tag:theconversation.com,2011:/institutions/augusta-university-3874/articlesAugusta University2023-12-12T09:10:47Ztag:theconversation.com,2011:article/2180972023-12-12T09:10:47Z2023-12-12T09:10:47ZWhat’s east Africa’s position on the Israel-Hamas war? An expert unpacks the reactions of Kenya, Tanzania and Uganda<p>The reactions of some east African countries to the ongoing conflict in Gaza have been less dramatic than South Africa’s. South Africa’s parliament has passed a resolution calling for the <a href="https://www.reuters.com/world/africa/safrican-lawmakers-vote-suspend-diplomatic-ties-with-israel-shut-embassy-2023-11-21/">closure</a> of its embassy in Tel Aviv. Algeria and South Africa have been the most supportive of the Palestinians. Thus far only South Africa and Chad have withdrawn their representatives from Tel Aviv.</p>
<p>In contrast, the reactions from east African capitals have been less dramatic. At the outset of the current conflict in Gaza, Kenya’s President William Ruto <a href="https://www.the-star.co.ke/news/2023-10-08-kenya-stands-with-israel-ruto-says-amidst-war-with-palestine/">expressed solidarity</a> with Israel and condemned</p>
<blockquote>
<p>terrorism and attacks on innocent civilians in the country.</p>
</blockquote>
<p><a href="https://www.monitor.co.ug/uganda/news/national/museveni-reacts-as-hamas-attack-on-israel-spirals-4393308">Uganda</a> and <a href="https://www.thecitizen.co.tz/tanzania/news/national/tanzania-calls-for-peace-as-israel-palestine-war-intensifies-4394110">Tanzania</a> condemned all forms of violence and called for</p>
<blockquote>
<p>restraint to stem further loss of human life.</p>
</blockquote>
<p>As a <a href="https://scholar.google.com/scholar?q=Michael+Bishku+research&hl=en&as_sdt=0&as_vis=1&oi=scholart">scholar</a> of Middle Eastern and African history, I have researched the relationship between Israel and African countries including those in <a href="https://www.researchgate.net/publication/312006990_Israel's_Relations_with_the_East_African_States_of_Kenya_Uganda_and_Tanzania_-_From_Independence_to_the_Present">east Africa</a>. </p>
<p>It is my conclusion that the reactions of the east African states to the conflict in the Middle East are shaped by two things: the perceived national threat of terrorism by Islamist factions and, for those states with democratic institutions, domestic public opinion.</p>
<p>In my view these three countries are unlikely to change their stance unless the current conflict escalates. On the one hand they will continue to limit their actions to voting in the United Nations for resolutions in support of the Palestinians. On the other they will continue to solicit technical assistance – especially in agriculture and security – from Israel.</p>
<h2>The history</h2>
<p>Relations between African countries and Israel have been tested before. For example, in 1973, <a href="https://www.jstor.org/stable/20455585">25 independent African states</a> cut diplomatic relations with Israel after its occupation of Egyptian territory. These included east African states, such as Kenya, which had enjoyed particularly <a href="https://www.dw.com/en/a-history-of-africa-israel-relations/a-43395892">close relations</a> with Israel since its independence from Britain in 1963.</p>
<p>East African countries colonised by Britain <a href="https://studies.aljazeera.net/en/reports/2016/09/israeli-penetration-east-africa-objectives-risks-160929102604246.html">sought</a> technical assistance after independence. This was particularly true in agriculture. They viewed Israel as complementary or an alternative to having to seek assistance from the big powers.</p>
<p>When African states cut off the diplomatic ties with Israel in 1973, Kenya was reluctant but had to act in solidarity with other independent African nations. It kept its cooperation with Israel even before the formal ties were restored in 1988. It facilitated Israel’s <a href="https://www.britannica.com/event/Entebbe-raid">1974 rescue operation</a> at Uganda’s Entebbe airport. The operation was meant to rescue passengers of a French jet airliner that was hijacked on its way from Israel to France, and flown to Entebbe. </p>
<p>Tanzania, on the other hand, sought a more neutral course after independence. It found the socialist character of the Israeli Labour governments appealing but Israel’s occupation of Palestinian territories following the <a href="https://www.britannica.com/event/Six-Day-War">1967 Six-Day War</a> complicated relations. </p>
<p>Tanzania was one of the last African states to <a href="https://digitallibrary.un.org/record/1481841?ln=en">renew</a> relations with Israel in 1994. That was a year after the <a href="https://www.britannica.com/topic/Oslo-Accords">Oslo Accords</a> between Israel and the Palestinian Liberation Organisation. Tanzania was also the <a href="https://www.middleeastmonitor.com/20200605-palestine-julius-nyerere-and-international-solidarity/">first African country</a> to recognise the Palestinian Liberation Organisation in 1973 and to host a representative office in its capital. </p>
<p>Uganda has had the most tempestuous relationship with Israel. Under the erratic <a href="https://www.britannica.com/biography/Idi-Amin">Idi Amin</a> the country broke off relations with Israel and embraced Libya. Israel and Uganda have had good relations under President Yoweri Museveni. Israeli companies <a href="https://embassies.gov.il/nairobi/bilateral-relations/Pages/Israel-and-Uganda.aspx">currently operate</a> in Uganda’s construction, infrastructure, agriculture and water management, communications and technology sectors.</p>
