tag:theconversation.com,2011:/us/topics/access-to-health-care-27740/articlesAccess to health care – The Conversation2023-06-29T10:39:41Ztag:theconversation.com,2011:article/2086042023-06-29T10:39:41Z2023-06-29T10:39:41ZSouth Africa’s National Health Insurance bill has noble aims but leaves too much uncertain: it needs more work<figure><img src="https://images.theconversation.com/files/534572/original/file-20230628-17-36iu2l.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><span class="source">Shutterstock</span></span></figcaption></figure><p>South Africa’s National Health Insurance (NHI) bill has <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(23)01294-1/fulltext">passed</a> the first hurdle towards becoming law, getting the country closer to its vision of achieving universal access to healthcare.</p>
<p>Section 27 of the country’s <a href="https://www.justice.gov.za/legislation/constitution/saconstitution-web-eng.pdf#page=15">constitution</a> states that everyone has the right to access to healthcare. The <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf">NHI bill</a>, which has been passed by the national assembly, is the manifestation of this provision.</p>
<p>Universal access to healthcare and the NHI are related. But they are not the same thing. </p>
<p>Universal access to healthcare is <a href="https://www.who.int/news-room/fact-sheets/detail/universal-health-coverage-(uhc)">an ideal</a> which supposes that everyone should have the same access to healthcare. The NHI bill is a tool to achieve universal health coverage. It aims to ensure that all South Africans have access to quality healthcare services. The bill also aims to provide for the establishment of a fund which will be used to pay for almost all medical treatments from accredited providers. </p>
<p>But this bill has been contentious from inception. There have been multiple court challenges, with <a href="https://businesstech.co.za/news/government/696225/nhi-heading-to-court-with-many-more-legal-challenges-to-come/">more to come</a>, and numerous different voices have been raised <a href="https://www.gov.za/speeches/health-welcomes-pretoria-high-court-judgement-national-health-insurance-10-nov-2022-0000">against it</a>.</p>
<p>The aim of the NHI is a good and noble one. But the bill is bad law because it fails to provide reasonable certainty. Several court rulings have flagged this. The bill will have massive consequences, so it should be <a href="https://www.news24.com/news24/southafrica/news/sama-rejects-nhi-bill-in-its-current-form-20230530">rejected</a> and not enacted in its current form.</p>
<h2>The vision</h2>
<p>South Africa has a two-tier healthcare system. Those who have the financial resources, or medical insurance, use private healthcare practitioners and facilities. Those who do not have these resources use public practitioners and the facilities provided and paid for by the state.</p>
<p>The current healthcare system has not sufficiently catered for good quality healthcare for all. This system has precluded the poor or those without medical aid from using a large number of health professionals, services and facilities. The NHI will establish <a href="https://moneytoday.co.za/national-health-insurance-pros-cons/">a single pool</a> of healthcare funding for private and public providers. It will pay both these providers on exactly the same basis and expect the same standard of care from them. </p>
<p>For South Africans without medical aid (health insurance) or in lower income groups, the NHI will offer more equitable access to healthcare services. It will allow them to consult private practitioners and to attend private facilities. The NHI also purports to improve the resourcing of public hospitals and healthcare services as the burden of care will be more evenly distributed.</p>
<p>For South Africans who do have medical aid, the NHI may be a shock to the system. Those who are accustomed to private care may have to settle for lower standards while still paying a similar or higher fee. South Africans within a certain income bracket will have to make mandatory monthly payments towards healthcare in addition to carrying a higher tax burden.</p>
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Read more:
<a href="https://theconversation.com/south-african-taxpayers-will-bear-the-brunt-of-national-health-insurance-122409">South African taxpayers will bear the brunt of National Health Insurance</a>
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<p>Medical aid schemes will not be able to offer any services that are offered by the NHI. Private medical insurance will only be able to provide for “complementary or top-up cover” that doesn’t overlap with services covered by the NHI. </p>
<p>These issues are clear, but the NHI bill contains lots of grey areas. </p>
<h2>Grey areas</h2>
<p>The rule of law requires that everyone, citizens and corporates and governments, adhere to the law. They can only do so if the law is clear and unambiguous. Laws must provide reasonable certainty. </p>
<p><a href="http://www.saflii.org/za/cases/ZACC/2005/3.html">South African courts</a> have explained it like this: </p>
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<p>The law must indicate with reasonable certainty to those who are bound by it what is required of them so that they may regulate their conduct accordingly. </p>
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<p>The current version of the bill is uncertain in the following key areas: </p>
<ul>
<li><p>the migration of hospitals to semi-autonomous entities </p></li>
<li><p>the structure of the contracting unit for primary healthcare needs</p></li>
<li><p>establishment of the fund </p></li>
<li><p>the Health Patient Registration System </p></li>
<li><p>accreditation issues</p></li>
<li><p>purchasing of services </p></li>
<li><p>the amendment of other pieces of legislation to make room for the NHI and payment concerns.</p></li>
</ul>
<p>A significant concern relates to the uncertainty regarding what will be covered by NHI and what will not. As the bill expressly aims to cover the costs of certain healthcare services, it is reasonable to expect that these services be clearly set out. How can we follow the law when we do not know what it is? Without this certainty, the bill is vague and so it cannot be seen as good law.</p>
<p>The bill is also vague on how the NHI fund will be financed. Recent estimates have put its cost at more than <a href="https://www.iol.co.za/news/south-africa/kwazulu-natal/nhi-bill-do-we-need-it-who-will-pay-for-it-how-will-it-affect-my-medical-aid-all-your-questions-answered-6574c217-8f19-4dd3-9f6b-7a5230ac02de">R500 billion a year</a> (about US$27.6 billion). And what will happen to medical aid schemes? <a href="https://www.gov.za/sites/default/files/gcis_document/201908/national-health-insurance-bill-b-11-2019.pdf#pag=19">Section 33</a> of the bill, which provides for the role of medical aid schemes, is open to the interpretation that these schemes will disappear. </p>
<p>Real doubt exists as to whether an NHI system will ever be workable in South Africa. The bill has been described as an <a href="https://www.dailymaverick.co.za/article/2023-06-25-national-health-insurance-is-a-big-fat-empty-promise-experts/">empty promise</a>. Again, this is bad.</p>
<h2>Ideal and practice</h2>
<p>Universal access to healthcare and the ideal of a national system of health insurance are important concepts which relate directly to core human rights, and as such are noble and necessary.</p>
<p>However, it’s often the case that an ideal falls short in practice. The NHI bill is no exception. Many concerns and critiques have been raised against the bill and its implementation. Satisfactory solutions have not yet been offered. </p>
<p>The NHI cannot be avoided. But to benefit all and live up to its potential, it should be fully thought through, planned in detail and not rushed.</p><img src="https://counter.theconversation.com/content/208604/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Larisse Prinsen 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>The NHI bill aims to ensure that all South Africans have access to quality healthcare services.Larisse Prinsen, Senior lecturer in law, University of the Free StateLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/2006562023-03-07T19:04:50Z2023-03-07T19:04:50ZHealth care offered to women in prison should match community standards – and their rights<figure><img src="https://images.theconversation.com/files/513093/original/file-20230302-28-lwt15j.jpg?ixlib=rb-1.1.0&rect=0%2C95%2C8000%2C5233&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-womans-hand-cell-prison-psychiatric-2208373333">shutterstock</a></span></figcaption></figure><p>On this <a href="https://www.un.org/en/observances/womens-day">International Women’s Day</a>, let’s not forget women in prison.</p>
<p>There are 3,088 women <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/justice/corrective-services">imprisoned in Australia</a> on any given day, representing 7.5% of the prison population. Aboriginal and Torres Strait Islander women are <a href="https://www.abs.gov.au/statistics/people/crime-and-justice/corrective-services-australia/latest-release#:%7E:text=The%20Aboriginal%20and%20Torres%20Strait,from%20423%20persons%20last%20quarter.">over-represented</a> in these numbers.</p>
<p>Australia spends <a href="https://www.pc.gov.au/ongoing/report-on-government-services/2023/justice/corrective-services">$4.44 billion</a> on prisons. Despite this, reproductive health care equivalent to that in the community is often not available where women are being detained.</p>
<p>This includes care related to <a href="https://search.informit.org/doi/abs/10.3316/ielapa.727381003357278">menstruation</a>, <a href="https://journals.lww.com/menopausejournal/Documents/Experiences%20of%20menopause%20during%20incarceration.pdf">menopause</a>, <a href="https://onlinelibrary.wiley.com/doi/full/10.1111/jocn.14837">contraception</a>, preventive health care such as <a href="https://equityhealthj.biomedcentral.com/articles/10.1186/s12939-020-1155-3">cervical screening tests</a>, and <a href="https://www.osce.org/files/f/documents/f/b/427448.pdf">access to abortions</a>. </p>
<p>Adequate health care <a href="https://www.ohchr.org/sites/default/files/Documents/ProfessionalInterest/BangkokRules.pdf">during pregnancy</a>, <a href="https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2021/08/Womens-Expectations-FINAL-July-2021-1.pdf">birth</a> and <a href="https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2021/08/Womens-Expectations-FINAL-July-2021-1.pdf">after birth</a> is often unavailable in these prisons.</p>
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Read more:
<a href="https://theconversation.com/the-un-committee-against-torture-has-found-australia-still-has-work-to-do-195420">The UN committee against torture has found Australia still has work to do</a>
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<h2>Protecting women’s dignity and health</h2>
<p>Reproductive health care must be delivered in appropriate ways to those who require it. Aboriginal and Torres Strait Islander people require <a href="https://www.ahpra.gov.au/About-Ahpra/Aboriginal-and-Torres-Strait-Islander-Health-Strategy/health-and-cultural-safety-strategy.aspx">culturally safe</a> health care, free from racism. There must also be inclusive care for <a href="https://yogyakartaprinciples.org/principle-9/">non-binary and transgender people</a>.</p>
<p>Failing to provide access to sanitary pads and tampons is a form of degrading treatment, according to the <a href="https://rm.coe.int/1680696a74">European Committee for the Prevention of Torture and Inhuman or Degrading Treatment or Punishment</a>. It can leave women and people who menstruate <a href="https://www.wcl.american.edu/impact/initiatives-programs/center/documents/gender-perspectives-on-torture/">vulnerable to exploitation</a>. For example, limited access to sanitary pads can lead to them being traded for favours. </p>
<p>In addition to menstrual items, underwear also needs to be available for people in prison. A 2019 consultation by the <a href="https://www.qhrc.qld.gov.au/__data/assets/pdf_file/0003/17139/2019.03.05-Women-In-Prison-2019-final-report-small.pdf">Queensland Human Rights Commission</a> reported one woman’s experience of being detained in a Brisbane watch-house. The woman had to stick a menstrual pad to her tracksuit, because she was not given underwear. “There was blood everywhere,” the woman’s cellmate recalled. “They eventually gave her an incontinence nappy, and a clean pair of pants.” </p>
<p>The <a href="https://www.ics.act.gov.au/reports-and-publications/critical-incident-reviews/critical-incident-reviews/use-of-force-to-conduct-a-strip-search-at-the-alexander-maconochie-centre-on-11-january-2021">ACT Inspector of Correctional Services</a> conducted a review into the Alexander Maconochie Centre, a prison in Canberra. The review investigated the use of force during a strip search on an Aboriginal woman. The woman had become distressed after being advised she was not allowed to attend her grandmother’s funeral and participate in Sorry Business. She was menstruating at the time, and was a victim-survivor of sexual assault.</p>
<p>The woman described her experience: </p>
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<p>At this time I was menstruating heavily due to all the blood thinning medication I take on a daily basis. Here I ask you to remember that I am a rape victim. So you can only imagine the horror, the screams, the degrading feeling, the absolute fear and shame I was experiencing [during the strip search].</p>
