early life.</p>
<p>Yet, our health professionals often recommend approaches to behaviour problems in infants - such as with <a href="https://www.ncbi.nlm.nih.gov/pubmed/27286289">breastfeeding</a>, <a href="https://www.ncbi.nlm.nih.gov/pubmed/24372749">crying</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26257315">fussing</a>, or <a href="https://www.ncbi.nlm.nih.gov/pubmed/26555938">sleep</a> - that have been demonstrated to be ineffective. Some <a href="https://www.ncbi.nlm.nih.gov/pubmed/23905907">recommendations</a> actually <a href="https://www.ncbi.nlm.nih.gov/pubmed/26895966">risk worse health outcomes</a> for both the mother and baby.</p>
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<img alt="" src="https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=406&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=406&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=406&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=510&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=510&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179928/original/file-20170727-32584-1v89fu2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=510&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">What happens after a woman gives birth is a matter of serious public interest.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>From the moment their baby is born, Australian parents receive vastly conflicting advice from <a href="https://www.ncbi.nlm.nih.gov/pubmed/22951297">different health disciplines</a>, or even from different health professionals in the one discipline. Confusion during an already challenging life transition drives parents to seek <a href="https://www.ncbi.nlm.nih.gov/pubmed/21679331">opinions from multiple providers</a>: the GP, paediatrician, midwife, child health nurse, pharmacy nurse, lactation consultant, dentist (yes dentist), and the emergency department. Many visit complementary and alternative medicine practitioners.</p>
<p>Yet <a href="https://www.mja.com.au/journal/2016/205/2/prioritising-general-practice-research">less than 2%</a> of the National Health and Medical Research Council funding goes to research into primary care, the first port of call for new parents. Research performed in hospitals or specialised settings, including concerning issues of early life care, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4221610/">often isn’t relevant in the community</a>. We must take primary care research seriously if we want to ensure parents are provided with consistent, evidence-based advice that is beneficial to the baby, themselves and society at large.</p>
<h2>Breastfeeding confusion</h2>
<p>Up to <a href="http://www.health.gov.au/breastfeeding">96% of Australian women</a> want to breastfeed at the time of the birth. Women want to breastfeed so much that not being able to do so <a href="https://www.ncbi.nlm.nih.gov/pubmed/25305429">affects their mental health</a>. Yet multiple studies demonstrate <a href="https://www.ncbi.nlm.nih.gov/pubmed/25864129">serious gaps</a> in health professional training in the two most common post-birth problems: <a href="https://www.ncbi.nlm.nih.gov/pubmed/28167998">breastfeeding difficulty</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/22951297">unsettled</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26257315">infant</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/24372749">behaviour</a>. Both <a href="https://www.ncbi.nlm.nih.gov/pubmed/25305429">increase</a> a woman’s <a href="https://www.ncbi.nlm.nih.gov/pubmed/19432839">risk of postnatal depression</a> and are <a href="http://www.bmj.com/content/343/bmj.d7772">linked with</a> <a href="https://www.ncbi.nlm.nih.gov/pubmed/26869575">poorer infant outcomes</a>.</p>
<p>Undiagnosed problems with the baby latching on to the breast and finding a stable position during breastfeeding (which I call “fit and hold”) can lead to a range of distressing infant behaviours. These include back arching, refusing or fussing at the breast, crying, poor weight gain and excessive night waking. These signs of positional instability are often thought to be signs of reflux and <a href="https://www.ncbi.nlm.nih.gov/pubmed/23495859">treated with acid medications</a>. But evidence shows these medications <a href="https://www.ncbi.nlm.nih.gov/pubmed/25556017">don’t help</a> the problem.</p>
<p>Existing approaches used to support fit and hold, including letting the baby find their own way to the breast, don’t <a href="https://www.ncbi.nlm.nih.gov/pubmed/27286289">improve outcomes</a> for many. Common advice, such as using one hand on the back of the baby’s neck while the other creates a particular shape of the breast, has been shown to <a href="https://www.ncbi.nlm.nih.gov/pubmed/26895966">increase nipple pain</a>. </p>
<p>I commonly see women who have been told by multiple professionals their fit and hold is good, even though the <a href="https://www.ncbi.nlm.nih.gov/pubmed/24075595">baby’s behaviour communicates</a> inability to fit stably into the mother’s body. That is, the baby is showing their <a href="https://www.ncbi.nlm.nih.gov/pubmed/18243594">position is uncomfortable</a> or there is a drag of breast tissue pulling in another direction in the baby’s mouth, in conflict with the inward pull created by the <a href="https://www.ncbi.nlm.nih.gov/pubmed/26928319">vacuum when the jaw drops</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=338&fit=crop&dpr=1 600w, https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=338&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=338&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=424&fit=crop&dpr=1 754w, https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=424&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/183593/original/file-20170828-1539-1afavwj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=424&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Australian mothers need more support to breastfeed.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Oral tie ‘epidemic’</h2>
<p>Then there’s the issue with tongue tie, upper lip tie, and buccal (cheek to gum) tie. This is another way health professionals are dealing with breastfeeding problems and unsettled behaviour – by referring the child for oral surgery. A classic tongue-tie needs a simple scissors snip. But normal <a href="http://www.pameladouglas.com.au/sites/default/files/pdfs/Douglas%20BFM%202013.pdf">variations of the frenulum</a> - the bits of connective tissue under the tongue and upper lip - are these days <a href="https://www.smartspeechtherapy.com/wp-content/uploads/2017/04/Three-experienced-lactation-consultants-reflect-upon-the-oral-tie-phenomenon.pdf">often labelled abnormal</a> and blamed for problems. </p>
<p>If we put aside the situation of a classic tongue-tie, the belief cutting or lasering the frenula (called a frenotomy) helps breastfeeding is <a href="http://www.cochrane.org/CD011065/NEONATAL_surgical-release-tongue-tie-treatment-tongue-tie-young-babies">not supported by research</a>. <a href="https://www.ncbi.nlm.nih.gov/pubmed/28614671">Our work</a> suggests that diagnoses of normal variants of connective tissue as abnormal are based on an <a href="https://www.ncbi.nlm.nih.gov/pubmed/26928319">outdated and inaccurate</a> model of how infants attach to the breast.</p>