<p>Uganda joined most other African countries in <a href="https://truman.huji.ac.il/publications/uganda-and-israel-history-complex-relationship">renewing</a> relations with Israel just after the end of the Cold War.</p>
<p>Uganda, along with Kenya, has militarily intervened in Somalia as part of an African Union mission. </p>
<p>The ebbs and flows of these relationships have to be seen against the backdrop of the hard work Israel has put in to building <a href="https://jewishstudies.washington.edu/israel-hebrew/benjamin-netanyahu-resetting-israel-africa-relations/">diplomatic relations</a> with a range of other African countries too. By 2023 it had ties with 46 of the <a href="https://au.int/">55 African Union member states</a>.</p>
<h2>National security threat</h2>
<p>Kenya has been affected by instability in neighbouring Somalia and has been the victim of terror attacks. </p>
<p>In 1998, al Qaeda attacks <a href="https://press.un.org/en/1998/19980813.sc6559.html">targeted</a> the US embassy in Nairobi and Dar es Salaam. The Nairobi attack <a href="https://www.voanews.com/a/kenya-victims-of-1998-us-embassy-bombing-demand-compensation-/7215264.html">resulted</a> in over 200 deaths and thousands of people were injured. Since then, Israel <a href="https://www.theguardian.com/world/2013/sep/23/nairobi-attack-israel-advising-kenyan-forces">has taken the lead</a> among foreign countries in aiding and advising Kenyan security.</p>
<p>Kenya has suffered attacks since then by al-Shabaab – across its <a href="https://theconversation.com/five-reasons-why-militants-are-targeting-kenyas-lamu-county-176519">border</a> as well as in <a href="https://www.state.gov/reports/country-reports-on-terrorism-2019/kenya/">Nairobi</a> in 2019. </p>
<p>Tanzania’s security situation has been different. Unlike Kenya, Tanzania has not militarily intervened in Somalia as part of an African Union mission (Amisom). The mission has been operating since 2007 to provide security in that country in the Horn of Africa.</p>
<p>Uganda has its own set of security problems. A terrorist bombing in Uganda’s capital Kampala in 2010 was <a href="https://www.aljazeera.com/news/2010/7/13/al-shabab-claims-uganda-bombings">attributed</a> to al-Shabaab. But a bigger threat to Uganda’s security has come from Islamist rebels known as the <a href="https://theconversation.com/tracking-the-drcs-allied-democratic-forces-and-its-links-to-isis-116439">Allied Democratic Forces</a> based in the Democratic Republic of Congo. </p>
<h2>Domestic institutions and public opinion</h2>
<p>There is one other factor that explains east Africa’s relations with Israel: the religious composition of populations in the region. </p>
<p>Israel is <a href="https://www.msnbc.com/opinion/msnbc-opinion/truth-many-evangelical-christians-support-israel-rcna121481">popular</a> with many devout Christians in east Africa, as is the case throughout the continent. If given the opportunity, these Christians would make a pilgrimage to the <a href="https://www.jstor.org/stable/10.2979/israelstudies.23.1.09">Holy Land</a>. This factor obviously affects <a href="https://www.bloomsbury.com/uk/israel-in-africa-9781786995056/">public opinion</a>. </p>
<p>Conversely, Muslims in east Africa have a greater concern for the situation of the Palestinians. All three countries – Kenya, Uganda and Tanzania – have populations adhering to these two religions. </p>
<p>Given the democratic characters of Kenya and Tanzania, where there have been peaceful transfers of power, public opinion has more of an impact. This explains Ruto’s <a href="https://nation.africa/kenya/news/president-ruto-changes-tune-on-israel-hamas-conflict-4431560">change of tone</a> after the initial statement strongly critical of Hamas.</p>
<p>Tanzania has remained consistent in condemning all forms of violence. That country calls for a two-state solution to the Israeli-Palestinian conflict, as do the other east African states. </p>
<p>Public pressure is less important in Uganda, where Museveni is quite autocratic.</p><img src="https://counter.theconversation.com/content/218097/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael B. Bishku 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>East Africa’s reaction to the war in Gaza appears shaped by history, affinity to the policies of the west and the threat of terrorism.Michael B. Bishku, Professor of Middle Eastern and African History, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1657732021-08-15T09:03:19Z2021-08-15T09:03:19ZIn search of advantages: Israel’s observer status in the African Union<figure><img src="https://images.theconversation.com/files/415852/original/file-20210812-24-z1fep5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Rwanda's President Paul Kagame meets Israel's then Prime Minister Benjamin Netanyahu in 2017.</span> <span class="attribution"><a class="source" href="https://www.flickr.com/photos/paulkagame/35029583353">Paul Kagame/Flickr</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc/4.0/">CC BY-NC</a></span></figcaption></figure><p>Since its establishment as a <a href="https://history.state.gov/milestones/1945-1952/creation-israel#:%7E:text=On%20May%2014%2C%201948%2C%20David,nation%20on%20the%20same%20day.">state in 1948</a>, Israel has placed great importance on foreign policy. This is because it had been under a <a href="https://www.foreignaffairs.com/articles/middle-east/1977-04-01/middle-east-arab-boycott-israel?amp">political and economic boycott</a> by surrounding Arab states. The boycott has been falling apart since the <a href="https://www.history.com/this-day-in-history/israel-egyptian-peace-agreement-signed">1979 peace treaty with Egypt</a>. But it is still in place with countries such as Syria, Lebanon, Algeria and Libya. </p>