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<p>On another issue at the same prison, the ACT office <a href="https://www.ics.act.gov.au/__data/assets/pdf_file/0011/2111888/11432RR-ACT-ICS-Healthy-Prison-Review-Nov-2022_Full-report_FA-tagged.pdf">recommended</a> “condoms, water-based lubricants and dental dams be made freely available in the units so detainees can access them without having to make a request to staff”. </p>
<p>In its prison review, the inspector had been told detained people in the Alexander Maconochie Centre wanting to practice safe sex were “making do” by “cutting open latex gloves”.</p>
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Read more:
<a href="https://theconversation.com/heres-some-context-missing-from-the-mparntwe-alice-springs-crime-wave-reporting-199481">Here's some context missing from the Mparntwe Alice Springs 'crime wave' reporting</a>
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<h2>Access to terminations and care following miscarriages</h2>
<p>The <a href="https://www.ohchr.org/sites/default/files/Documents/HRBodies/HRCouncil/RegularSession/Session22/A.HRC.22.53_English.pdf">United Nations Special Rapporteur on Torture</a> has stated “denial of legally available health services such as abortion and post-abortion care” amounts to “mistreatment of women seeking reproductive health services”. Forcing people to continue their pregnancy is a form of <a href="https://www.osce.org/files/f/documents/f/b/427448.pdf">sexual and gender-based violence</a>. </p>
<p>The <a href="https://rm.coe.int/1680696a74">European Committee for the Prevention of Torture</a> has affirmed that respect for a detained “woman’s right to bodily integrity” requires they have the same access to the “morning after pill and/or other forms of abortion at later stages of a pregnancy” as “women who are free.”</p>
<p>It is also crucial for <a href="https://www.justiceinspectorates.gov.uk/hmiprisons/wp-content/uploads/sites/4/2021/08/Womens-Expectations-FINAL-July-2021-1.pdf">people who miscarry</a> to be provided with the appropriate mental health and physical care.</p>
<p>Increased transparency and oversight is needed to ascertain whether minimum standards for reproductive health care are being met in Australian prisons. However, accounts from women in prison have <a href="https://apo.org.au/sites/default/files/resource-files/2020-04/apo-nid306852.pdf">indicated</a> access to even basic healthcare is often a challenge.</p>
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<h2>Birth and separation</h2>
<p>In Australia, there have been instances of an Aboriginal woman <a href="https://www.oics.wa.gov.au/wp-content/uploads/2018/12/Birth-at-Bandyup-Media-release.pdf">giving birth</a> alone in a locked prison cell while staff observed through the hatch. Another example featured attempts to remove a baby from their Aboriginal mother <a href="https://www.hrlc.org.au/news/2018/4/27/aboriginal-baby-to-stay-with-her-mother-at-bandyup-womens-prison">against medical advice</a> due to insufficient capacity at the prison. And an Aboriginal woman was <a href="https://www.vals.org.au/wp-content/uploads/2022/05/VALS-Submission-to-Inquiry-into-Children-of-Imprisoned-Parents-FINAL-version.pdf">denied</a> the right to bond with her newborn and breastfeed them.</p>
<p>Yet the UN <a href="https://www.ohchr.org/sites/default/files/Documents/ProfessionalInterest/BangkokRules.pdf">Rules for the Treatment of Women Prisoners and Non-custodial Measures for Women Offenders</a> state women “shall not be discouraged from breastfeeding their children, unless there are specific health reasons to do so”. </p>
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<h2>We need more transparency in prisons, so we can fix these issues</h2>
<p>Implementation of the <a href="https://www.ohchr.org/en/instruments-mechanisms/instruments/optional-protocol-convention-against-torture-and-other-cruel">UN Optional Protocol</a> to the Convention against Torture and other Cruel, Inhuman or Degrading Treatment or Punishment could bring attention to what is happening in Australian prisons. </p>
<p>This protocol calls for <a href="https://theconversation.com/why-has-a-un-torture-prevention-subcommittee-suspended-its-visit-to-australia-193295">regular visits</a> to places of detention by independent bodies to prevent ill-treatment of detained people, including denial of reproductive health care.</p>
<p>But <a href="https://theconversation.com/australias-twice-extended-deadline-for-torture-prevention-is-today-but-weve-missed-it-again-197793">in January</a> Australia missed its implementation deadline. Australia is currently at risk of being added to the <a href="https://www.ohchr.org/en/treaty-bodies/spt/non-compliance-article-17">UN list of non-compliant countries</a>. Australian commonwealth, state and territory governments have some work to do before this tool can be effectively used to prevent mistreatment of incarcerated women.</p>
<p>And while shining a light in the dark corners of prisons is essential, there are concrete steps governments can take now to improve reproductive health care and provide community-equivalent care. </p>
<p>These include ending the <a href="https://www.theguardian.com/australia-news/2023/jan/20/people-before-profits-victoria-to-ditch-private-health-providers-in-womens-prisons">privatisation of prison health care</a>, having <a href="https://www.coronerscourt.vic.gov.au/sites/default/files/2023-02/COR%202020%200021%20-%20Veronica%20Nelson%20Inquiry%20-%20Form%2037%20-%20Finding%20into%20Death%20with%20Inquest%20-%2030%20January%202023%20-%20Amended.pdf">accessible health services</a> provided by Aboriginal Community Controlled Health Organisations, and reducing the number of women who are incarcerated in the first place.</p><img src="https://counter.theconversation.com/content/200656/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andreea Lachsz is currently contracted to the ACT government as the ACT National Preventive Mechanism (NPM) Coordination Director. The opinions expressed herein are those of the author and do not necessarily reflect those of ACT government, ACT NPM or any extant policy.</span></em></p>Despite Australia spending so much money on prisons, incarcerated women’s reproductive health care is lacking to the point of being degrading.Andreea Lachsz, PhD Candidate, University of Technology SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1917542022-12-05T19:04:03Z2022-12-05T19:04:03ZWhen does mental distress become a mental illness?<figure><img src="https://images.theconversation.com/files/487649/original/file-20221002-54720-5p5ek.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C1000%2C667&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/different-ethnicity-female-friends-hold-hands-1918840193">shutterstock</a></span></figcaption></figure><p>Human beings experience a range of emotions, some of which are pleasant, such as joy and happiness, and others that are uncomfortable or even painful, such as anxiety, anger or grief. Often, emotional discomfort or pain is temporary and appropriate to the circumstances. It is natural, and even helpful, to experience anxiety when facing a difficult decision, or grief when a loved one dies. </p>
<p>However, when painful mental states are long-lasting and interfere with our ability to function well in our daily lives and relationships, it can mean we are experiencing a form of mental illness. </p>
<p>Mental illnesses usually have <a href="https://www.healthdirect.gov.au/mental-illness">other impacts</a> apart from mood, including physical symptoms, changes in thinking, changes in behaviour, and sometimes changes in perception, including hallucinations, severe nightmares or flashbacks. </p>
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<a href="https://theconversation.com/menopause-hrt-linked-to-depression-heres-what-the-evidence-actually-says-194284">Menopause: HRT linked to depression – here's what the evidence actually says</a>
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<h2>What causes mental illness?</h2>
<p>Mental illness is complex. Medical science, philosophy, psychology and other disciplines are <a href="https://theconversation.com/is-depression-a-mental-or-physical-illness-unravelling-the-inflammation-hypothesis-37410">still debating</a> whether the mental “mind” and physical “brain” are <a href="https://qz.com/866352/scientists-say-your-mind-isnt-confined-to-your-brain-or-even-your-body">separate or integrated</a>. Some researchers believe mental illness originates in the <a href="https://www.apa.org/monitor/2012/06/roots">physical body and brain</a>, influenced by <a href="https://www.nature.com/articles/d41586-020-00922-8">genetics</a>, <a href="https://impact.deakin.edu.au/2021/06/lowering-inflammation-to-treat-mental-health-the-burgeoning-field-of-immuno-psychiatry/">inflammatory processes</a>, <a href="https://theconversation.com/teenage-mental-health-how-growing-brains-could-explain-emerging-disorders-154007">neurological development</a> and even <a href="https://www.bbc.com/future/article/20190218-how-the-bacteria-inside-you-could-affect-your-mental-health">hormones in the gut</a>. Other researchers believe mental illness originates <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3708113/">in the mind</a>, from learned responses that are unhelpful or damaging, or lived experiences that are traumatic. </p>
<p>Mental health is also influenced by the world in which a person lives, which might include family and kin, community, culture, Country or spirituality.</p>
<p><a href="https://www.aihw.gov.au/reports/mental-health-services/stress-and-trauma">Trauma experiences are important</a>. It is <a href="https://www.mhcc.org.au/wp-content/uploads/2018/05/ticp_awg_position_paper__v_44_final___07_11_13-1.pdf">profoundly disrespectful</a> to see a person who has experienced adversity such as intergenerational trauma, domestic violence, racial discrimination, poverty or any other systemic abuse, and apply a disease label like “depression” without acknowledging the crucial role of their trauma experiences in their health. </p>
<p>Managing mental health involves understanding how all these elements fit together. </p>
<h2>Why is a diagnosis important?</h2>
<p>Psychiatric diagnoses may be only one way of understanding mental illness, but they are important. In severe mental illnesses such as schizophrenia, medication can be essential to wellbeing. The evidence for <a href="https://www.nimh.nih.gov/health/topics/mental-health-medications">medication</a> and specific <a href="https://psychology.org.au/psychology/advocacy/position-papers-discussion-papers-and-reviews/psychological-interventions-mental-disorders">psychological strategies</a> in therapy are often based on making an accurate psychiatric diagnosis. It is also important to make sure mental illness symptoms are not <a href="https://health.clevelandclinic.org/is-a-hidden-medical-condition-causing-your-anxiety/">caused by physical diseases</a>. </p>
<p>Most people with mental illness diagnosis should also have a “formulation”, which is a description of why this person may be experiencing mental illness at this time. A formulation may include historical factors (such as childhood trauma), features of their personality (such as perfectionism), details of their lived experience (such as discrimination and harassment based on their gender identity), and acute stressors (such as living through a natural disaster).</p>
<p>Brought together, the diagnosis and formulation should help clinicians, patients and carers understand why they are unwell and develop a plan of action to optimise their mental health. A formulation includes aspects of lifestyle (including avoiding damaging social environments such as mentally unhealthy workplaces), psychosocial strategies (such as therapy) and, in some cases, medication. </p>
<p>Usually, a person with mental illness will choose which <a href="https://www.rethink.org/advice-and-information/living-with-mental-illness/treatment-and-support/recovery/">strategies</a> to use in collaboration with their treating team. </p>
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<img alt="A person sits at a desk looking at a box of tablets." src="https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/495015/original/file-20221114-20-oquxet.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">
<figcaption>
<span class="caption">Medication is one strategy to address mental health, sometimes alongside therapy.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/university-college-student-poor-mental-health-2149313661">shutterstock</a></span>
</figcaption>
</figure>
<h2>Recovering from mental illness</h2>
<p>Mental illness can range from a single episode to a lifetime condition, and from mild to severe. It can involve a single condition such as depression, but it is common to have more than one illness at a time (such as depression <em>and</em> anxiety). It is also common for physical and mental illnesses to occur together (eating disorders and diabetes, heart disease and depression). Mental illnesses can change over time. For many people, there will be times of stability, times of crisis, and times when mental health is consistently poor. </p>
<p>Because there is so much variation in people’s conditions and lived experiences, different people will have different approaches to treatment. Treatment often involves <a href="https://vcoss.org.au/health-and-wellbeing/2019/04/rethinking-mental-health/">social interventions</a> such as securing safe housing, addressing <a href="https://www1.racgp.org.au/ajgp/2019/october/lifestyle-interventions-for-mental-health">lifestyle</a> issues or helping with <a href="https://theconversation.com/when-its-easier-to-get-meds-than-therapy-how-poverty-makes-it-hard-to-escape-mental-illness-114505">financial stress</a>. It can also involve <a href="https://www.headtohealth.gov.au/">self-help strategies, helplines or psychological therapy</a>. </p>