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Read more:
<a href="https://theconversation.com/deep-cuts-under-babies-tongues-are-unlikely-to-solve-breastfeeding-problems-54040">Deep cuts under babies' tongues are unlikely to solve breastfeeding problems</a>
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<p>Parents are <a href="http://tonguetie.net/consequences/">sometimes warned</a> if the baby doesn’t have a frenotomy for the diagnoses of posterior tongue-tie or upper lip-tie, their baby is at risk of speech and swallowing problems, expensive orthodontic problems, sleep disorders and other developmental problems in later childhood, though <a href="http://pediatrics.aappublications.org/content/early/2015/04/28/peds.2015-0658">there is no evidence</a> to support these claims. </p>
<p>There are now studies demonstrating that the diagnosis of “oral ties” in breastfeeding babies has reached epidemic proportions in the <a href="https://www.ncbi.nlm.nih.gov/pubmed/28168891">United States</a> and <a href="https://www.ncbi.nlm.nih.gov/pubmed/27280112">Canada</a>. Exponential increases in frenotomy rates are also evident in our team’s analysis of early Australian Medicare data (yet to be published). Many, if not most, frenotomies are <a href="https://www.smartspeechtherapy.com/wp-content/uploads/2017/04/Three-experienced-lactation-consultants-reflect-upon-the-oral-tie-phenomenon.pdf">performed by dentists</a> using laser, and are not captured by Medicare. </p>
<p>I regularly see <a href="https://griffithreview.com/articles/tongues-tied-about-tongue-tie/">babies after laser surgery</a> with worsened breastfeeding problems. Sometimes their <a href="http://onlinelibrary.wiley.com/doi/10.1111/jpc.12773/abstract">wounds become infected</a>. I often see pale cords of scarred tissue under the tongue. I have also seen the underbelly of a little tongue somewhat separated by a too-deep cut. I have seen suture knots hanging from a newborn’s upper gum after scissors frenotomy. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=487&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=487&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=487&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=612&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=612&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179936/original/file-20170727-30152-1bs39l4.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=612&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Breastfeeding problems are often blamed on the baby’s frenulum - the bit of connective tissue under the tongue and upper lip.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The tongue-tie epidemic hasn’t come from a sudden burst of new congenital abnormalities in the mouths of infants in the English-speaking world in the past ten years, as <a href="http://mthfr.net/the-intersection-of-tongue-tie-mthfr/2014/05/23/">some proponents argue</a>. The epidemic parallels broader <a href="http://www.thelancet.com/journals/lancet/article/PIIS0140-6736(16)32585-5/abstract">international trends of medical overtreatment</a> and is, in my mind, a painful sign clinical breastfeeding support is in crisis.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/how-to-rein-in-the-widening-disease-definitions-that-label-more-healthy-people-as-sick-76804">How to rein in the widening disease definitions that label more healthy people as sick</a>
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<h2>The importance of sleep</h2>
<p>Parents are also being advised their child’s healthy development and their own wellbeing depends on implementing sleep training. This includes strategies such as: don’t breastfeed your baby to sleep; don’t let the baby get overtired or overstimulated; put the baby down in the cot at the first tired sign; teach the baby to self-settle in the cot; make sure the baby is getting big blocks of sleep instead of catnapping during the day; and use feed-play-sleep cycles. </p>
<p>Technically known as <a href="http://www.pameladouglas.com.au/sites/default/files/pdfs/Whittingham2014_Optimising%20parent-infant%20sleep%20from%20birth%20to%206%20months%20a%20new%20paradigm.pdf">first wave behaviourism</a>, these approaches arose in the 1950s and 1960s. Girls like me were taught them in the 1970s in compulsory mothercraft classes at high school – a long time before the emergence of evidence-based medicine. </p>
<p>But now, <a href="https://www.nhmrc.gov.au/book/promoting-social-and-emotional-development-and-wellbeing-infants-nhmrc-report-evidence-5">high-level evidence</a> demonstrates these approaches do not <a href="http://www.smrv-journal.com/article/S1087-0792(15)00100-8/abstract">decrease night waking</a> or reliably improve women’s mental wellbeing in the first year of life, and especially not in the <a href="http://www.pameladouglas.com.au/sites/default/files/pdfs/Douglas_Hill%20JDBP%20%2023_9_13.pdf">first six months</a>. </p>
<p>A <a href="http://onlinelibrary.wiley.com/doi/10.1111/bjep.12109/abstract">small subgroup of babies</a> with sleep problems go on to have sleep problems in later childhood. The evidence <a href="https://www.ncbi.nlm.nih.gov/pubmed/22748447">does not support</a> the idea that applying sleep training in the first year will prevent this, yet I hear parents are often told if the baby doesn’t get enough sleep, or if they let “bad habits” grow, their baby’s development and capacity to learn in later childhood will suffer. The threat they are doing the wrong thing if they don’t sleep train <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4934563/">heightens parental anxiety</a>.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/179915/original/file-20170727-28585-akghxu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Parents are advised their baby’s healthy development depends on implementing conventional sleep strategies.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/search/sleeping-baby?photo=WCbCRXk7nmU">Carlo Navarro/Unsplash</a></span>
</figcaption>
</figure>
<p>In my experience in general practice, where I’ve had the privilege of following many families over months and years, first wave behavioural approaches cause parent-baby communication confusion, and also unnecessarily disrupted nights for many, due to <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4312214/">disruption of the baby’s circadian clock</a>. </p>
<p>In Australia, many sleep-deprived mothers seek help from <a href="https://www.stayathomemum.co.uk/my-kids/behaviour/sleep-schools-in-australia">residential sleep schools</a>. Some are even referred there by health professionals if the baby just <a href="http://www.saveoursleep.com.au/free-reading/triggers-sleep-problems/">catnaps during the day</a> and doesn’t go to sleep alone in the cot, due to fear of developmental implications. Yet only families with the most severe problems should require this hospital-based solution, which is extremely expensive to the health system. </p>