<p>As a result Israel pursues reliable political allies and trading partners on the periphery of the Arab world – and beyond. </p>
<p>This is true in Africa too. Israel’s strongest relations on the continent are with countries in west, central and east Africa. It now has <a href="https://jewishstudies.washington.edu/israel-hebrew/benjamin-netanyahu-resetting-israel-africa-relations/">diplomatic relations</a> with 46 of the <a href="https://au.int/">55 African Union member states</a>.</p>
<p>The recent <a href="https://www.aljazeera.com/news/2021/7/23/israel-granted-observer-status-at-the-african-union">decision</a> by the African Union to grant Israel observer status has once again raised the profile of Israel’s relations with the continent. </p>
<p>For over half a decade under former prime minister Benjamin Netanyahu’s tenure, Israel lobbied hard for this outcome. </p>
<p>Netanyahu visited sub-Saharan Africa in <a href="https://www.nytimes.com/2016/07/07/world/africa/israel-africa-netanyahu-uganda-kenya-rwanda.html">July 2016</a>, the first Israeli head of state to visit since Levi Eshkol in 1966. In addition to encouraging further political and economic ties, his mission was to secure the support of African leaders for observer status at the African Union. </p>
<p>He carefully chose Ethiopia, Kenya, Uganda and Rwanda. Ethiopia and Kenya had had close ties with Israel in the past. And they were engaged in security cooperation against the threat of Islamist terrorism and were sympathetic to Israel’s goal of achieving African Union observer status. </p>
<p>Connections with Uganda were developing, while Rwanda’s leader Paul Kagame shared an affinity with Israel given his country’s experience with genocide. </p>
<p>The following year Netanyahu visited Liberia <a href="https://www.africanews.com/amp/2017/06/04/israeli-prime-minister-woos-west-african-leaders-to-join-forces/">to address</a> the 15-member countries of the Economic Community of West African States – the first non-African head of state to do so. He made <a href="https://www.youtube.com/watch?app=desktop&v=sFRsPT-OTFY&autoplay=1">an appeal</a> for political support in return for economic aid and technical assistance in sectors such as agriculture, water resources, energy and health.</p>
<p>He also lobbied for African Union observer status. Israeli officials – both in public and private – continued with these efforts in the intervening years.</p>
<p>In recent years, Israel has made inroads in North Africa too. In 2019 it re-established relations with Chad, which had been broken off in 1972 because of Israel’s then-continued occupation of Egypt’s Sinai peninsula since the 1967 War. The current African Union Commission chairperson, Moussa Faki Mahamat, who granted Israel observer status in late July 2021, comes from Chad. Mahamat’s decision was supported by the Democratic Republic of the Congo’s president and current chairman of the African Union, Félix Tshisekedi. </p>
<p>Israel also has normalised relations with Morocco and Sudan through the <a href="https://www.state.gov/the-abraham-accords/">Abraham Accords</a>. These were brokered by the US and came into action initially with the United Arab Emirates and Bahrain signing the agreement in August 2020.</p>
<p>The reasons for wanting observer status are not hard to decipher. Firstly, Palestine <a href="https://egyptindependent.com/au-grants-palestine-observer-status/">had been granted observer status</a> in the African Union in 2013. Secondly, African countries form a large bloc at the United Nations and many vote in a similar fashion. Israeli policymakers felt that the African Union would be an easier place to lobby for their positions in the conflict with the Palestinians. Israel had had observer status in the Organisation of African Unity. But <a href="https://www.haaretz.com/israel-news/.premium-19-years-after-its-ouster-african-union-reinstates-israel-as-an-observer-country-1.10020545">it was denied</a> the status when the African Union replaced the Organisation of African Unity in 2002. </p>
<p>Israel hopes to get African countries to support it on issues of political interest at the United Nations, and at the very least to abstain or absent themselves. Beyond that, Israel wants to increase security cooperation and economic ties. This includes the sale of civilian as well as military items. </p>
<p>Observer status at the African Union enables Israel to have closer contacts with African policymakers and to address attendees of the organisation’s meetings. </p>
<h2>The history</h2>
<p>During the 1950s, as the Cold War evolved, Israel placed emphasis on ties with the US and countries in Western Europe. </p>