<p>Treatment needs to be individualised. Just because a treatment is said to be “<a href="https://theconversation.com/my-doctor-says-theres-a-guideline-for-my-treatment-but-is-it-right-for-me-67768">evidence-based</a>” in one context, doesn’t mean it can treat everyone across the entire spectrum. Most evidence is developed through research in urban, middle-class, well-educated, predominantly white people, and it may not necessarily be the best psychological strategy to use for a <a href="https://theconversation.com/cognitive-behavioural-therapy-we-discovered-a-data-gap-on-its-effectiveness-for-different-ethnic-groups-158171">person from a completely different environment</a>. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/we-cant-solve-australias-mental-health-emergency-if-we-dont-train-enough-psychologists-here-are-5-fixes-190135">We can't solve Australia's mental health emergency if we don't train enough psychologists. Here are 5 fixes</a>
</strong>
</em>
</p>
<hr>
<h2>When to seek help</h2>
<p>If you have thoughts of self-harm or symptoms are severe enough to affect your ability manage everyday life, it is time to work with a <a href="https://www.theguardian.com/australia-news/2021/may/02/navigating-a-confusing-and-complex-mental-health-system-a-guide-to-care">mental health professional</a> to get a good, holistic diagnosis and formulate a management plan. </p>
<p>A <a href="https://theconversation.com/your-first-point-of-contact-and-your-partner-in-recovery-the-gps-role-in-mental-health-care-124083">GP</a> is a good place to start to check there are no physical reasons why your mental health is deteriorating. GPs are likely to have the best understanding of <a href="https://www.theguardian.com/australia-news/2021/apr/19/like-hunting-for-unicorns-australians-on-the-search-for-adequate-affordable-mental-healthcare">appropriate, accessible and affordable</a> options for care for your needs in your area. Unfortunately, specialised mental health services can be <a href="https://www.abc.net.au/news/2020-03-07/mental-health-care-costs-out-of-reach-for-those-who-need-it-most/12025060">expensive and difficult to access</a>.</p>
<p>Then it is time to identify the key issues impacting your mental health, and plan your recovery.</p>
<hr>
<p><em>If this article has raised issues for you, you can call <a href="https://www.lifeline.org.au">Lifeline</a> on 13 11 14 or <a href="https://www.13yarn.org.au/">13Yarn</a> on 13 92 76.</em></p><img src="https://counter.theconversation.com/content/191754/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Louise Stone receives funding from ACT Health to research mental health services for young people in the ACT</span></em></p>Mental distress can be a temporary reaction to life stress, or the beginning of a serious mental illness. It’s important to choose strategies and supports that work best for the individual.Louise Stone, General practitioner; Associate Professor, ANU Medical School, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1907452022-09-27T20:21:39Z2022-09-27T20:21:39ZHow health-care leaders can foster psychologically safer workplaces<figure><img src="https://images.theconversation.com/files/486635/original/file-20220926-26-578e68.JPG?ixlib=rb-1.1.0&rect=134%2C143%2C2694%2C1895&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, abuse from patients and a pandemic have contributed to overwhelming burnout and job dissatisfaction among workers.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span></figcaption></figure><p>Every day it seems the Canadian health-care staffing crisis worsens, with <a href="https://www.nytimes.com/2022/09/14/world/canada/nurse-shortage-emergency-rooms.html">emergency room closures</a>, <a href="https://theconversation.com/with-family-doctors-heading-for-the-exits-addressing-the-crisis-in-primary-care-is-key-to-easing-pressure-on-emergency-rooms-189199">not enough family doctors</a> and <a href="https://www.wellesleyinstitute.com/wp-content/uploads/2020/09/Waiting-for-Long-Term-Care-in-the-GTA.pdf">long wait times to get into long-term care</a>. </p>
<p>At the core are health-care workers who are physically and mentally burnt out from the unsafe work environments they’ve been asked to work in for years, which were made remarkably worse during COVID-19. </p>
<p>Health-care leaders have a key role to play in developing psychologically safer workplaces to support the well-being of our health-care workers. Building safer workplaces requires leaders who understand how years of resource constraints, unhealthy work environments, <a href="https://doi.org/10.1186/s12913-020-05084-x">abuse from patients</a>, and <a href="https://doi.org/10.3389/fpubh.2021.750529">the pandemic</a> have contributed to the overwhelming burnout and job dissatisfaction evident among workers.</p>
<h2>Physically and emotionally unsafe</h2>
<p>Even before the COVID-19 pandemic, Canadian health-care workers were experiencing <a href="https://www.cma.ca/sites/default/files/2018-11/nph-survey-e.pdf">burnout and depression</a>. The pandemic has worsened already poor working environments, exposing them not only to a life-threatening virus, but <a href="http://doi.org/10.1001/jama.2021.2701">mounting physical and verbal abuse</a>, <a href="https://www.cma.ca/sites/default/files/2022-08/NPHS_final_report_EN.pdf">increasing rates of burnout and depression</a>.</p>
<p>It is not surprising, then, that health-care workers are leaving the profession in greater numbers, <a href="https://www.cbc.ca/news/canada/nurses-canada-overtime-pandemic-burnout-1.6545963">further exacerbating the working conditions for the remaining health-care workers</a>. </p>
<figure class="align-center ">
<img alt="A paramedic in a face shield wearing a neon yellow jacket walks past patients on gurneys in a hospital corridor" src="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=417&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=417&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=417&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=524&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=524&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486636/original/file-20220926-21-w3atsc.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=524&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers, nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting burnout.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>The challenges are not limited to one group of health-care workers, or one type of workplace; personal support workers (PSWs), nurses, physicians, paramedics working in hospitals, long-term care, primary care clinics and emergency services are all reporting higher levels of stress. <a href="https://clri-ltc.ca/files/2021/02/PSW_Perspectives_FinalReport_Feb25_Accessible.pdf">PSWs working in long-term care report</a> physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</p>
<p>We know that <a href="https://www.mentalhealthcommission.ca/wp-content/uploads/drupal/Workforce_Psychological_Safety_in_the_Workplace_ENG.pdf">psychological health and safety in the workplace</a> is directly tied to productivity, retention, absenteeism, workplace conflict and the overall operational success of the workplace. Canadian health-care leaders, managers and supervisors are exceptionally placed to help health-care organizations build work environments where staff feel supported and safe. </p>
<figure class="align-right ">
<img alt="An outdoor sign reading 'Hiring PSWs - many shifts - benefits'" src="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=409&fit=crop&dpr=1 600w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=409&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=409&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=514&fit=crop&dpr=1 754w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=514&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/486638/original/file-20220926-879-z9tmaw.JPG?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=514&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">PSWs working in long-term care report physically and emotionally unsafe work environments, insufficient staff-to-patient ratios and disrespectful work environments.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span>
</figcaption>
</figure>
<p>Our research team was recently funded by the <a href="https://mentalhealthcommission.ca">Mental Health Commission of Canada</a> to examine the facilitators and barriers that health-care organizations face in creating safe work environments. We surveyed and interviewed <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">hundreds of health-care workers from across disciplines, workplaces and provinces</a>. Here’s what they told us: </p>
<ul>
<li><p>There is much focus placed on health-care workers building resiliency, but without giving them the time and space to do so. Organizations can help by protecting time off for workers. </p></li>
<li><p>Health-care workers have told us that long-term organizational resources such as wellness champions, ethicists and effective health benefits for all health-care workers (for example, benefits that cover counselling services) would help support their well-being. </p></li>
<li><p>Appropriate and transparent operational policies and procedures related to clinical care and/or human resources that pervade an entire organization help to develop a fair and safe working climate. Managers can further support their workers by ensuring those policies and procedures are consistently applied and followed.</p></li>
<li><p>Organizations should seek out and support effective, compassionate and authentic leaders. Developing health-care leaders who are skilled and rise to the job in their stressful environments is critical and should be cultivated and rewarded. Managers have also been through the wringer over the past several years and need to be supported by their organizations. </p></li>
<li><p>Fewer than 50 per cent of health-care workers in our study reported working in an ethical climate. For example, many health-care workers do not have access to the necessary supports to work through ethical dilemmas. This is a great place for health-care organizations to focus; cultivating an ethical work environment can demonstrate to its employees that they want to protect them from moral distress. </p></li>
<li><p>Health-care workers have told us that transparency and effective communications are critical and increase trust in their leaders. </p></li>
</ul>
<p>The future of our health system is dependent on recruiting and retaining passionate, hardworking and highly skilled health-care workers. Every health-care worker, in ever workplace, across every province needs an organization that values and prioritizes their psychological health and safety. For the full report please visit: <a href="https://mentalhealthcommission.ca/resource/exploring-two-psychosocial-factors-for-health-care-workers/">MHCC – Exploring Two Psychosocial Factors for Health-Care Workers</a>.</p><img src="https://counter.theconversation.com/content/190745/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>The future of our health system depends on recruiting and retaining passionate and highly skilled health-care workers. It’s essential to build work environments where they feel supported and safe.Angela Coderre-Ball, Assistant Professor (Adjunct), Family Medicine, Queen's University, OntarioColleen Grady, Associate Professor, Family Medicine, Queen's University, OntarioDenis Chênevert, Professor and director of healthcare management hub, HEC MontréalLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1901352022-09-21T02:04:00Z2022-09-21T02:04:00ZWe can’t solve Australia’s mental health emergency if we don’t train enough psychologists. Here are 5 fixes<figure><img src="https://images.theconversation.com/files/483927/original/file-20220912-12-17hd3f.jpg?ixlib=rb-1.1.0&rect=70%2C50%2C6639%2C4225&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/african-female-school-psychologist-supporting-sad-2169268299">Shutterstock</a></span></figcaption></figure><p>Almost 50% of Australians experience mental illness in their lifetime, costing our economy up to A$220 billion annually, according to <a href="https://www.pc.gov.au/inquiries/completed/mental-health/report">pre-pandemic figures</a>. </p>
<p>The full impact of the pandemic on our nation’s mental health is still emerging, but <a href="https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release">early signs</a> are bleak, with <a href="https://www.abs.gov.au/statistics/health/mental-health/national-study-mental-health-and-wellbeing/latest-release">one in five Australians</a> experiencing a mental health disorder between 2020 and 2021. </p>
<p>This includes 3.3 million people with anxiety disorders, 1.5 million with mood disorders, 650,000 with substance use disorders, and <a href="https://www.suicidepreventionaust.org/wp-content/uploads/2022/02/SPA_National-Policy-Platform_2022_FINAL.pdf">more than 3,000 deaths by suicide every year</a>.</p>
<p>But accessing help can be very <a href="https://www.abc.net.au/news/2021-09-18/australia-mental-health-wait-times-covid-pandemic/100457162">difficult</a>. Government investment in psychology training programs is part of this problem.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/suicide-rates-reveal-the-silent-suffering-of-australias-ageing-men-187925">Suicide rates reveal the silent suffering of Australia’s ageing men</a>
</strong>
</em>
</p>
<hr>
<h2>A severe shortage of psychologists</h2>
<p>Currently, the federal government is meeting only <a href="https://acilallen.com.au/uploads/media/NMHWS-BackgroundPaper-040821-1628485846.pdf">35% of its psychology workforce target</a>. </p>
<p>One in three psychologists report having <a href="https://www.abc.net.au/news/2022-05-19/unis-lose-money-on-degrees-needed-to-boost-psychologist-numbers/101078968">closed their books to new patients</a>, due to overwhelming demand. Despite this, psychology workforce issues were not on the agenda at the recent <a href="https://treasury.gov.au/sites/default/files/2022-08/2022-302672-ip-easy-read.pdf">jobs and skills summit</a>.</p>