<h2>So, what are the solutions?</h2>
<p>We have enough evidence to show what works. For instance, <a href="http://www.cppah.com/article/S1538-5442(11)00049-6/pdf">latest research</a> tells us it is important to respond to our baby’s cues for the baby to develop secure psychological attachment. Babies should not be left to <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0113571">grizzle or cry</a> as a pattern over time, and breastfeeding to sleep is one sensible tool for making the days and nights manageable. </p>
<p>It’s also important to know about the young human’s biological need for <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3223372/">rich sensory nourishment</a>. This means encouraging parents to enjoy a social life outside the house, trusting that the baby’s biological sleep regulators will take whatever sleep he or she needs with minimal effort on the parent’s part.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/185407/original/file-20170911-9406-gh0c5l.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Parents should trust the child’s natural sleep sensors will kick in when he or she is tired.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>We’ve developed an <a href="https://education.possumsonline.com/sleep-film">alternative parent-baby sleep program</a>. This repairs <a href="http://www.pameladouglas.com.au/sites/default/files/pdfs/Whittingham2014_Optimising%20parent-infant%20sleep%20from%20birth%20to%206%20months%20a%20new%20paradigm.pdf">unnecessary disruption to night-time sleep</a> either by identifying underlying breastfeeding problems in younger babies, or by helping to reset the circadian clock, which is commonly disrupted by the first wave behavioural focus on long blocks of sleep during the day. </p>
<p>And breastfeeding problems can resolve when women are <a href="https://www.ncbi.nlm.nih.gov/pubmed/28614671">helped to stabilise</a> the way their and their baby’s <a href="https://education.possumsonline.com/programs/gestalt-breastfeeding-online-program">unique anatomies fit together</a>. This is when the baby’s breastfeeding reflexes are turned on, his or her face is symmetrically buried into the breast, and as much breast tissue as possible is drawn deep into the baby’s mouth without a drag in another direction. </p>
<p>Our programs have a well-developed and published evidence base, and <a href="http://www.publish.csiro.au/PY/PY13011">promising preliminary evaluations</a>. Obviously, these require bigger trials. But there is too little funding available for clinical primary care research. The UK’s <a href="https://www.nuffieldtrust.org.uk/">Nuffield Trust</a> recently issued <a href="http://adc.bmj.com/content/101/12/1084">a report</a> advising that if we are to care for our children’s health needs in a sustainable health system, models need to shift the focus from hospital-based care to integrated child health care in community settings.</p>
<p>Investing in primary health care <a href="http://onlinelibrary.wiley.com/doi/10.1111/1753-6405.12348/abstract">has been demonstrated</a> to be more effective, at a fraction of the price of treating problems in hospitals. Just a single visit to an Australian hospital’s emergency department costs the tax-payer <a href="https://theconversation.com/medicare-spending-on-general-practice-is-value-for-money-33948">ten times</a> the cost of a visit to a GP. </p>
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Read more:
<a href="https://theconversation.com/medicare-spending-on-general-practice-is-value-for-money-33948">Medicare spending on general practice is value for money</a>
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<p>We can’t expect hospital-based parenting support centres to improve outcomes when mothers and babies are seen there by health professionals who continue to offer conflicting advice. It would be much cheaper and more cost effective to invest in freely accessible, evidence-based, perinatal services in a family’s own community, co-ordinated by their own GP.</p>
<p>In view of the health system costs and tsunami of mental health problems and chronic disease, this is a matter for urgent political and health system attention.</p><img src="https://counter.theconversation.com/content/77943/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dr Pamela Douglas is Medical Director of a charitable organisation, the Possums Clinic <a href="http://www.possumsonline.com">www.possumsonline.com</a> (Possums for Mothers and Babies Ltd). Possums Education sells two educational products online, the Gestalt Breastfeeding Online Program and the Possums Sleep Film (also available as a DVD). All proceeds are invested into the development of further educational materials.</span></em></p>From the moment their baby is born, Australian parents receive conflicting advice on how to cope with newborn issues. What we are doing wastes our resources, but we’re not investing in alternatives.Pamela S Douglas, General Practitioner, Researcher, The University of QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/791162017-07-03T20:08:20Z2017-07-03T20:08:20ZEssays on health: microbes aren’t the enemy, they’re a big part of who we are<figure><img src="https://images.theconversation.com/files/176532/original/file-20170703-751-b3kd8o.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Modern diets are changing the compositions of our gut microbiota, and with that, our personalities.</span> <span class="attribution"><span class="source">from shutterstock.com</span></span></figcaption></figure><p>We have long believed that “good” immune cells recognise and defend against “bad” invaders. That’s why a large proportion of medicine has been directed at killing microbial enemies and conquering microbial infections. </p>
<p>This militaristic understanding of immunity reflected the culture of the 20th century, which was dominated by nation building and world wars between “us” and “them.” It was a time when “survival of the fittest” came to be seen as the driver of evolution and competition and war were considered a natural part of what it is to be human.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=581&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=581&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=581&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=730&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=730&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176159/original/file-20170629-6546-1dm1dn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=730&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There are millions of microorganisms in our gut.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>But a radical shift in understanding the relationship between humans and microorganisms occurred with the discovery that only <a href="http://www.biorxiv.org/content/early/2016/01/06/036103">50% of the cells in our bodies are human</a>. The rest are microbes, such as bacteria, yeasts (members of the fungus family), viruses, and even insects. Together, these make up the microbiome.</p>