<p>At the same time there was a hope of developing promising relations with the independent states in Asia. The <a href="https://history.state.gov/milestones/1953-1960/bandung-conf">Bandung Conference of 1954</a> stymied these efforts as Israel was not invited to the gathering. Many of its prominent figures would later establish the <a href="https://www.nti.org/learn/treaties-and-regimes/non-aligned-movement-nam/">Non-Aligned Movement</a>, which often opposed Israel’s policies, especially towards the Palestinians.</p>
<p>One of the consequences was that when African states began achieving their independence in the 1960s, a number received a great deal of interest from Israeli policymakers. Two factors drove Israeli efforts. One was a desire to counteract diplomatic movements by Egypt. Another was an attempt to portray Israel as a model for development and as an alternative to the former imperial European states as a conveyor of technical assistance. </p>
<p>However, all African countries, except apartheid South Africa, Malawi, Eswatini, Lesotho, and Mauritius, broke off formal relations with Israel around the time of the 1973 War. This was due to the continued occupation of Arab territory <a href="https://escholarship.org/content/qt9309h7t3/qt9309h7t3.pdf?t=mnipnf">as a result of the 1967 Arab-Israeli War</a>.</p>
<p>Some informal ties through embassies and business relations were maintained until many African countries began re-establishing relations with Israel at the end of the Cold War. This was also a period during which Israel and the Palestinian Liberation Organisation began a process that resulted in normalising ties.</p>
<h2>Opposition</h2>
<p>South Africa <a href="https://m.jpost.com/israel-news/south-africa-downgrade-embassy-in-israel-to-liaison-office-585883/amp">downgraded its representation</a> in Israel in 2019 from an embassy to a liaison office over Israel’s actions in Gaza in 2018. South Africa has been at the forefront of the <a href="https://bdsmovement.net/">Boycott, Divestment and Sanctions campaign</a> against Israel. The organisation’s raison d’etre is that isolating Israel will force it to relinquish Palestinian territory in the West Bank and end its blockade of Gaza. The movement has some appeal among left-wing individuals and groups in the west. But it is largely ignored by other African states.</p>
<p>The strong feelings of the South African government and the ruling African National Congress party are driven by two factors. The first is Israel’s military – and possibly nuclear – cooperation with the apartheid regime. The second is the affinity that many South Africans have with the Palestinian cause for self-determination. </p>
<p>South Africa was the country most strongly opposed to Mahamat’s decision. </p>
<p>However, most African countries have chosen to separate the issue of the Palestinians from economic cooperation with Israel, even though a number still vote against Israel on political issues at international forums such as the United Nations.</p>
<p>Some, like South Africa, <a href="https://www.aljazeera.com/news/2021/7/28/shocking-south-africa-slams-israels-au-observer-status">opposed Israel’s observer status</a> on the grounds of its treatment of the Palestinians and the continued occupation of their territory. They <a href="https://africa.businessinsider.com/local/markets/botswana-and-three-other-african-countries-oppose-israels-au-observer-status/dwep03m">included</a> Arab League members Algeria, Comoros, Djibouti, Libya, Mauritania and Tunisia as well as Namibia and Botswana.</p>
<p>Just as vocal critics – such as South Africa and Algeria – could do nothing about Morocco’s readmission to the African Union, it remains to be seen what they can do about reversing the decision on Israel. </p>
<p>Meanwhile, Israel has an important forum in which to lobby for its interests.</p><img src="https://counter.theconversation.com/content/165773/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michael B. Bishku 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>Most countries in Africa have chosen to separate the issue of the Palestinians from economic cooperation with Israel.Michael B. Bishku, Professor of Middle Eastern and African History, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1616362021-06-11T12:41:33Z2021-06-11T12:41:33ZOver half of adults unvaccinated for COVID-19 fear needles – here’s what’s proven to help<figure><img src="https://images.theconversation.com/files/402979/original/file-20210526-17-1f6ei8o.jpeg?ixlib=rb-1.1.0&rect=0%2C0%2C7951%2C5304&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Though many adults report a fear of needles, most research on needle fear has focused on children.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-a-happy-woman-in-a-car-with-a-get-royalty-free-image/1303039108?adppopup=true">FG Trade/E+ via Getty Images</a></span></figcaption></figure><p>If you’re among the 25% of Americans averse to needles, you’re probably not surprised by the COVID-19 immunization stall. Even for those who want immunity, bribes with beer or lottery tickets may not be enough to override anxiety made worse by <a href="https://doi.org/10.1016/j.vaccine.2015.08.064">pervasive images of needles in the media</a>. </p>