<p>Brain and mental health disorders including <a href="https://www.ahajournals.org/doi/full/10.1161/STROKEAHA.120.032215?af=R">stroke</a>, <a href="https://www.dementia.org.au/sites/default/files/NATIONAL/documents/The-economic-cost-of-dementia-in-Australia-2016-to-2056.pdf">dementia</a>, <a href="https://theconversation.com/myths-and-stigma-about-adhd-contribute-to-poorer-mental-health-for-those-affected-161591">ADHD</a>, <a href="https://www.aihw.gov.au/reports/mental-health-services/mental-health">depression</a> and <a href="https://www.latrobe.edu.au/news/articles/2022/release/alcohol-bystanders-burden-revealed">alcohol/substance misuse</a> are major causes of disability, with significant personal and societal <a href="https://finalreport.rcvmhs.vic.gov.au/">impacts</a>. </p>
<p>Timely diagnosis, assessment and treatments for these complex conditions are crucial. However, these services require psychologists with advanced training. This includes clinical psychologists, clinical neuropsychologists, counselling psychologists, educational and developmental psychologists, forensic psychologists and health psychologists. These psychologists are comprehensively trained in assessment, intervention and treatment of people with mental illness and brain conditions. </p>
<p>Hundreds of hospital-based psychology positions <a href="https://www.health.vic.gov.au/strategy-and-planning/mental-health-workforce-strategy">remain unfilled</a>, with patients (including children) waiting up to two years for <a href="https://www.curtin.edu.au/friends/curtin-commons/curtin-research-%20provides-lifeline-for-wa-children-needing-mental-health-care/">care</a>. Positions are often advertised for months with no qualified applicants, particularly in <a href="https://www.abc.net.au/news/2022-08-30/remote-and-regional-health-staff-battle-extreme-burnout/101366968">regional and remote hospitals</a>.</p>
<figure class="align-center ">
<img alt="University students sit with laptops." src="https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485028/original/file-20220916-26-z109tc.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">
<figcaption>
<span class="caption">Some students are unable to undertake psychology university courses due to affordability, which can impact equity of access and student diversity.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/multinational-group-students-auditorium-1424174663">Shutterstock</a></span>
</figcaption>
</figure>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/white-female-and-high-rates-of-mental-illness-new-diversity-research-offers-a-snapshot-of-the-publishing-industry-189679">White, female, and high rates of mental illness: new diversity research offers a snapshot of the publishing industry</a>
</strong>
</em>
</p>
<hr>
<h2>Psychology training places are declining despite high demand</h2>
<p>Postgraduate psychology courses are costly to run, requiring high staff-to-student ratios and incurring high clinical supervision and placement costs. </p>
<p>Unlike medical degrees, government funding for these programs <a href="https://www.smh.com.au/politics/federal/universities-lose-money-on-psychology-degrees-as-waitlists-languish-20211203-p59ei0.html">does not come close to covering the costs of the courses</a>. The recently reduced federal government support is <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp2021/GovernmentFundingHigherEducation#_Toc70073557">half</a> that given to veterinary science. This means universities lose money on these programs, making them an unattractive financial prospect for ever-tightening higher education budgets. </p>
<p>This has led to <a href="https://www.theage.com.au/national/victoria/diminished-capacity-australia-tipped-to-lose-one-in-10-university-jobs-20200930-p560mv.html">program closures</a>, despite consistently high demand for training places. Across Australia, the number of clinical neuropsychology training programs has fallen from eight to five in the past ten years. There have been similar reductions in health, counselling and forensic psychology training. </p>
<p>La Trobe University’s neuropsychology program received more than 300 applications annually for up to ten places, yet the program was closed in 2020. Similarly, according to course conveners, clinical psychology programs regularly receive at least 20 applicants for each available place.</p>
<p>Universities are now resorting to reducing government-funded masters places in favour of costly full-fee places (around $35,000 each year), impacting affordability, equity of access and student diversity. This disrupts any endeavour to develop a culturally and socioeconomically representative workforce and fails to meet the needs of our healthcare sector. </p>
<p>Many psychologists choose to enter better-paying private practices straight out of university, bypassing public health roles. This affects the general public’s access to mental health services. </p>
<p>We must do better. Vulnerable people living with mental health problems deserve to be supported and protected. </p>
<figure class="align-center ">
<img alt="A person is on a train looking sad." src="https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/485025/original/file-20220916-26-45ags5.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">
<figcaption>
<span class="caption">Vulnerable people might miss out on mental health services due to lack of affordability and limited psychologists available.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/melancholic-woman-looks-out-window-tram-320450978">shutterstock</a></span>
</figcaption>
</figure>
<h2>5 solutions to the psychology workforce problem</h2>
<p>There are straightforward steps that could go a long way to addressing this issue.</p>
<ol>
<li><p>Increase funding for postgraduate psychology training so universities do not lose money by offering these programs.</p></li>
<li><p>Ensure a minimum number of <a href="https://www.studyassist.gov.au/help-loans/commonwealth-supported-places-csps">Commonwealth Supported Places</a> (that is, with no, or reduced, student fees) are protected for students in psychology training programs and make sure these align with workforce demands and job vacancies.</p></li>
<li><p>Consider training models that incorporate “return-of-service” obligations. This is when the government subsidises student fees but requires graduates to engage in paid health services work for a minimum period, such as two years.</p></li>
<li><p>Invest in joint university/health service psychology staff positions (as occurs in medical training) to provide supervision and placements within the sector.</p></li>
<li><p>Increase placement opportunities for postgraduate students via better collaboration between universities, services and government.</p></li>
</ol>
<p>All Australians deserve to have their mental health needs supported by trained and qualified psychologists. Investing in the psychology workforce will be <a href="https://www.pc.gov.au/inquiries/completed/mental-health/report/mental-health-volume1.pdf">good for the economy</a>, increase total workforce participation, reduce wait times and save lives.</p>
<hr>
<p><em>The authors would like to thank Tamara Cavenett (President, Australian Psychological Society) and Lynda Katona (Manager, Psychology Services, Alfred Health) for their contributions to this article.</em></p><img src="https://counter.theconversation.com/content/190135/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Dana Wong receives research grant funding from the National Health and Medical Research Council (NHMRC), Medical Research Future Fund (MRFF) and the Stroke Foundation. Dana is President-Elect of the Australasian Society for the Study of Brain Impairment, and a member of the APS College of Clinical Neuropsychologists.</span></em></p><p class="fine-print"><em><span>Catriona Davis-McCabe is the President-Elect of the Australian Psychological Society and an Adjunct Senior Lecturer/Researcher at Curtin University.</span></em></p><p class="fine-print"><em><span>Joanne Wrench is the Manager, Psychology at Austin Health and Chair of the Victorian Hospital Heads of Psychology. </span></em></p><p class="fine-print"><em><span>Katherine Lawrence has previously received research grant funding from Australian Rotary Health. </span></em></p><p class="fine-print"><em><span>Lorelle Burton is Chair of the Heads of Departments and Schools of Psychology Association (HODSPA) and is Professor and Head of the School of Psychology and Wellbeing at the University of Southern Queensland</span></em></p>At the time Australia needs it most, there is a crisis in the workforce of psychologists trained to assess and treat brain and mental health conditions.Dana Wong, Associate Professor & Clinical Neuropsychologist, La Trobe UniversityCatriona Davis-McCabe, Adjunct Senior Lecturer - Curtin School of Population Health, Curtin UniversityJoanne Wrench, Honorary Fellow, Melbourne School of Psychological Sciences, The University of MelbourneKatherine Lawrence, Associate Professor & Clinical Psychologist, Monash UniversityLorelle Burton, Professor, University of Southern QueenslandLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1870682022-09-15T02:59:09Z2022-09-15T02:59:09ZHow do we support Indigenous people in Australia living with musculoskeletal conditions?<figure><img src="https://images.theconversation.com/files/481245/original/file-20220826-23-r0mowc.jpg?ixlib=rb-1.1.0&rect=5%2C130%2C3783%2C2545&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/mri-scan-human-spine-168563063">shutterstock</a></span></figcaption></figure><p>There have been national, state and local campaigns to “<a href="https://www.closingthegap.gov.au/national-agreement/targets">Close the Gap</a>” in Australia. Despite this, considerable health gaps still exist between Indigenous and non-Indigenous people.</p>
<p>Musculoskeletal conditions are an area of health where there is a significant difference between Indigenous and non-Indigenous people. Although Indigenous people experience musculoskeletal conditions <a href="https://pubmed.ncbi.nlm.nih.gov/29245188/">more</a>, their access to high-quality and culturally informed support remains low.</p>
<p>Musculoskeletal conditions can have a considerable <a href="https://pubmed.ncbi.nlm.nih.gov/22392923/">effect</a> on people’s lives. Such conditions can affect a person’s ability to walk, complete simple tasks at home without help, and participate in sports or work.</p>
<p>Government health organisations need to provide better support for Indigenous people suffering from these conditions by encouraging culturally safe community-based care.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-mothers-are-more-likely-to-die-during-childbirth-more-first-nations-midwives-could-close-this-gap-182935">First Nations mothers are more likely to die during childbirth. More First Nations midwives could close this gap</a>
</strong>
</em>
</p>
<hr>
<h2>What are musculoskeletal conditions?</h2>
<p><a href="https://www.health.gov.au/health-topics/chronic-conditions/what-were-doing-about-chronic-conditions/what-were-doing-about-musculoskeletal-conditions#:%7E:text=We%20are%20providing%20%244%20million,and%20training%20for%20health%20professionals">Musculoskeletal conditions</a> include disorders that affect the bones, muscles and joints such as back pain and osteoarthritis. They affect approximately one in three <a href="https://pubmed.ncbi.nlm.nih.gov/35505334/#:%7E:text=In%202019%2C%2022.3%25%20and%2039.8,particular%20females%20and%20older%20Australians">Australians</a>. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1560044779941302272"}"></div></p>
<p>Internationally, low back pain is the leading cause of <a href="https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(18)30480-X/fulltext">disability</a>, and osteoarthritis is the leading cause of physical activity <a href="https://pubmed.ncbi.nlm.nih.gov/24553908/">limitation</a>. Both of these ailments are more common in <a href="https://pubmed.ncbi.nlm.nih.gov/29245188/">Indigenous people</a>, who are 20-50% more likely to have osteoarthritis and 10% more likely to report current back pain than the non-Indigenous population in Australia. </p>
<p>Musculoskeletal conditions have also been shown to contribute to the development of <a href="https://pubmed.ncbi.nlm.nih.gov/30249247/#:%7E:text=Pooled%20adjusted%20estimates%20from%20these,total%20n%20%3D%202%2C686%2C113%20people">chronic diseases</a> such as diabetes and cardiovascular disease. With 46% of Australia’s Indigenous population having at least <a href="https://www.abs.gov.au/statistics/people/aboriginal-and-torres-strait-islander-peoples/national-aboriginal-and-torres-strait-islander-health-survey/latest-release">one</a> chronic condition, this may lead to even <a href="https://pubmed.ncbi.nlm.nih.gov/22818936/">higher</a> rates of chronic diseases.</p>
<p>Many Indigenous people resign themselves to being in <a href="https://pubmed.ncbi.nlm.nih.gov/15885010/">pain</a> and living with their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808686/">condition</a>. The social impact of living with these conditions is important to consider. For some First Nations people, it has the potential to restrict participation in activities of cultural significance and minimising connection with family and Country. </p>
<p>For example, the ability to care for and connect with extended family, attend community and family gatherings and enjoy activities on Country. These <a href="https://pubmed.ncbi.nlm.nih.gov/22392923/">limitations</a> often have considerable emotional effects on individuals, leading to feelings of anger, depression and fear.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/colonial-ideas-have-kept-nz-and-australia-in-a-rut-of-policy-failure-we-need-policy-by-indigenous-people-for-the-people-188583">Colonial ideas have kept NZ and Australia in a rut of policy failure. We need policy by Indigenous people, for the people</a>