<p>The 23,000 genes that comprise the human genome pale in comparison with the <a href="http://onlinelibrary.wiley.com/doi/10.1111/j.1753-4887.2012.00493.x/abstract">3.3 million genes</a> in the microbes that live in our guts. These produce proteins that help us digest food and support our immune systems. </p>
<p>Through the gut-brain axis, these genes even <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4259177/">influence mood and memory</a>. The gut-brain axis is a set of communication pathways between the gut and brain occurring largely through the actions of the gut microbiome.</p>
<p>Because we have evolved with microorganisms inside us, we now have specialised communities in our guts, on our skin, and in our mouths. Our microbes are understood to be so critical to our existence, <a href="http://www.publish.csiro.au/ma/pdf/MA15005">many scientists</a> consider us to be symbiotic organisms, made up of the host, the microbiome and the environment. This holy trinity is what they call the “holobiont”. </p>
<p>Considering human life as a function of the microbiome and our environment allows us to acknowledge that we may be affected by entities that harbour different evolutionary needs. For example, our food choices don’t just affect human health through nutrients and caloric balance, but also through their impacts on the gut microbiome.</p>
<h2>Microbes and diet</h2>
<p>The food we eat feeds our gut microbes and directly impacts their survival. Within two days of changing diet, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3957428/">our gut species change</a>. Different gut bacteria thrive on different diets. For instance, <em>Prevotella</em> strains consume carbohydrates while <em>Bacteroidetes</em> prefer some fats, and <em>Candida</em> prefer glucose over protein. So, some species starve and others thrive based on what we eat.</p>
<p>The species in ours guts are also proving to be relevant to health and disease. <em>Prevotella</em>, for instance, has been <a href="http://www.sciencedirect.com/science/article/pii/S1550413115005173#undfig1">linked to improved glucose tolerance</a> and is much more prevalent in the guts of <a href="https://www.nature.com/articles/ncomms4654?WT.ec_">hunter-gatherer societies</a> (such as the Hadza people in Tanzania) than those in Western societies. The reduction of <em>Prevotella</em> in gut-bacteria in Western populations is thought to partially explain modern epidemics such as diabetes and obesity. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=390&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=390&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=390&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=490&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=490&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176533/original/file-20170703-751-t7q3vu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=490&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">The Hadza people of Tanzania have a much higher prevalence of glucose-tolerating Prevotella bacteria in their guts than those in Western societies.</span>
<span class="attribution"><a class="source" href="https://www.flickr.com/photos/woodlouse/3990736265/in/photolist-75DyRF-25aGVc-75HnHQ-bsmuJX-8qR7Jy-8qR9q3-bsmf9R-pixAaV-8qR1Af-8qR2ZQ-8qMWtt-8qQXah-8qQYs5-bsmvjn-8qR8wS-8qR5vW-8qQWy3-8qMYRn-75Hmyo-8qMST6-bsmqkc-5USDw8-bsmnVe-8qMZxz-bsmpHP-bsm7ov-5UX4so-8qR4BL-5UWV3u-5USuFK-5USqw2-bsmtAP-5USrkr-5UWS1J-5UWX6W-5USFjK-bsmt3X-bsmycg-bsmdop-bsmeET-5UWW4A-bsmuqH-5UWMEY-bsm8AV-5USB3F-bsmmHT-bsm6kk-5USpd4-bsmvPt-5UWYTS">Woodlouse/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>It shouldn’t surprise us then, that microbes can shape our food choices to ensure their own survival. Some metabolites, the small byproducts of microbial digestion, can make us feel hungry, full or crave certain foods. However, the evidence in humans is so far somewhat circumstantial. A study of chocolate-craving and chocolate-indifferent people <a href="http://pubs.acs.org/doi/abs/10.1021/pr070431h">found different microbial metabolites</a> in their urine, suggesting different bacteria were present in the gut. </p>
<p>Metabolites are important in terms of function, because we know these can send signals to the brain. Signals to regulate eating behaviour are also transmitted via the vagus nerve that runs between the brain and the gut. At least two human studies have shown <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270213/">blocking the vagus nerve</a> induces weight loss in obesity, while <a href="https://www.ncbi.nlm.nih.gov/pubmed/7030452">stimulating it in rats has led to overeating</a>. </p>
<h2>Microbes and behaviour</h2>
<p>Behaviour is also a function of the holobiont, not just the human host. Some metabolites are neuroactive, which means they can travel along the gut–brain axis and affect human mood, mental health and behaviour. </p>
<p>Much of the work exploring direct microbe-related behaviour has been done in mice and rats. These studies have had some pretty interesting results though. They’ve shown that <a href="http://www.sciencedirect.com/science/article/pii/S0022395616301571">behaviour can be transferred through poo transplants</a>, that animals bred without any bacteria show <a href="https://www.ncbi.nlm.nih.gov/pubmed/21054680">unusual social and emotional behaviours</a>, and that serotonin - the brain chemical associated with mood and depression - is <a href="https://www.ncbi.nlm.nih.gov/pubmed/26805875">produced largely in the gut</a>. Together, these findings indicate a strong evidence base for the fact that the microbiome can affect host behaviour. </p>
<p>The best human evidence comes from the observed impacts of food on mood and behaviour – and microbes are the likely explanation. A good example is a study of healthy women <a href="http://www.sciencedirect.com/science/article/pii/S0016508513002928">some of whom consumed yogurt with a certain probiotic</a> for one month. The researchers had the participants lie in a functional MRI scanner while they were shown pictures of faces with different emotions. </p>
<p>Those who had received the yogurt had reduced activity in the emotional processing brain regions, suggesting a dampening of the stress response, than those who didn’t have yogurt.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176530/original/file-20170703-751-cpnsxx.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Research suggests the gut microbiome may have a role in the development of autism spectrum disorders (ASD).</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>The protective value of a <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0087657">whole-food diet for depression</a> also points to the importance of gut microbes for brain health. Mood disorders that can accompany conditions such as irritable bowel syndrome and inflammatory bowel diseases are thought to be related to <a href="http://onlinelibrary.wiley.com/doi/10.1111/nmo.12198/full">microbial disruption in the bowel</a>. </p>