<p>As a <a href="https://www.practicalpainmanagement.com/author/29618/baxter">physician specializing in pain management</a>, I study the impact of pain on vaccination. Research-proven adult interventions for pain, fainting, panic and fear can make vaccination more tolerable. At a minimum, understanding the reasons needle fear has become common might make the embarrassment easier to bear.</p>
<h2>Why needle anxiety has increased</h2>
<p>Needle fear has increased dramatically since a landmark 1995 study by J.G. Hamilton reported that <a href="https://pubmed.ncbi.nlm.nih.gov/7636457/">10% of adults and 25% of children</a> feared needles. In that paper, adult patients who remembered when their fear began described a stressful needle experience around age 5. </p>
<p>The childhood experiences of the patients usually related to an unexpected illness; at the time the Hamilton participants were in preschool, vaccines were scheduled only until age 2. For most people born after 1980, however, <a href="https://www.immunize.org/timeline/">booster injections</a> given between ages 4 to 6 years became a routine part of the vaccine experience. The timing of boosters maximizes and prolongs immunity, but unfortunately falls <a href="http://ppl.childpain.org/issues/v10n2_2008/v10n2_yap.pdf">within the age window</a> when phobias form. A 2012 Canadian study of 1,024 children found that <a href="https://doi.org/10.1016/j.vaccine.2012.05.011">63% of those born in 2000 or later</a> now fear needles. In a 2017 study, my colleagues and I confirmed this increase in prevalence: <a href="https://doi.org/10.1016/j.vaccine.2017.06.029">Half of preschoolers</a> who got all their boosters on one day – often four or five injections at once – were still severely afraid of needles as preteens. </p>
<p>[<em>The Conversation’s science, health and technology editors pick their favorite stories.</em> <a href="https://theconversation.com/us/newsletters/science-editors-picks-71/?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=science-favorite">Weekly on Wednesdays</a>.]</p>
<p>Unsurprisingly, needle fear affects how willing teens and adults are to get vaccinated. A 2016 study found needle fear to be the most common reason teens didn’t get a <a href="https://doi.org/10.1177/003335491613100304">second HPV vaccine</a>. Health care workers are no exception: A 2018 study found that <a href="https://doi.org/10.1111/jan.13818">27% of hospital employees</a> dodged flu vaccines due to needle fear. And most recently, an April 2021 national survey of 600 not-yet-COVID-19-vaccinated U.S. adults found that <a href="https://www.pollfish.com/dashboard/results/256471406/1978802675">52% reported moderate to severe needle fear</a>. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Nurse applying band-aid to a person's arm." src="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/402986/original/file-20210526-15-a2mqex.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">The shame accompanying needle fear can make it difficult to research among adults.</span>
<span class="attribution"><a class="source" href="https://unsplash.com/photos/90ejoVTj2-M">CDC/Unsplash</a>, <a class="license" href="http://creativecommons.org/licenses/by/4.0/">CC BY</a></span>
</figcaption>
</figure>
<h2>Potential solutions for adults</h2>
<p>For children, evidence shows that addressing their <a href="https://doi.org/10.1016/j.pcl.2013.06.012">fear and pain while distracting them</a> from the procedure is most effective in reducing distress.</p>
<p>While adults are not just big children, combining these concepts with findings from available adult injection studies suggest a few potential interventions. For the many who want a vaccine but need some support, here’s what we know: </p>
<h2>1. Pain reduction</h2>
<p>Relieving injection pain may reduce needle fear by giving patients a feeling of control. For example, a group of patients in New Zealand were repeatedly missing their monthly antibiotic injections for rheumatic heart disease. Their doctors created a special clinic, offering either anesthetics, a vibrating cold device or both during the shot. The interventions in 107 adults <a href="https://doi.org/10.1111/jpc.12400">reduced pain and fear by 50%</a> after three months. Six months later, half the patients still used the interventions, and the special “missed dose” clinic was no longer needed.</p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Venn diagram showing the intersection of pain, fear, and focus is distress" src="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/404587/original/file-20210604-10042-18lge05.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">Interventions targeting the pain, fear and focus components of distress can help reduce needle fear.</span>
<span class="attribution"><a class="source" href="https://doi.org/10.1016/j.pcl.2013.06.012">Amy Baxter</a>, <a class="license" href="http://creativecommons.org/licenses/by-nc-nd/4.0/">CC BY-NC-ND</a></span>
</figcaption>
</figure>
<p>Specifically for vaccination, <a href="https://doi.org/10.1016/j.pmn.2018.07.001">applying a vibrating cold device</a> to the injection site a minute prior to injection, then pressing just above the site during injection, relieved pain and improved satisfaction for adults, and was <a href="https://doi.org/10.1097/PEC.0b013e318237ace4">most effective for those with needle fear</a>. A <a href="https://doi.org/10.1097/hnp.0000000000000105">horseshoe-shaped plastic device</a> using sharp prongs to confuse the nerves also reduced injection pain but increased anxiety, possibly due to discomfort from the prongs themselves.</p>