</strong>
</em>
</p>
<hr>
<h2>Community-based care is needed</h2>
<p>Indigenous people’s <a href="https://pubmed.ncbi.nlm.nih.gov/24127305/">access</a> to health-care services to manage pain is half the expected rate compared to non-Indigenous people. Part of the reason for lower health care access is due to <a href="https://pubmed.ncbi.nlm.nih.gov/25945587/">negative experiences</a> with health-care services due to discriminatory attitudes toward pain from health-care providers. Unfortunately this is a common occurrence for Indigenous people. More than half (53%) of all Indigenous people have <a href="https://www.westernsydney.edu.au/__data/assets/pdf_file/0009/1201203/OMAC1694_Challenging_Racism_Report_4_-_FINAL.pdf">experienced racism</a> when when seeking health care. </p>
<p>Ways to increase Indigenous peoples’ access to health services is for them to have better support with self-managing their condition. In addition, community-based approaches to health care would provide a safer space for these patients. The <a href="https://www.health.gov.au/initiatives-and-programs/indigenous-australians-health-programme">Indigenous Australians’ Health Programme</a> and other funding bodies must work with communities, clinicians, and researchers to deliver programs addressing musculoskeletal conditions and chronic diseases. These programs need to ensure local communities are at their <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7999419/">centre</a> and cultural safety for participants is a priority. Such programs could be led by community-based allied health clinicians, but should include a range of health professionals to ensure optimal care is provided that addresses all factors related to musculoskeletal conditions.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/indigenous-people-with-disabilities-face-racism-and-ableism-whats-needed-is-action-not-another-report-187528">Indigenous people with disabilities face racism and ableism. What's needed is action not another report</a>
</strong>
</em>
</p>
<hr>
<h2>Health care needs to include cultural safety</h2>
<p>A whole of system approach is required to improve access to health care for Indigenous people in Australia. National, state, and local services must work together to ensure culturally safe care is provided, placing Indigenous clients and local communities at its <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7999419/">core</a>. This shift will likely require changes in how clinicians deliver care, how the services organise care, and how the health-care system supports this care.</p>
<p>Ineffective communication is often sighted as a <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808686/">barrier</a> to care for Indigenous people. This is why clinicians building connections and rapport with the Indigenous community they are treating is important. Undertaking training in cultural safety and effective communication strategies is essential to assist clinicians in providing optimal care.</p>
<p>To improve health services, programs providing care for musculoskeletal conditions should aim to partner with Aboriginal Community Controlled Health Organisations and ensure Indigenous people are trained and employed as part of the team. The health system should also ensure <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7808686/">policies prioritise</a> these employment opportunities as well as the importance of providing culturally safe care and working with local Indigenous communities.</p>
<p>A person’s musculoskeletal pain and the presence of chronic diseases are often intertwined. We must develop community-based models of care to address these conditions in Indigenous people, and ensure culturally safe care is being provided.
These changes will require ongoing training for health-care staff. </p>
<p>The fundamental shift is the inclusion of local Indigenous communities in all health care initiatives. These improvements will help ensure Indigenous people have the opportunity to self-manage their musculoskeletal pain, general health and well being.</p><img src="https://counter.theconversation.com/content/187068/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Christopher Williams receives funding from National Health and Medical Research Council of Australia. </span></em></p><p class="fine-print"><em><span>Jane Linton and Simon Davidson 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>Government health organisations need to provide better support for Indigenous people suffering from musculoskeletal conditions.Simon Davidson, PhD Candidate, University of NewcastleChristopher Williams, Associate Professor, University of SydneyJane Linton, Affiliate, University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1879862022-09-12T02:24:32Z2022-09-12T02:24:32ZRather than focusing on the negative, we need a strength-based way to approach First Nations childrens’ health<figure><img src="https://images.theconversation.com/files/476816/original/file-20220801-70755-5dvq9l.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5615%2C3741&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">
</span> <span class="attribution"><a class="source" href="https://www.gettyimages.com.au/detail/photo/brother-and-sister-having-fun-playing-in-the-royalty-free-image/1191210791?adppopup=true">GettyImages</a></span></figcaption></figure><p>First Nations children represent the future of the world’s oldest continuing culture. Of the 66,000 Victorians who identified as Aboriginal and/or Torres Strait Islander in the <a href="https://www.abs.gov.au/articles/victoria-aboriginal-and-torres-strait-islander-population-summary">2021 Census</a>, one-third were aged under 15 years.</p>
<p>First Nations children in Victoria are doing well in several health outcomes, our recent <a href="https://www.vaccho.org.au/adapt">report</a> has found. This report provides valuable insight into nutrition, physical activity and wellbeing among First Nations children living in regional Victoria. </p>
<p>Our <a href="https://onlinelibrary.wiley.com/doi/10.1111/1753-6405.13271">survey</a> found more than 300 First Nations primary school children were meeting guidelines for physical activity, healthy eating and screen time. Those who met these guidelines also had higher health-related quality of life.</p>
<p>However, our study is rare. Before our report, there was no information available about nutrition and physical activity among primary school-aged First Nations children in Victoria. </p>
<p>More evidence is needed about First Nations children’s health in Victoria. And it needs to be strengths-based, as opposed to highlighting deficits.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/i-am-country-and-country-is-me-indigenous-ways-of-teaching-could-be-beneficial-for-all-children-187424">'I am Country, and Country is me!' Indigenous ways of teaching could be beneficial for all children</a>
</strong>
</em>
</p>
<hr>
<h2>A strengths-based approach</h2>
<p>To examine First Nations childrens’ health, Aboriginal and non-Aboriginal researchers from <a href="https://iht.deakin.edu.au/2022/07/the-murnong-health-research-mob-growing-cultural-strengths-in-aboriginal-and-torres-strait-islander-nutrition-and-health-research/">Deakin University</a> partnered with the Victorian Aboriginal Community Controlled Health Organisation (VACCHO). This organisation is the peak body representing Victoria’s Aboriginal community-controlled <a href="https://drive.google.com/file/d/16zCFTZyK9ZZVF7qc6hMMXn74T2_Y8m77/view">health sector</a>.</p>
<p>VACCHO’s <a href="https://www.vaccho.org.au/member-services/workforce-development-2/nutrition/">nutrition team</a> works to improve food security and nutrition outcomes among Aboriginal communities across Victoria. Aboriginal Community Controlled Organisations such as these provide culturally safe care, and support self-determination.</p>
<p>In our research, we found there is potential for health data to stigmatise First Nations peoples by focusing on negative outcomes instead of progress. To avoid this, when collating data, we focused on measuring positive health outcomes (such as healthy weight) rather than measuring “problems” (like obesity). </p>
<p>We were interested in identifying factors that contribute to positive wellbeing. This <a href="https://www.sciencedirect.com/science/article/pii/S2352827320302743">strengths-based approach</a> acknowledges and celebrates the strength of First Nations children.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aboriginal-and-torres-strait-islander-population-has-increased-but-the-census-lacks-detail-in-other-facets-of-indigenous-lives-185692">Aboriginal and Torres Strait Islander population has increased, but the census lacks detail in other facets of Indigenous lives</a>
</strong>
</em>
</p>
<hr>
<h2>Many First Nations children are meeting the health guidelines</h2>
<p>Our findings indicate that many of the children surveyed were meeting nutrition and physical activity <a href="https://www.eatforhealth.gov.au/guidelines/about-australian-dietary-guidelines">guidelines</a>.</p>
<iframe src="https://flo.uri.sh/visualisation/11044441/embed" title="Interactive or visual content" class="flourish-embed-iframe" frameborder="0" scrolling="no" style="width:100%;height:600px;" sandbox="allow-same-origin allow-forms allow-scripts allow-downloads allow-popups allow-popups-to-escape-sandbox allow-top-navigation-by-user-activation" width="100%" height="400"></iframe>
<div style="width:100%!;margin-top:4px!important;text-align:right!important;"><a class="flourish-credit" href="https://public.flourish.studio/visualisation/11044441/?utm_source=embed&utm_campaign=visualisation/11044441" target="_top"><img alt="Made with Flourish" src="https://public.flourish.studio/resources/made_with_flourish.svg"> </a></div>
<p>For most of these measures, there was no significant difference between Aboriginal and non-Aboriginal children in the survey. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/aboriginal-and-torres-strait-islander-population-has-increased-but-the-census-lacks-detail-in-other-facets-of-indigenous-lives-185692">Aboriginal and Torres Strait Islander population has increased, but the census lacks detail in other facets of Indigenous lives</a>
</strong>
</em>
</p>
<hr>
<h2>There’s still work to do</h2>
<p>Our survey found Aboriginal children were more likely to report meeting vegetable consumption guidelines than their non-Aboriginal classmates. However, only 21% of Aboriginal children who participated reported eating the recommended number of vegetables each day.</p>
<p>While 53% of Aboriginal children had a healthy body weight, just under half did not. Non-Aboriginal children were more likely to have a healthy weight and on average had a lower body mass index than Aboriginal children.</p>
<p>This could be addressed through the development of a national First Nations food and nutrition plan. This plan would need to address issues such as <a href="https://www.aph.gov.au/Parliamentary_Business/Committees/House/Former_Committees/Indigenous_Affairs/Foodpricing">food security</a> and workforce capacity while directing funding to First Nations community-controlled nutrition programs.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/decolonising-classrooms-could-help-keep-first-nations-kids-in-school-and-away-from-police-188067">'Decolonising' classrooms could help keep First Nations kids in school and away from police</a>
</strong>
</em>
</p>
<hr>
<h2>Connecting physical health with social and emotional wellbeing</h2>
<p>Our survey also evaluated perceived physical, social, emotional and school-related wellbeing. This was measured using the Paediatric Quality of Life <a href="https://journals.lww.com/lww-medicalcare/Abstract/1999/02000/The_PedsQL___Measurement_Model_for_the_Pediatric.3.aspx">Inventory</a>. </p>
<p>We found non-Aboriginal children in our survey had significantly higher average health-related quality of life scores compared to Aboriginal children. This highlights this importance of promoting children’s mental health and social and emotional wellbeing alongside healthy eating and physical activity.</p>
<p>It’s important to recognise the connection between physical health (such as body weight) and health behaviours (diet, physical activity, screen time and sleep) with <a href="https://www.vaccho.org.au/balitdurndurncentre/">social and emotional wellbeing</a>.</p>
<p>This view of health is defined by the National Aboriginal Community Controlled Health Organisation as “not just the physical wellbeing of an individual but the social, emotional and cultural wellbeing of the whole Community”. This is why culturally appropriate research undertaken in partnership with Aboriginal organisations is so important, and something we prioritised in our work. </p>
<p>It is our hope our findings can be used by health services to plan culturally appropriate health promotion programs for First Nations children in Victoria. Ideally governments can use these findings to better support Victorian Aboriginal community controlled health organisations to implement these programs. </p>
<p>Our strengths-based approach should be replicated in future surveys of First Nations childrens’ health. Importantly, Aboriginal health must be in Aboriginal hands.</p>
<p><em>Holly Beswick from the Victorian Aboriginal Community Controlled Health Organisation (VACCHO) contributed to this article.</em></p><img src="https://counter.theconversation.com/content/187986/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Browne receives funding from the Heart Foundation and VicHealth.