<p>Recent research has also suggested the gut microbiome may have a role in the development of autism spectrum disorders (ASD). Research has found people with ASD have <a href="https://link.springer.com/article/10.1007/s11046-015-9949-3">significantly higher numbers</a> of <em>Candida</em> species in their intestines, for instance. Although determining causation is complicated, these microbes reduce the absorption of carbohydrates and release ammonia and other toxins which are thought to contribute to autistic behaviours. </p>
<p>There is also <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4342262/">emerging evidence</a> showing that differences in gut bacteria in children are related to behavioural problems, and potentially to future mental health risk. </p>
<p>There are <a href="https://www.ncbi.nlm.nih.gov/pubmed/26372511">numerous reports</a> of changed gut bacteria in people experiencing mental illness such as schizophrenia and depression, as well as neurological disorders such as Parkinson’s disease. However, it is difficult to establish causation. </p>
<p>A compelling argument is made by studies that show microbiota transplants from people to mice actually change the behaviour of the recipient mice. <a href="http://www.the-scientist.com/?articles.view/articleNo/48678/title/Human-Gut-Microbe-Transplant-Alters-Mouse-Behavior/">One study</a> used microbiota from people experiencing irritable bowel syndrome (IBS) and showed the mice who received the transplants experienced the same anxious behaviour that often accompanies IBS.</p>
<h2>Changing the game</h2>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=600&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=600&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=600&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=754&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=754&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176171/original/file-20170629-31297-26d3bu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=754&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Many of our microbes aren’t good or bad, but they become bad because we change the game.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>We are ecosystems, whose members are intricately balanced by cooperation and competition. Many of our microbes are neither good nor bad. But they become bad because we change the game, giving them the opportunity to be bad.</p>
<p>For example, we are increasingly interfering in the ecosystem by using antibiotics and sanitisers, hormone and immune system treatments, cosmetic and plastic surgery, or biomedical implants and devices such as contact lenses or heart valves. </p>
<p>Although sanitation and nutrition have greatly improved in much of the world, antibiotic overuse has led to the rise of <a href="https://theconversation.com/antibiotic-resistance-sorry-not-my-problem-44011">antibiotic resistant bacteria</a>. Antibiotics also change what is in our microbiome. Many women would be familiar with <em>Candida</em> infections (thrush) that <a href="http://jcm.asm.org/content/44/9/3213.short">flourish after they use antibiotics</a>, for instance.</p>
<p>Biomedical implants, contact lenses and dentures provide warm, moist and nutritious conditions for colonisation by microbes. Increased oestrogen use in birth control pills and other hormone treatments has been shown to <a href="https://www.termedia.pl/Journal/-10/Streszczenie-20833">promote yeast infection</a> and reduce immune efficiency. </p>
<p>In fact, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841828/">the hygiene hypothesis</a> argues that infections help build our immune system and the proliferation of sanitising disinfectants in our homes could be contributing to skin allergies and respiratory conditions.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=900&fit=crop&dpr=1 600w, https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=900&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=900&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1130&fit=crop&dpr=1 754w, https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1130&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/176560/original/file-20170703-7743-j2m8km.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1130&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Body odours aren’t inherently unhealthy.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>Our definitions of good and bad are cultural as much as biological. For example, body odours and stale breath which are caused by microbes are not inherently unhealthy, but the market for antiperspirants, deodorisers and mouthwash is flourishing. Increasing skin conditions, allergies and illness could be the result of our attempts to control and groom our microbes, good and bad. </p>
<p>Our diets have also changed rapidly and the flow–on changes to both human and microbial health are apparent. Non–communicable disease epidemics such as obesity and heart disease are clear consequences of <a href="http://www.who.int/mediacentre/factsheets/fs355/en/">highly processed foods and increasingly inactive lifestyles</a>. </p>
<p>The changing modern diet may also have effects over generations, as we pass on our microbial communities to our children. Research in mice has found some <a href="http://www.nature.com/nature/journal/v529/n7585/full/nature16504.html">bacterial strains could not recover</a> in the grandchildren of mice fed low–fibre western diets, even when a high–fibre diet was reintroduced. It may not be long then, before the modern western diet will have irrevocably changed the gut bugs and health of future humans.</p>
<h2>Rethinking the metaphor</h2>
<p>For most of the twentieth century, we were at war with microbes. Vigilant immune systems defended against vicious and sneaky microbial attacks. The cold and flu medication Codral, as just one example, famously helped us “<a href="https://www.youtube.com/watch?v=4Dk60kWcP8o">soldier on</a>.”</p>
<p>We have to rethink this militaristic metaphor. If we are a complex ecosystem which relies on the microbes in it, we cannot wage war against them. If microbes are part of our immune systems, who is fighting whom?</p>
<p>How we <a href="http://iai.asm.org/content/83/1/2.abstract">talk about our microbes</a> reflects how we think about ourselves and others. As holobionts, we need to figure out how to live with all the members of our bodies. How might our worlds (and bodies) be different if we behave as resilient communities where the “others” are different selves, rather than invaders, terrorists, colonisers, or competitors?</p>
<hr>