<p>Cold spray doesn’t help reduce <a href="https://doi.org/10.1097/ajp.0b013e3181a00414">vaccination pain for children</a>, but has been shown to be more effective than topical anesthetics for <a href="https://doi.org/10.2310/7060.2004.19101">adult injections</a>.</p>
<h2>2. Psychological therapy</h2>
<p><a href="https://www.apa.org/ptsd-guideline/patients-and-families/exposure-therapy">Exposure-based therapy</a> involves asking a patient to rank anxiety caused by parts of a procedure, like seeing a picture of a tourniquet or thinking about sharp things, and gradually exposing them to these parts in a controlled environment. Free <a href="https://martinantony.com/wp-content/uploads/Overcoming-Medical-Phobias1.pdf">self-guided resources</a> are available for fears ranging from flying to spiders. However, <a href="https://doi.org/10.1097/AJP.0000000000000273">none of the three studies</a> testing this approach on adult needle fear showed long-term fear reduction. </p>
<p>One of the studies that taught techniques to reduce fainting, however, was considered a success. Fainting, or <a href="https://www.ncbi.nlm.nih.gov/books/NBK470277/">vasovagal syncope</a>, and needle fear are often conflated. While passing out due to injections is more common with anxiety, it is often <a href="https://doi.org/10.3389/fcvm.2019.00175">a genetic response</a>. Tensing the <a href="https://doi.org/10.1002/da.22616">stomach muscles</a> increases the volume of blood the heart can pump, keeping blood in the brain to prevent lightheadedness during needle procedures.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Health care worker pointing at arm after getting vaccinated." src="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405725/original/file-20210610-25-1dwi9ad.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">Planning ahead can help make vaccine day more approachable.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/photo/portrait-of-happy-frontline-helathcare-worker-royalty-free-image/1304460904?adppopup=true">recep-bg/E+ via Getty Images</a></span>
</figcaption>
</figure>
<h2>3. Distraction</h2>
<p>Surprisingly, there are <a href="https://doi.org/10.1097/AJP.0000000000000270">no studies on adults</a> using distraction for injections. Two studies, however, have found that <a href="https://doi.org/10.1155/2019/9459103">pretending to cough</a> reduces pain from blood draws. </p>
<p>Dropping F-bombs could also help: A recent study found that <a href="https://doi.org/10.3389/fpsyg.2020.00723">swearing reduced pain by one-third</a> compared to saying nonsense words. Distraction with virtual reality games or videos has been shown to be more effective in children, although there have been <a href="https://doi.org/10.2196/17980">mixed results in adults</a>.</p>
<p>Mentally engaging tasks may also help. <a href="https://doi.org/10.1111/wvn.12359">A visual finding task</a> given to children during intramuscular shots has been shown to reduce pain and fear, with 97% rating the experience more pleasant than previous blood draws. Adults may need a more complicated task, but a similar intervention could work for them as well.</p>
<h2>Use multiple interventions and go in with a plan</h2>
<p>To reduce needle fear, research suggests the more interventions, the better. A 2018 study summarizing research on vaccine pain concluded that patient-operated <a href="https://doi.org/10.1080/21645515.2018.1480238">cold and vibration devices combined with distraction techniques</a> were most effective. Canada has implemented a practical <a href="https://immunize.ca/sites/default/files/Resource%20and%20Product%20Uploads%20(PDFs)/COVID-19/preparing-for-your-covid-19-vaccine-a-guide-for-adults_web_e.pdf">national needle fear intervention</a> for their vaccine rollout, emphasizing preparing ahead to help make vaccine day more comfortable. </p>
<p>Adults who don’t like needles are in the majority. Taking control of your vaccination experience may be the best way to combat needle anxiety.</p>
<p><em>Editor’s note: Portions of this article originally appeared in a previous <a href="https://theconversation.com/fear-of-needles-could-be-a-hurdle-to-covid-19-vaccination-but-here-are-ways-to-overcome-it-139029">article published</a> on June 8, 2020.</em></p><img src="https://counter.theconversation.com/content/161636/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Baxter founded and owns Pain Care Labs, makers of Buzzy. She previously received funding from the NICHD for vaccine pain research, and is currently funded by NIDA for work with mechanical stimulation for low back pain as part of the HEAL initiative to end opioid addiction long-term. </span></em></p>Free doughnuts and lotteries may drive some people to get their COVID-19 vaccine. But for those who are afraid of needles, other interventions may be necessary.Amy Baxter, Clinical Associate Professor of Emergency Medicine, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1390292020-06-08T12:22:06Z2020-06-08T12:22:06ZFear of needles could be a hurdle to COVID-19 vaccination, but here are ways to overcome it<figure><img src="https://images.theconversation.com/files/337195/original/file-20200524-124822-1grajvf.jpg?ixlib=rb-1.1.0&rect=5%2C5%2C3452%2C2373&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The widespread fear of needles is a public health problem, particularly in the time of COVID-19.</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/childrens-doctor-injects-a-vaccine-against-measles-rubella-news-photo/464478020?adppopup=true">Getty Images / Sean Gallup</a></span></figcaption></figure><p>As progress continues toward finding a vaccine that prevents COVID-19, millions of Americans are frightened at even the notion of getting a shot: Studies suggest <a href="https://pubmed.ncbi.nlm.nih.gov/22617633/">63% of young adults</a> – those born in 2000 or later – fear needles.</p>