This story is part of the Breaking the Cycle series, funded by the Ramsay Foundation.</span></em></p><p class="fine-print"><em><span>Jill Gallagher, Joleen Ryan, Mark Lock (Ngiyampaa), and Troy Walker 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>A recent report has found First Nations children in Victoria have better health outcomes, however culturally appropriate research can better highlight what’s going well for First Nations kids’ health.Jennifer Browne, Research Fellow, Deakin UniversityJill Gallagher, CEO of Victorian Aboriginal Community Controlled Health Organisation, Indigenous KnowledgeJoleen Ryan, Lecturer, Deakin UniversityMark Lock (Ngiyampaa), Casual Research Fellow, Deakin UniversityTroy Walker, Deakin UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1848442022-06-28T01:55:59Z2022-06-28T01:55:59ZThe Northern Territory is about to ease alcohol restrictions, but more consultation from First Nations community members is needed first<figure><img src="https://images.theconversation.com/files/471002/original/file-20220627-19-sfo457.jpg?ixlib=rb-1.1.0&rect=0%2C0%2C5227%2C3482&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/sydney-australia-september-2018-shelves-stocked-1180583470">Shutterstock</a></span></figcaption></figure><p>In 2012, <a href="https://www.niaa.gov.au/resource-centre/indigenous-affairs/stronger-futures-northern-territory">legislation</a> was introduced in the Northern Territory to restrict the possession and supply of alcohol without a liquor license or permit in designated alcohol protected <a href="https://nt.gov.au/law/alcohol/bans-and-dry-areas/changes-to-alcohol-restrictions-in-nt-communities">areas</a> in the Northern Territory.</p>
<p>This legislation will expire at midnight on 16 July 2022, <a href="https://nt.gov.au/law/alcohol/bans-and-dry-areas/changes-to-alcohol-restrictions-in-nt-communities">when 344</a> areas where Aboriginal people live will go back to unrestricted alcohol access. Alcohol restrictions in about 100 <a href="https://nt.gov.au/law/alcohol/bans-and-dry-areas/changes-to-alcohol-restrictions-in-nt-communities">general restricted areas (GRAs)</a> that were in place prior to the Stronger Futures legislation will continue under the <a href="https://legislation.nt.gov.au/en/Legislation/LIQUOR-ACT-2019">Liquor Act 2019</a>.</p>
<figure class="align-left zoomable">
<a href="https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A map is shown of restricted alcohol areas in the Northern Territory." src="https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=848&fit=crop&dpr=1 600w, https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=848&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=848&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=1066&fit=crop&dpr=1 754w, https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=1066&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/470995/original/file-20220627-14-ua55lc.png?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=1066&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">A map of the current restricted alcohol areas in the Northern Territory.</span>
<span class="attribution"><a class="source" href="https://nt.gov.au/__data/assets/pdf_file/0020/1107281/nt-alcohol-protected-areas-map-ao-size.pdf">Government of Northern Territory</a></span>
</figcaption>
</figure>
<p>Is restricting the sale of alcohol in communities racist and paternalistic? Without consultation, perhaps. But Indigenous and non-Indigenous <a href="https://www.amsant.org.au/wp-content/uploads/2022/05/LIQUOR-LAWS-JOINT-MEDIA-RELEASE.pdf">organisations </a> have come out against the lifting of restrictions. They call for transparent negotiation <a href="https://www.nit.com.au/a-relic-of-nt-intervention-is-being-lifted-but-peak-aboriginal-groups-are-furious/">processes,</a> that involve key community stakeholders, including women’s groups and youth groups.</p>
<p>Consultation with First Nations community members is vital to avoid making policy decisions without affected communities. This would ensure any strategies implemented would be culturally safe and be informed by people who have better knowledge of what respective communities need.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/national-reconciliation-centre-to-help-lead-national-systemic-change-183434">National reconciliation centre to help lead national systemic change</a>
</strong>
</em>
</p>
<hr>
<h2>Last minute legislation could lead to more overpolicing in the NT</h2>
<p>An Australian Institute of Health and Welfare <a href="https://www.aihw.gov.au/reports/burden-of-disease/illness-death-indigenous-2018/summary">report</a> estimated alcohol misuse accounts for 10.5% of total disease burden among Indigenous people in Australia, with that number doubling for Indigenous males aged 25–44. Reducing alcohol misuse can significantly <a href="https://www.indigenoushpf.gov.au/measures/2-16-risky-alcohol-consumption#references">improve</a> overall health and well-being, reduce levels of crime and disability and improve educational achievement.</p>
<p>According to one <a href="https://www2.deloitte.com/content/dam/Deloitte/au/Documents/Economics/deloitte-au-economics-alcohol-related-emergency-department-presentations-310719.pdf">report</a>, the Northern Territory has around five times the level of alcohol-related emergency department presentations compared to the next closest state or territory. Despite these numbers, both Commonwealth and Territory governments seem to be turning their backs on remote communities when it comes to alcohol policy. </p>
<p>The NT government will implement an <a href="https://nt.gov.au/law/alcohol/bans-and-dry-areas/changes-to-alcohol-restrictions-in-nt-communities">“opt-in” policy</a> when the restrictions are lifted. The NT government claims this policy will “<a href="https://www.riverineherald.com.au/national/new-nt-liquor-law-ends-remote-booze-ban/">empower communities</a>” as communities themselves can determine whether or not a designated area continues with an alcohol ban.</p>
<p>However this new “opt-in” process comes with barriers and risks. It assumes community awareness of these new laws and that communities will know how required procedures and processes for this will work, and have the required technology and internet access to do this. Another significant barrier will be communities achieving consensus about whether or not to “opt-in” to alcohol restrictions for their area. Applications to opt in must have written support of the registered land owner, which could be an NT incorporated association, a land trust or a corporation formed under Commonwealth legislation.</p>
<p>If communities are unaware of, or are unable to complete opt in process, this could result in a <a href="https://nacchocommunique.com/wp-content/uploads/2022/05/Media-Release-CAAC-concerns-re-end-APAs-3.5.22.pdf">significant increase</a> in alcohol-related harm and crime. The NT government says extra support will be provided to communities who decide not to re-implement the ban to help ensure safety. </p>
<p>However it is not clear what this “extra support” will look like, and communities are concerned it will mean “<a href="https://www.abc.net.au/news/2022-04-11/alcohol-bans-remote-communities-lifting-nt-police-concerned/100981856">extra policing</a>”. This is a concern for First Nations people, given the history of over policing of Aboriginal people and unfair or overzealous treatment by police.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/first-nations-people-in-the-nt-receive-just-16-of-the-medicare-funding-of-an-average-australian-183210">First Nations people in the NT receive just 16% of the Medicare funding of an average Australian</a>
</strong>
</em>
</p>
<hr>
<h2>Communities in The Northern Territory need a better way forward</h2>
<p>There is urgent need for a reconsideration of policy approaches to alcohol regulation in the NT. One example of this is the government approval of a Dan Murphy’s super liquor store in Darwin, with the owners themselves commissioning a report that <a href="https://www.woolworthsgroup.com.au/page/community-and-responsibility/corporate-responsibility-news-updates/people/independent-panel-review-into-the-proposed-dan-murphy%E2%80%99s-development-in-darwin">found</a> the new superstore approval was against the advice of health experts and community feedback.</p>
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<p>Many jurisdictions in the world <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1876414/">regulate alcohol</a>, and regulations vary depending on particular needs and circumstances. <a href="https://regulationbodyofknowledge.org/wp-content/uploads/2013/03/AustralianGovernment_Best_Practice_Regulation.pdfis">Regulation</a> should be tailored to local requirements determined by community consultation. </p>
<p>Consultation can be complicated, time-consuming and expensive, but it is the process called for in Australia’s own <a href="https://humanrights.gov.au/sites/default/files/content/social_justice/nt_report/ntreport09/pdf/ntr_nx3.pdf">guidelines</a> for engaging with
Indigenous communities.</p>
<p>Communities have expressed support for modification of drinking environments, through <a href="https://www.abc.net.au/news/2017-06-02/social-clubs-can-help-reduce-harm-in-communities-says-study/8581046">social clubs</a>, better <a href="https://drinkwise.org.au/our-work/indigenous-education-resources-and-partnerships/#">education</a> around alcohol consumption and public messaging about alcohol behaviours. Also culturally appropriate treatment programs and early intervention or <a href="http://www.amsant.org.au/wp-content/uploads/2019/07/AMSANT-Submission_Liquor-Bill-2019_FINAL1.pdf">preventative</a> measures have been recommended.</p>
<p>Any future misuse of alcohol in these communities will lead to blame and punishment of individuals despite some affected communities being vocal about not wanting these restrictions lifted in the first place.</p>
<p>Successful community outcomes can only be found through respectful and collaborative support from the government, industry and the wider community to better support First Nations people in controlling their social environment, including the use of alcohol. </p>
<hr>
<p><em>The authors wish to thank Neil Westbury for his time and insights, as reflected in <a href="https://johnmenadue.com/albanese-government-protect-women-children-in-remote-nt-communities/">this commentary</a>.</em></p><img src="https://counter.theconversation.com/content/184844/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Andrew Lockyer Works for North Australian Aboriginal Justice Agency. He is affiliated with NT Government Youth Justice Advisory Committee. </span></em></p><p class="fine-print"><em><span>Elizabeth Crawford Spencer 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>The Northern Territory has had alcohol restrictions since 2012. These restrictions are going to be lifted in July of this year, despite concerns expressed by First Nations people in the community.Elizabeth Crawford Spencer, Professor of Law, Charles Darwin UniversityAndrew Lockyer, Community Legal Educator, North Australian Aboriginal Justice Agency, Indigenous KnowledgeLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1784202022-03-04T01:57:53Z2022-03-04T01:57:53ZLike many disasters in Australia, Aboriginal people are over-represented and under-resourced in the NSW floods<p>The flooding crisis that has engulfed much of Australia’s east coast is yet more evidence of the catastrophic impacts of climate change. While all people are forced to confront similar challenges such as forced evacuations, loss of property and damage to businesses, Aboriginal people are once again over-represented in the number of people impacted by disaster. </p>
<p>Northern NSW is home to many Aboriginal people living in large townships such as Lismore, Ballina, Casino and Kempsey. It is also home to a vast array of discrete Aboriginal communities such as Cabbage Tree Island, Box Ridge, Gundurimba, Wardell, Maclean (Hill Crest), and more. </p>