<p><em>The authors will be presenting on this topic at the upcoming Emerging Issues in Science and Society event at <a href="http://www.deakin.edu.au/adi/our-research/research-networks/science-and-society-network">Deakin University</a> on Thursday, 6 July 2017. For more information and to book tickets, see the event’s <a href="https://www.eventbrite.com.au/e/emerging-issues-in-science-and-society-registration-33136207288">website</a>.</em></p><img src="https://counter.theconversation.com/content/79116/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Tarsh Bates is affiliated with SymbioticA, The University of Western Australia. </span></em></p><p class="fine-print"><em><span>Amy Loughman does not work for, consult, own shares in or receive funding from any company or organisation that would benefit from this article, and has disclosed no relevant affiliations beyond their academic appointment.</span></em></p>For most of the twentieth century, we were at war with microbes, leading to substantial changes in our body’s ecosystem. This has changed our diets, disease profile, moods and even personalities.Amy Loughman, Senior Research Fellow, Deakin UniversityTarsh Bates, PhD candidate, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/658732016-11-01T19:07:35Z2016-11-01T19:07:35ZEssays on health: how food companies can sneak bias into scientific research<figure><img src="https://images.theconversation.com/files/141182/original/image-20161011-3903-1rt4e5s.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Proper nutrition is critical to combatting the costly and deadly epidemics of obesity, diabetes and cardiovascular disease. </span> <span class="attribution"><span class="source">from www.shutterstock.com</span></span></figcaption></figure><p><em>This is the first in our occasional series of longer reads titled, Essays on health. Enjoy!</em></p>
<hr>
<p>Should we eat breakfast every day? How much dairy should we have? Should we use artificial sweeteners to replace sugar? If we had the answers to these questions, we could address some of today’s biggest public health problems such as <a href="https://theconversation.com/how-australians-die-cause-1-heart-diseases-and-stroke-57423">heart disease</a>, <a href="https://theconversation.com/how-australians-die-cause-2-cancers-58063">cancer</a>, <a href="https://theconversation.com/how-australians-die-cause-5-diabetes-57874">diabetes</a> and <a href="http://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/4338.0%7E2011-13%7EMain%20Features%7EOverweight%20and%20obesity%7E10007">obesity</a>.</p>
<p>Consumer choice is often guided by recommendations about what we should eat, and these recommendations also play a role in the food that’s available for us. Recommendations take the form of dietary guidelines, food companies’ health claims, and clinical advice.</p>
<p>But there’s a problem. Recommendations are often conflicting and the source of advice not always transparent.</p>
<p>In September, a <a href="http://jamanetwork.com/journals/jamainternalmedicine/article-abstract/2548255">JAMA Internal Medicine</a> study revealed that in the 1960s, the sugar industry paid scientists at Harvard University to minimise the link between sugar and heart disease. The historical papers the study was based on showed researchers were paid to shift the blame from sugar to fat as responsible for the heart disease epidemic. </p>
<p>The paper’s authors suggested many of today’s dietary recommendations may have been largely shaped by the sugar industry. And some experts have since questioned whether such misinformation can have <a href="http://www.nytimes.com/2016/09/13/well/eat/how-the-sugar-industry-shifted-blame-to-fat.html?_r=0">led to today’s obesity crisis</a>. </p>
<p>We’d like to think industry influence of this scale won’t happen again. We’d like to have enough systems in place to shine a spotlight on any potential bias, or risk of it, as soon as it happens. But the reason it took so long to expose the sugar industry’s tactics is bias can be well hidden. To avoid the potentially huge ramifications, we need much better systems in place when it comes to nutrition research.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143856/original/image-20161031-15783-1nr46d7.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Partnerships between industry and research institutions aren’t uncommon.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<h2>How are national guidelines put together?</h2>
<p>Governments issue national dietary guidelines to inform people’s food choices and the nation’s food policies. To be credible and scientifically sound, they should obviously be built on rigorous evidence.</p>
<p>Best practice for creating guidelines includes beginning the process with a systematic review, which is a study that identifies all the available evidence on a particular research question. This ensures studies favourable to a particular party can’t be cherry-picked. But systematic reviews are only as valid as the studies out there. </p>
<p>An important part of any systematic review is to evaluate the biases in the studies included. Public health dietary guidelines and policies are influenced by <a href="http://www.oxfordscholarship.com/view/10.1093/acprof:oso/9780199691975.001.0001/acprof-9780199691975">political</a>, <a href="https://theconversation.com/food-industry-digs-in-heels-over-traffic-light-labels-311">economic</a> and social factors. That’s inescapable. But if the evidence on which these decisions are based is flawed, the entire foundation for systematic reviews, guidelines and policy, crumbles.</p>
<p>So <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726025/">identifying and minimising bias</a> in <a href="https://www.questia.com/library/journal/1G1-236332510/corporate-manipulation-of-research-strategies-are">each part of the research process</a> – from the researcher’s decision on which question to answer in the study, to the publication of the results – is essential to having a strong evidence base. </p>
<p>Bias in research is the systematic error or deviation from true results or inferences of a study. Pharmaceutical, <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497700/">tobacco</a> or chemical industry funding of research <a href="https://www.ncbi.nlm.nih.gov/pubmed/23235689">biases human studies</a> towards outcomes favourable to the sponsor. </p>
<p>Even when studies use similar rigorous methods – such as keeping study information away from participants (blinding) or removing selection bias between groups of patients (randomisation) – studies sponsored by a drug’s manufacturer are more likely to find the drug is more effective or less harmful than a placebo or other drugs. </p>
<p>This bias in pharmaceutical industry sponsored studies is just like the sugar industry sponsored studies that downplayed sugar’s link to heart disease while putting the blame on fat.</p>
<p>Financial conflicts of interest between <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050217">researchers and industry</a> have also been associated with research outcomes that favour companies researchers are affiliated with.</p>
<p>So how does this happen? How can industry-funded studies use methods similar to non-industry funded studies but have different results? Because bias can be <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3726025/">introduced in several ways</a>, such as in the research agenda itself, the way research questions are asked, how the studies are conducted behind the scenes, and the publication of the studies. </p>
<p>Industry influences on these <em>other</em> sources of bias in research often remains hidden for decades.</p>
<h2>Types of hidden bias</h2>
<p>It took over 40 years to show how the <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497700/">tobacco industry undermined the research agenda</a> on the health effects of secondhand smoke. </p>