<p>As a <a href="https://www.practicalpainmanagement.com/author/29618/baxter">physician trained in pediatrics</a>, I think we found the answer for the huge rise in needle phobia. Now – and even more critical: What might alleviate needle pain and fear? </p>
<p>A landmark 1995 study on <a href="https://mdedge-files-live.s3.us-east-2.amazonaws.com/files/s3fs-public/jfp-archived-issues/1995-volume_40-41/JFP_1995-08_v41_i2_needle-phobia-a-neglected-diagnosis.pdf">needle phobia</a> reported that 10% of adults and 25% of children were afraid of needles. The study also noted what typically caused their fear: a “needle event” around five years of age.</p>
<p>In 2010, our team conducted a study of vaccination pain in preteens. Of the 120 children screened, 114 said they had needle anxiety. This really surprised us. As with the earlier study, we thought perhaps 25% would be afraid; instead, it was 95%. (Incidentally, some of the parents were annoyed – not a few called their children out for being “wimps.”)</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=305&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=305&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=305&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=383&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=383&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336514/original/file-20200520-152344-1dra1zu.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=383&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Needle Fear Correlates with Scheduled Vaccine Injection Number by Birth Year. Spearman’s Rho = .87.</span>
<span class="attribution"><span class="source">AAAAI Annual Meeting</span></span>
</figcaption>
</figure>
<h2>Why there’s more needle phobia</h2>
<p>We wanted to understand what was creating this new anxiety. So we looked at the vaccination records of the group since birth. Maybe then we could find patterns that caused this abrupt rise in fear. </p>
<p>Turned out it was the needles. </p>
<p>Over the past 40 years, we have <a href="https://www.chop.edu/centers-programs/vaccine-education-center/vaccine-history">added 30 injections</a> to a child’s vaccine schedule. This is a good thing: Today in the U.S., kids almost never die from a childhood infectious disease. But needle fear has blossomed. </p>
<p>The number of infant vaccines were fine. But we found that half of kids who got all their preschool boosters on one day – that’s four or five injections at once – were in the <a href="https://pubmed.ncbi.nlm.nih.gov/28647169/">highest quartile of fear</a> five years later. Worth noting: Over the next three years, this group was two-and-a-half times less likely to get the HPV vaccine. </p>
<p>But none of the kids who got only a single shot each visit over the full four- to six-year window was fearful. Perhaps they became resilient, capable of coping with one quick poke. Maybe five injections per visit is too much, particularly when you’re old enough to remember them. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=397&fit=crop&dpr=1 600w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=397&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=397&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=499&fit=crop&dpr=1 754w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=499&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/337202/original/file-20200524-124810-r3udsi.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=499&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Needle fear could lower vaccination rates.</span>
<span class="attribution"><a class="source" href="https://www.gettyimages.com/detail/news-photo/marisa-grunder-27-of-wilton-iowa-is-given-a-shot-during-news-photo/89747046?adppopup=true">Getty Images / David Greedy</a></span>
</figcaption>
</figure>
<h2>Potential solutions</h2>
<p>Experts in the field – like <a href="http://www.sickkids.ca/AboutSickKids/Directory/People/T/Anna-Taddio.html">Dr. Anna Taddio</a> of the University of Toronto – realized needle fear could impact vaccination rates. She and other Canadian scientists created <a href="https://www.cmaj.ca/content/187/13/975">guidelines to reduce vaccination pain</a>. Issued in 2015, those guidelines suggested that interventions, occurring while preparing for and receiving the shot, would help. </p>
<p>Interventions can mean distractions. For young children, fear might be reduced by letting them blow their breath on a toy pinwheel. For an older child, it might be through watching videos or listening to music. For pain, topical anesthetics help numb the skin. So does numbing the muscle with “Buzzy,” the vibrating cold device we tested in preteens. Pain is reduced when placed on the shot area for a minute, then moved near the area while the injection takes place. Two <a href="https://pubmed.ncbi.nlm.nih.gov/31021972/">meta-analyses</a> showed Buzzy provided <a href="https://pubmed.ncbi.nlm.nih.gov/30829735/">significant pain and fear relief</a> – a 40% to 74% decrease for children, and a better experience for adults when receiving an <a href="https://pubmed.ncbi.nlm.nih.gov/30425014/">flu shot</a>. </p>