<p>A quick glance at the regions that have been officially <a href="https://www.nsw.gov.au/disaster-recovery/natural-disaster-declarations">declared a natural disaster zone in NSW</a> reveals that approximately 36,509 Aboriginal and Torres Strait Islander people have been directly impacted by the floods in NSW, or <a href="https://www.abs.gov.au/ausstats/abs@.nsf/Lookup/by%20Subject/2940.0%7E2016%7EMain%20Features%7EIndigenous%20Status%7E16">4.2%</a> of those affected by floods.</p>
<p>Focusing on regional areas outside of Sydney, the proportion of Aboriginal and Torres Strait Islander people affected by the floods jumps to 6.2%. Compare this with the fact Aboriginal people make up 3.3% of the general population and it becomes clear Aboriginal and Torres Strait Islander people are once more disproportionately affected by disaster.</p>
<p>But these numbers are just one dimension. Aboriginal and Torres Strait Islander people are a youthful population, with <a href="https://quickstats.censusdata.abs.gov.au/census_services/getproduct/census/2016/quickstat/IQS036">more than half being under 24 years old</a>. This means that of the Aboriginal and Torres Strait Islander people affected, most are children and young people.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/5-big-ideas-how-australia-can-tackle-climate-change-while-restoring-nature-culture-and-communities-172156">5 big ideas: how Australia can tackle climate change while restoring nature, culture and communities</a>
</strong>
</em>
</p>
<hr>
<h2>Stories of survival and strength</h2>
<p>With such widespread flooding, emergency services and disaster relief organisations have struggled to keep up, and in the midst of the chaos, Aboriginal communities have found themselves isolated and in some cases forgotten. </p>
<p>At Cabbage Tree Island outside of Ballina, the entire community has been inundated. In the midst of the evacuation, elders and families did not want to evacuate because they had nowhere to go. Bundjalung woman Delia Rhodes shared with <a href="https://www.abc.net.au/radio/programs/pm/first-nations-communities-isolated-by-rising-flood-waters/13776702">ABC PM Radio</a>: </p>
<blockquote>
<p>You have Elders and families with children sitting around for hours waiting to get accommodation. It’s very frustrating.</p>
</blockquote>
<p>Community members with access to boats took it upon themselves to drop food, baby supplies, and medicine to people who found themselves stranded. </p>
<p>Naomi Moran, General Manager of Indigenous newspaper The Koori Mail shared with <a href="https://www.sbs.com.au/ondemand/watch/2000839747949">NITV</a>:</p>
<blockquote>
<p>You know what Blackfullas are like, if it happens to one of us, it happens to all of us. The outpouring of offers to support our communities. You know, taking calls from Sydney mob, from Melbourne mob, saying “how can we help?”</p>
</blockquote>
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<p>In Dubbo, Bundjalung woman Noelle King is organising donations and relief for families in Lismore and surrounding communities, she said to me:</p>
<blockquote>
<p>I have lots of family in Lismore who have lost everything but are so grateful they all made it out to safety in time. I have family in Corakai, on the mission who were isolated with no access to supplies and the same seeing Gundurimba and Cabbo going under […] So I’ve reached out to the community of Dubbo and donations have flowed in of clothes, household items, food and other supplies. We will be organising a truck next week and heading over to help where we can.</p>
</blockquote>
<p>Sadly, these stories of Aboriginal communities being left behind with little support, or none at all, are all too common. I have written about similar experiences during the <a href="https://theconversation.com/strength-from-perpetual-grief-how-aboriginal-people-experience-the-bushfire-crisis-129448">2019-20 bushfires</a> and the <a href="https://theconversation.com/the-covid-19-crisis-in-western-nsw-aboriginal-communities-is-a-nightmare-realised-166093">COVID-19 pandemic</a> in Aboriginal communities. </p>
<p>There are also questions about when or even if communities can return to their home communities, as Dyonne Anderson, Principle of Cabbage Tree Island public school shared with <a href="https://www.theguardian.com/australia-news/2022/mar/03/fears-for-indigenous-community-of-nsw-island-as-anger-rises-about-government-response">The Guardian</a>:</p>
<blockquote>
<p>We may not return for many months. </p>
</blockquote>
<p>These disasters have exposed the consequences of a lack of planning and preparation in and with Aboriginal communities. They have also shown how entrenched inequality produces further vulnerabilities in times of crisis. The same consequences are now being felt in northern NSW.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-covid-19-crisis-in-western-nsw-aboriginal-communities-is-a-nightmare-realised-166093">The COVID-19 crisis in western NSW Aboriginal communities is a nightmare realised</a>
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<hr>
<h2>How can First Nations communities be better supported during climate change?</h2>
<p>Disasters such as this have always been a common feature in Australia, but as more and more emissions are pumped into the atmosphere, the impacts of climate change mean the scale and severity of these disasters will continue to increase.
Aboriginal and Torres Strait Islander communities are already bearing the brunt of these disasters. A number of things need to happen now, before climate impacts worsen.</p>
<p>It’s vitally important Aboriginal people throughout flood impacted areas are provided with as much community and government support as they require to return home and recover what has been lost. Aboriginal community members have organised a number of crowdfunding campaigns to support Aboriginal people in flood-affected areas. </p>
<p>Two of note include the <a href="https://www.gofundme.com/f/bundjalung-community-flood-relief?qid=282d6b0445aebe6cbe3d7b6dc64f3e2c">Bundjalung community flood relief</a> and <a href="https://chuffed.org/project/support-aboriginal-families-of-lismore">Support Aboriginal families of Lismore</a>.</p>
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<p>It is also time to look beyond individual disasters and develop an integrated response that is led by and centres Indigenous peoples. I suggest this can be done in two ways.</p>
<p>Firstly, we need a national Indigenous disaster resilience framework. <a href="https://caepr.cass.anu.edu.au/events/aboriginal-community-governance-black-summer-bushfires">My research</a> has uncovered how Indigenous peoples have been made absent in national disaster resilience policies in the past. Without a framework that focuses on our communities, including the distinct impacts of disasters on our peoples, culture and heritage, and the unique legal and governing arrangements within our communities, future policies and responses will continue to fall short.</p>
<p>Second, there is an urgent need to develop and resource an Indigenous climate resilience and adaptation strategy. The recent report by the Intergovernmental Panel on Climate Change, <a href="https://www.ipcc.ch/report/ar6/wg2/">Impacts, Adaptation and Vulnerability</a>, recognises the specific challenges for Indigenous peoples in a changing climate. While closer to home Future Earth Australia, a peak expert group based at the Australian Academy of Science, is developing a <a href="https://www.futureearth.org.au/news/our-most-vulnerable-risk-being-left-behind-australia-adapts-climate-change">National Strategy for Just Adaptation</a>. </p>
<p>But even these strategies and reports are incapable of capturing and communicating our voices, experiences, and ambitions if they are not Indigenous-led and owned.</p>
<p>What these floods have shown, as the bushfires and COVID-19 have shown before, is the indomitable strength of Aboriginal people. </p>
<p>Perhaps it is fitting the national NAIDOC theme for 2022 is “<a href="https://www.naidoc.org.au/get-involved/2022-theme">Get Up! Stand Up! Show Up!</a>” - because that is exactly what we continue to do for our people in times of disaster.</p><img src="https://counter.theconversation.com/content/178420/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>I thank Dr Francis Markham for his contributions in the development of this article. </span></em></p>Australia’s east coast flooding is forcing people to confront challenges such as evacuations and loss of property. However, Aboriginal people are being left to find their own way through this crisis.Bhiamie Williamson, Research Associate & PhD Candidate, Australian National UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1692452021-10-25T01:44:12Z2021-10-25T01:44:12ZGetting vaccinated is the act of love needed right now to support the survival of Aboriginal and Torres Strait Islander peoples during the pandemic<p>Redfern’s Community Chaplain Pastor Ray Minniecon, recently made a compelling video urging people to get the COVID-19 vaccination. Pastor Minniecon regarded the simple act of becoming vaccinated as an <a href="https://www.health.gov.au/resources/videos/covid-19-vaccination-video-pastor-ray-minniecon-encourages-everyone-to-get-vaccinated-to-protect-loved-ones">act of love</a> for family and community, encouraging all to get vaccinated as quickly as possible.</p>
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<p>There have been many barriers for Aboriginal communities to access the vaccine and <a href="https://www.mja.com.au/journal/2021/214/5/indirect-impacts-covid-19-aboriginal-communities-across-new-south-wales">culturally safe health-care</a> during the pandemic. However for some communities, access to health services is a struggle that predates the COVID-19 pandemic. </p>
<p>Aboriginal people have faced decades of exclusion from government decision making resulting in <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(20)30007-9/fulltext">poor and inappropriate housing and service provision</a> which has impacted their health. </p>
<p>This did not change when the Commonwealth government declared Aboriginal and Torres Strait Islander peoples as a <a href="https://www.health.gov.au/news/update-for-aboriginal-and-torres-strait-islander-peoples-about-australias-covid-19-vaccines">priority community</a> during the initial roll-out of the COVID-19 vaccine. </p>
<p>Aboriginal communities have struggled to get <a href="https://time.com/6092560/covid-19-australia-aboriginal-communities/">access</a> to the vaccine. Some were also concerned by <a href="https://www.abc.net.au/news/health/2021-09-13/covid-19-vaccine-hesitancy-indigenous-communities/100451174">inconsistent messaging</a> about the vaccine from federal and state governments. </p>
<p>All of this has contributed to a lack of trust in governments to ensure the rights and needs of Aboriginal people and communities are met. </p>
<p>A big concern about the current levels of vaccination in community is for younger children, Elders and others ineligible or unable to get the jab. These people could face exposure to COVID and other significant diseases.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/whiteness-in-the-time-of-covid-australias-health-services-still-leaving-vulnerable-communities-behind-167701">Whiteness in the time of COVID: Australia's health services still leaving vulnerable communities behind</a>
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</p>
<hr>
<h2>Vulnerable communities taking the lead</h2>
<p>Communities recognised the threat of this outbreak early on with <a href="https://www.aph.gov.au/About_Parliament/Parliamentary_Departments/Parliamentary_Library/pubs/rp/rp2021/Chronologies/COVID19-IndigenousAustralians#_Toc47013368">actions</a> such as developing a pandemic response plan (<a href="https://www.apunipima.org.au/coronavirus-covid/">Apunipima, January 2020</a>) and the development of appropriate language resources for communities (<a href="https://www.youtube.com/user/NorthernLandCouncil">Northern Territory Land Councils, February 2020</a>.