<p>It did this by <a href="https://www.ncbi.nlm.nih.gov/pubmed/8784687">funding “distracting” research </a> through The Center for Indoor Air Research, which three tobacco companies created and funded. Throughout the 1990s, this centre funded dozens of research projects that suggested components of indoor air, such as carpet off-gases or dirty air filters, were more harmful than tobacco. The centre did not fund research on secondhand smoke. </p>
<p>There is a high risk of bias when the methodology of the study (how the study is designed) leads to an error when assessing the magnitude or direction of results. Clinical trials with a high risk of methodological bias (such as those lacking randomisation or blinding) are more likely to <a href="https://www.ncbi.nlm.nih.gov/pubmed/7823387">exaggerate the efficacy</a> of drugs and underestimate their harms. </p>
<p>A 2007 <a href="https://www.ncbi.nlm.nih.gov/pubmed/17954797">paper that compared over 500 studies</a> found those funded by pharmaceutical companies were half as likely to report negative effects of corticosteroid drugs (used to treat allergies and asthma) as those not funded by pharmaceutical companies.</p>
<p>Many <a href="https://www.ncbi.nlm.nih.gov/pubmed/23235689">industry-sponsored studies</a> of drugs are conducted for regulatory approval and the regulators require certain methodological standards. So often, the design of industry-sponsored studies is pretty good and the bias is elsewhere. It can be in how the questions are framed or another common form: publication bias.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=470&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=470&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=470&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=591&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=591&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143857/original/image-20161031-15728-19a0mmj.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=591&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Clinical trials with a high risk of methodological bias are more likely to exaggerate the efficacy of drugs and underestimate their harms.</span>
<span class="attribution"><span class="source">shutterstock.com</span></span>
</figcaption>
</figure>
<p>Publication bias occurs when entire research studies are not published, or only selected results from the studies are published. It is a common myth <a href="https://www.ncbi.nlm.nih.gov/pubmed/2406472">publication bias</a> comes about because scientific journal editors reject studies that don’t support the hypothesis or question the studies were asking. These are called negative or statistically non-significant studies. But <a href="https://abstracts.cochrane.org/2004-ottawa/methodological-quality-accepted-and-rejected-papers-submitted-three-leading-biomedical">negative research is as likely to get published</a> as positive research. So it’s not that.</p>
<p>Analysis of <a href="https://www.ncbi.nlm.nih.gov/pubmed/16908919">internal pharmaceutical industry documents</a> from 1994 to 1998 shows the pharmaceutical industry had a deliberate strategy to suppress publication of sponsored research unfavourable to its products. Industry-funded investigators were not allowed to publish negative research that did not support the efficacy or safety of the drugs being tested.</p>
<p>This has contributed to a clinical literature dominated by studies demonstrating the efficacy or safety of drugs. The tobacco industry also has a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1497700/">history of stopping the publication of research</a> it funded if the findings didn’t lean in favour of tobacco products.</p>
<p>Previous research on bias in tobacco, pharmaceutical, and other industry-sponsored research is relevant here because the biases that affect research outcomes are the same, regardless of the exposure or intervention being studied. When it comes to nutrition research, we actually know little about how corporate sponsorship or conflicts of interest might bias the research agenda, design, outcomes and reporting. </p>
<h2>Industry influence on nutrition research</h2>
<p>The credibility of nutrition research has <a href="https://www.washingtonpost.com/news/wonk/wp/2016/02/04/what-this-scathing-exchange-between-top-scientists-reveals-about-what-nutritionists-actually-know/">come under attack</a> because the funding source is often not transparent and <a href="https://www.ncbi.nlm.nih.gov/pubmed/26595855">industry-funded research</a> affects food policy. But we actually know very little about how sponsorship biases nutrition research.</p>
<p>Our systematic review, published this week in <a href="http://jamanetwork.com/journals/jamainternalmedicine/fullarticle/10.1001/jamainternmed.2016.6721">JAMA Internal Medicine</a>, identified and evaluated all studies that assessed the association between food industry sponsorship and published outcomes of nutrition studies.</p>
<p>We were surprised to find few studies examining the effects of industry sponsorship on the actual, numerical findings of the studies. Only two of 12 studies assessed the association between food-industry sponsorship and the statistical significance of research results, and neither found a link.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143858/original/image-20161031-15728-1qg5nml.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">We know very little about the association between industry sponsorship or authors’ conflicts of interest and the results of nutrition research.</span>
<span class="attribution"><a class="source" href="https://images.unsplash.com/photo-1473360526459-100c8e8ec8d8?ixlib=rb-0.3.5&q=80&fm=jpg&crop=entropy&cs=tinysrgb&s=7049742c2ff3515292f2ed87d6edc07f">Jordan Whitfield/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<p>Only one paper found studies sponsored by the food industry reported significantly smaller harmful effects of consuming soft drinks than those without industry sponsorship. Overall, our review showed we know very little about the association between industry sponsorship or authors’ conflicts of interest and the actual results of nutrition research.</p>
<p>More studies assessed the association of industry sponsorship with authors’ conclusions or interpretations of their findings (not the results). Eight reports, when taken together, found industry sponsored studies had a 31% increase in risk, compared to non-industry sponsored studies, of having a conclusion favouring the sponsor’s product.</p>
<p>So what we know is that food industry sponsorship is associated with researchers interpreting their findings to favour the sponsor’s products. Conclusions don’t always agree with results but can be spun to make readers’ interpretations more favourable.</p>
<p>For example, a study might find that a particular diet leads to weight loss and an increase in heart disease but the harmful effects of heart disease are omitted from the conclusion. Only the weight loss is mentioned. This <a href="https://www.ncbi.nlm.nih.gov/pubmed/20501928">spin on conclusions</a> is a tactic <a href="https://www.ncbi.nlm.nih.gov/pubmed/18024482">in other industries</a> and can influence how research is interpreted.</p>