<p>In addition to Buzzy: Cold spray, topical anesthetics and Shotblocker – a horseshoe-shaped device placed near the area of the shot – have been studied for adult injections. Compared to no intervention, they <a href="https://pubmed.ncbi.nlm.nih.gov/30425014/">helped reduce pain</a>.</p>
<p>And in studies looking at <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3626759/">blood donation</a>, reducing anxiety and pain can lead to lower rates of the “passing out” feelings in adults. Using vibration combined with cold can also help <a href="https://www.semanticscholar.org/paper/An-integration-of-vibration-and-cold-relieves-pain-Baxter-Cohen/dcfed110e06a76f1687a3155048e1a74e36a01cd">adults who are fearful</a>.</p>
<p>New guidelines could come out later this year. This too will be helpful; our knowledge of vaccine pain has greatly increased over the past five years. Many of the 2015 recommendations were speculative and extrapolated from studies of IV insertions, which do not directly correlate to pain interventions for shots. In addition, many studies evaluating distractions from blowing bubbles to wearing <a href="https://pubmed.ncbi.nlm.nih.gov/29559294/">virtual reality goggles</a> are from lab draws. Reliable data on immunizations is relatively scant.</p>
<h2>Use multiple distractions, go in with a plan</h2>
<p>Yet all the suggested interventions have a commonality. They address pain, fear and the frightening memories of past events by
<a href="https://pubmed.ncbi.nlm.nih.gov/24093902/">changing the patient’s focus</a> during a procedure.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=549&fit=crop&dpr=1 600w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=549&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=549&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=690&fit=crop&dpr=1 754w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=690&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/336522/original/file-20200520-152284-10ned1f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=690&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Distress Venn Diagram.</span>
<span class="attribution"><span class="source">https://pubmed.ncbi.nlm.nih.gov/24093902/</span></span>
</figcaption>
</figure>
<p>A <a href="https://pubmed.ncbi.nlm.nih.gov/29792557/">systematic review</a> for vaccine pain concluded that interventions should have cold and vibration, plus distraction elements – for instance, using Buzzy as the patient watches a video or listens to music. The patient should choose the activity, and then remain engaged as the shot is prepared and administered. </p>
<p>If you’re facing a needle – a vaccination, lab draw or blood donation – the best strategy is to have a plan beforehand. Discuss the procedure with the clinician; bring a friend along. Have a game you can play while it’s all happening – that way, the brain is too busy to be afraid, and pain perception goes down. Any smartphone app involving touch and skill is a great place to start. Maybe it’s time to play Pokemon Go again.</p>
<p>A physical intervention during the procedure – pointing, touching, coughing – can help. Or combine rote performance and visual identification. During the poke, look at something on the wall with writing on it; focus on one sentence and count the number of letters with holes in them (for example, there are two in “holes”). This engages the part of the brain responsible for analyzing risk. </p>
<p>Needle phobia is a direct threat to public health. Those who are afraid of shots may not get them. With COVID-19 upon us, addressing needle fear becomes more than making a doctor’s visit more pleasant. Now, it’s truly a lifesaving endeavor.</p>
<p><em>Editor’s Note: An updated version of this article was published on June 11, 2021. <a href="https://theconversation.com/over-half-of-adults-unvaccinated-for-covid-19-fear-needles-heres-whats-proven-to-help-161636">Read it here</a>.</em></p>
<p>[<em>You’re smart and curious about the world. So are The Conversation’s authors and editors.</em> <a href="https://theconversation.com/us/newsletters/weekly-highlights-61?utm_source=TCUS&utm_medium=inline-link&utm_campaign=newsletter-text&utm_content=weeklysmart">You can get our highlights each weekend</a>.]</p><img src="https://counter.theconversation.com/content/139029/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Amy Baxter founded and works for Pain Care Labs, a dba of MMJ Labs which manufactures and researches neuromodulation pain products Buzzy, VibraCool, and DistrAction cards. She has received funding from NICHD to develop and test Buzzy for vaccine-related pain reduction, and from NIDA to research frequencies and modalities to reduce opioid use resulting from low back pain. </span></em></p>What happens when we have a COVID-19 vaccine – and millions are afraid of a needle?Amy Baxter, Clinical Associate Professor of Emergency Medicine, Augusta UniversityLicensed as Creative Commons – attribution, no derivatives.