<p>But it is the results (the research data) that really matters. From the standpoint of developing systematic reviews and evidence-based recommendations, the results are more important than conclusions because only the data, and not a researchers interpretation of them, are included in the reviews.</p>
<p>We need more rigorous investigation of the effects of industry sponsorship on the results of both primary nutrition studies and reviews. For example, <a href="http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0162198">our recent study</a> examined 31 reviews of the effects of artificial sweeteners on weight loss. We found reviews funded by artificial sweetener companies were about 17 times as likely to have statistically significant results showing artificial sweeteners use is associated with weight loss, compared to reviews with other sponsors.</p>
<h2>Nutrition research agenda</h2>
<p>Our studies mentioned above didn’t identify any differences in the quality of industry-sponsored and non-industry sponsored nutrition research. But, similar to research sponsored by the pharmaceutical or tobacco industries, sponsors could affect outcomes by setting the research agenda, framing the questions or influencing publication.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="" src="https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=401&fit=crop&dpr=1 600w, https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=401&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=401&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/143859/original/image-20161031-15810-5l72oq.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=503&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">There is a lack of transparency about funding sources and conflicts of interest in the area of nutrition research.</span>
<span class="attribution"><span class="source">from shutterstock.com</span></span>
</figcaption>
</figure>
<p>A <a href="https://cup.columbia.edu/book/nutritionism/9780231156561">research agenda</a> focused on single ingredients (such as sugar) or foods (such as nuts) rather than their interactions or dietary patterns may favour food-industry interests. This is because it may provide a platform to market a certain type of food or processed foods containing or lacking specific ingredients, such as sugar-free drinks.</p>
<p>Most data sources used to study publication bias in other research areas are not available for nutrition research, which make it more difficult to detect.</p>
<p>Researchers have identified publication bias in pharmaceutical and tobacco research by <a href="http://journals.plos.org/plosmedicine/article?id=10.1371/journal.pmed.0050217">comparing the full reports</a> of drug studies submitted to regulatory agencies with publications in the scientific literature. Researchers have also <a href="https://www.ncbi.nlm.nih.gov/pubmed/16908919">compared data released</a> in legal settlements with published research articles. There are no similar regulatory databases for foods or dietary products.</p>
<p>It is possible to use statistical methods to estimate publication bias in large samples of nutrition research, as in other <a href="https://www.ncbi.nlm.nih.gov/pubmed/25880564">research areas</a>. Interviewing industry-funded researchers could be another way to <a href="https://www.ncbi.nlm.nih.gov/pubmed/9676672">identify publication bias</a>.</p>
<p>Another obstacle to rigorously assessing bias in nutrition research is the lack of transparency about funding sources and conflicts of interest. Our review of artificial-sweetener studies found authors of 42% of them had conflicts of interest not disclosed in the published article.</p>
<p>Also, about one third of the reviews didn’t disclose their funding sources. Although disclosure in journals is improving over time, not all journals enforce disclosure guidelines for author conflicts of interest and research funding sources.</p>
<h2>Reducing bias in nutrition research</h2>
<p>Studies on research bias related to pharmaceutical and tobacco industry sponsorship and conflicts of interest has <a href="http://www.cochrane.org/about-us/our-governance-and-policies/cochrane-policies/access-data-alltrials">led to international reforms</a>. These have been in the area of government requirements for research transparency and data accessibility, stricter journal and university standards for managing conflicts of interest, and methodological standards for critiquing and reporting evidence (and conducting systematic reviews). Similar reforms are needed in nutrition research.</p>
<p>Further studies will determine which mechanisms to reduce bias should be urgently implemented for nutrition research. Options include:</p>
<ul>
<li><p>refined methods for evaluating studies used in systematic reviews</p></li>
<li><p>enforced policies for disclosing, managing or eliminating financial conflicts of interest across all nutrition-related journals and professional associations</p></li>
<li><p>mechanisms to reduce publication bias, such as study registries that describe the methods of ongoing studies, or providing open access data</p></li>
<li><p>revised research agendas to address neglected topics and to produce studies relevant to population health, without corporate sponsors driving the agenda</p></li>
<li><p>independent sources of funding for nutrition research, or, at a minimum, industry sources pooling their funding with research funds administered by an independent party.</p></li>
</ul>
<p>In the current economic climate, in which industry funding is encouraged by universities, studying bias is important and contentious research. </p>
<p>Research institutions should implement strategies that reduce the risk of bias when industry sponsors research. They could do this by a risk-benefit assessment for accepting industry sponsorship of research. This would evaluate the sponsor’s control of the design, conduct and publication of the research, as well as any risk to the institution’s reputation.</p>
<p>The full effects of industry sponsorship and financial conflicts of interest on nutrition research remain hidden. An evidence base as rigorous and extensive as the the one on bias in pharmaceutical and tobacco research is needed to illuminate how nutrition research is at risk of bias.</p><img src="https://counter.theconversation.com/content/65873/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In the last 5 years, Lisa Bero has received research funding from the California Breast Cancer Research Program, The Cochrane Collaboration Methods Innovation Fund, US Office of Research Integrity, and the US National Institute of Environmental Health Sciences.
She is Co-Chair, Cochrane Governing Board since 2013 and receives remuneration that is paid to the University of Sydney.</span></em></p>Food, drug and other companies often sponsor research in the hope it might produce results favourable to their products. How can we ensure such research remains independent?Lisa Bero, Chair professor, University of SydneyLicensed as Creative Commons – attribution, no derivatives.