In addition, The National Aboriginal Community Controlled Health Organisation co-chaired the first <a href="https://www.health.gov.au/committees-and-groups/aboriginal-and-torres-strait-islander-advisory-group-on-covid-19">Aboriginal and Torres Strait Islander Advisory Group on COVID-19</a> in March 2020.</p>
<p>Particularly for those living in communities outside of urban and regional areas, the <a href="https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/advice-for-people-at-risk-of-coronavirus-covid-19/coronavirus-covid-19-advice-for-aboriginal-and-torres-strait-islander-peoples-and-remote-communities#why-remote-communities-are-at-risk">risks related to COVID-19</a> are exacerbated by many factors. These include existing chronic illnesses and disabilities, mobility of people between communities and regions, poor and overcrowded housing and reliance on health outreach for regular health care. </p>
<p>Much of the care to communities is through the 143 local <a href="https://healthinfonet.ecu.edu.au/key-resources/health-professionals/health-workers/map-of-aboriginal-and-islander-healthmedical-services/">Aboriginal community controlled health</a> organisations and their 300 clinics. </p>
<p>Recent gains by the health sector in the <a href="https://www.pmc.gov.au/news-centre/indigenous-affairs/new-national-agreement-closing-gap">National Agreement on Closing the Gap</a> offers a new era of collaboration between government, non-government organisations and community-controlled organisations. Recently in Western NSW we saw the positive impact of such collaboration when combined efforts <a href="https://www.theguardian.com/news/datablog/ng-interactive/2021/aug/31/which-parts-australia-have-highest-vaccination-rate-by-state-nsw-sydney-victoria-melbourne-lga-suburb-check-your-area-vaccine-rates-number-coverage-percentage-percent-population-look-up-interactive-map">resulted in an increase of COVID-19 vaccine doses</a> from 20% first dose coverage to 70% in a month. </p>
<p>However these organisations - like many other health-care providers in Australia - are dealing with significant staffing shortages because of COVID-related workloads, furloughing of staff and of staff themselves becoming sick. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-in-wilcannia-a-national-disgrace-we-all-saw-coming-167348">COVID in Wilcannia: a national disgrace we all saw coming</a>
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<hr>
<h2>Low vaccination rates and poor housing in Aboriginal communities</h2>
<p>The current outbreaks of the COVID-19 Delta variant have highlighted the gap in health services for communities already under-serviced. Some of these communities have witnessed the virus “<a href="https://nacchocommunique.com/2021/07/27/naccho-aboriginal-health-news-27-july-2021/">rip through communities</a>”.</p>
<p>This is what has been seen in NSW and many other parts of Australia, despite the tremendous vaccine uptake of Aboriginal community members. Aboriginal people continue to be vaccinated at a rate that is 20% lower than the general population. This indicates devastating outbreaks will continue - not only in remote regions, but in communities closer to towns and cities. </p>
<p><a href="https://www.mja.com.au/journal/2021/modelling-direct-and-herd-protection-effects-vaccination-against-sars-cov-2-delta">Modelling shows</a> this vaccine uptake lag could translate into a doubling of deaths.</p>
<p>Pat Turner, CEO of the <a href="https://www.naccho.org.au/">National Aboriginal Community Controlled Organisation</a> argues that to protect communities, the aim must be to vaccinate as close as possible to 100% of Aboriginal people over the age of 12. <a href="https://iview.abc.net.au/video/NC2107H177S00">Auntie Pat</a>, whom Indigenous people will often title thus as a mark of respect, also describes how overcrowded housing and lack of places to quarantine has enabled the wildfire-like spread of COVID in some remote NSW communities, causing <a href="https://www.thelancet.com/journals/lanwpc/article/PIIS2666-6065(20)30007-9/fulltext">sickness and loss of life</a>. </p>
<p>COVID is causing a further housing crisis in places where many Aboriginal people live. One example is the NSW North Coast where jobs have become precarious. This is due to long and fluctuating lockdowns and property demand from wealthy Sydney-siders anxious to <a href="https://www.abc.net.au/news/2021-07-20/north-coast-rent-prices-off-the-charts/100303728">escape</a> to regional areas. </p>
<p>Escalating house prices diminished the already stressed stock of affordable rentals held by multiple housing organisations. In addition, rent rises under these conditions have pushed families into <a href="https://www.ncoss.org.au/wp-content/uploads/2020/10/A-WAVE-OF-DISADVANTAGE_-COVID-19_Final.pdf">homelessness, poverty</a> and <a href="https://www.sciencedirect.com/science/article/abs/pii/S0165178120306491">higher risk of COVID infection</a>. </p>
<p>These challenges and others have been years in the making, with calls from Aboriginal organisations’ for a centralised housing support strategy <a href="https://www.echo.net.au/2021/03/storylines-call-for-aboriginal-housing-and-support/">falling on deaf ears</a>. </p>
<p>The pandemic has amplified ongoing inequalities for Aboriginal and Torres Strait Islander people. Communities have been placed at risk of losing their jobs and roofs over their heads at the same time. Overcrowding and homelessness bring multiple risks to health and well-being. These risks range from infectious diseases to mental health and safety concerns. </p>
<p>Uncle Ray’s and Auntie Pat’s messages, along with those of many other Aboriginal and Torres Strait Islander <a href="https://onlinelibrary.wiley.com/doi/epdf/10.1111/1753-6405.13172">epidemiologists</a>, <a href="https://www.croakey.org/innovative-research-explores-responses-to-covid-19-among-indigenous-communities-in-brisbane/">researchers</a>, <a href="https://www.health.gov.au/resources/videos/dr-mark-wenitong-find-out-the-facts-of-covid-19-vaccines">doctors</a>, <a href="https://www.health.gov.au/resources/videos/covid-19-vaccination-video-aboriginal-nurse-mandy-debenham-encourages-us-all-to-get-tested-and-vaccinate">nurses</a>, <a href="https://www.sbs.com.au/nitv/article/2021/09/09/its-escalating-redfern-rallies-combat-covid-19-after-infection-spike">health-workers and community leaders</a>, are exactly what Australia needs right now. Why? because not leaving anyone behind is a characterisic of how we care for one another.</p>
<p>As Auntie Yvonne Cadet-James says:</p>
<blockquote>
<p>People shouldn’t be listening to gossip, there’s a lot of that in the media […] the more we get vaccinated, the more we build up that immunity as a community, <a href="https://www.youtube.com/watch?v=JtI1CbpXJzE">so that protects everybody</a>.</p>
</blockquote>
<p>The message is clear - get vaccinated, look after one another, don’t leave anyone behind. Find love in your heart and act to protect yourself, your family and your community. </p>
<p>For government, Auntie Pat says, the time for others to make decisions for Aboriginal and Torres Strait Islander people is over.</p>
<p>Now is the time to address the long standing inequities in health, well-being and the ongoing housing and employment crisis impacting Aboriginal people. </p>
<p>During this age of COVID, Australians must show the world our full capability to listen, get behind and champion the rights and needs of Aboriginal people.</p>
<p>We have never been so strong. And we can’t leave anyone behind.</p><img src="https://counter.theconversation.com/content/169245/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Jennifer Barrett has received funding from the Australian Research Council. </span></em></p><p class="fine-print"><em><span>Kalinda Griffiths receives funding from the National Health and Medical Research Council and the Australian Research Council. She is also Thinker in Residence at the Australian Health Promotion Association.</span></em></p><p class="fine-print"><em><span>Emma McBryde, Ian Ring, Jason Agostino, Lisa Jackson Pulver, Melissa Haswell, and Michael Doyle 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>There have been many barriers for Aboriginal communities to access the vaccine during the pandemic. Despite this, communities are taking the lead in ensuring everyone gets vaccinated.Lisa Jackson Pulver, Deputy Vice-Chancellor, Professor of Public Health and Epidemiology, University of SydneyJennifer Barrett, Pro Vice Chancellor Indigenous (Academic) and Director, National Centre for Cultural Competence, University of SydneyKalinda Griffiths, Scientia lecturer, UNSW SydneyMelissa Haswell, Professor of Practice in Environmental Wellbeing, Office of the Deputy Vice Chancellor (Indigenous Strategy and Services), University of SydneyLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1677012021-09-20T01:23:18Z2021-09-20T01:23:18ZWhiteness in the time of COVID: Australia’s health services still leaving vulnerable communities behind<p>Due to the ongoing effects of colonisation, First Nations peoples often experience socio-economic disadvantage and health inequality. The pandemic has no doubt worsened these conditions for some. </p>
<p>In addition, the health of Australia’s First Nations peoples is framed in a deficit focus. This means representing First Nations people through a narrative of difference, disparity, disadvantage, dysfunction, and deprivation, what is sometimes referred to as the <a href="https://press-files.anu.edu.au/downloads/press/n2140/pdf/ch05.pdf">5Ds</a>.</p>
<p>Viewing First Nations peoples through a deficit or negative lens is a form of racial segregation. However, this practice of white privilege or “whiteness” in health services can only cause harm to marginalised communities.</p>
<p>For instance, COVID-19 is more common in disadvantaged areas, where people face a triple threat – low vaccination rates, greater likelihood of getting COVID-19, and greater risk of dying.</p>
<p>Though the government has <a href="https://www.health.gov.au/ministers/the-hon-greg-hunt-mp/media/boosting-covid-19-vaccination-support-for-indigenous-australians">recently boosted efforts</a> to reach vulnerable First Nations communities, there have long been complaints of <a href="https://www.theaustralian.com.au/nation/wiradjuri-elder-riverbank-frank-doolan-leads-indigenous-vaccine-push/news-story/0cf12c0a2ad5f057cf992b94b0f6e069">lack of access</a> to vaccines in high-risk areas.</p>
<p>Therefore, when the federal government speaks of 80% vaccination rate targets, it has somewhat felt like this means 80% of white, middle-class people without disabilities.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/the-first-indigenous-covid-death-reminds-us-of-the-outsized-risk-nsw-communities-face-166888">The first Indigenous COVID death reminds us of the outsized risk NSW communities face</a>
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<h2>Whiteness dominating health services</h2>
<p>Whiteness refers to perspectives, practices and policies that enable the dominance of white people and their culture in society and institutions. </p>
<p>Historically, pretty much every political and health system has been under the leadership of white, cis-gendered heterosexual (often middle-aged) men without disabilities. This has resulted in white perspectives <a href="https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5951245/">being interwoven</a> in health practice and policy development.</p>
<p>White, cis-gendered health is often the norm against which deviation is measured in health practices. This is detrimental to First Nations peoples and other marginalised communities. </p>
<p>For First Nations peoples, good health is holistic and includes physical, social, emotional, cultural, spiritual and ecological wellbeing. This is why First Nations peoples need to be included in health planning, particularly during the global pandemic.</p>
<h2>COVID-19 disproportionately impacting First Nations people</h2>
<p>First Nations peoples were identified as a priority group early in the vaccine rollout because globally, First Nations peoples are <a href="https://www.un.org/development/desa/indigenouspeoples/covid-19.html">disproportionally more likely</a> to die from COVID-19. </p>
<p>However, until recently First Nations peoples in Australia were <a href="https://www.forbes.com/sites/williamhaseltine/2021/05/05/protecting-indigenous-populations-from-covid-19-the-australian-example/?sh=4aa87a37801f">six times less likely</a> to contract COVID-19 because communities responded quickly to the first wave in 2020. </p>
<p>Aboriginal organisations came together drawing on experience from the 2009 H1N1 influenza pandemic and implemented culturally appropriate resources to <a href="https://www.abc.net.au/news/2020-11-14/indigenous-community-covid-response-blueprint-self-determination/12882080">share with the community</a>.</p>
<p>However, there have been further waves of COVID-19 since then and increasingly restricted access to health care in response to lockdowns, border closures and the inadequate vaccine rollout. This has led to over <a href="https://www.abc.net.au/news/2021-09-07/nsw-covid-outbreak-vaccinations-urgent-as-aboriginal-cases-grow/100436516">1,000 COVID cases</a> in First Nations communities, and deaths that <a href="https://www.abc.net.au/news/2021-09-06/second-western-nsw-covid-death/100436920">could have been avoided</a>.</p>
<p>This is occurring while First Nations peoples and other communities continue to be <a href="https://www.theguardian.com/world/2021/mar/17/australia-urged-to-adopt-plan-to-fight-resurgence-of-racism">confronted with racism</a> when trying to access health care. </p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-covid-19-crisis-in-western-nsw-aboriginal-communities-is-a-nightmare-realised-166093">The COVID-19 crisis in western NSW Aboriginal communities is a nightmare realised</a>
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<h2>Misinformation and government negligence</h2>
<p>In Australia, First Nations peoples are significantly more likely to have two or more <a href="https://theconversation.com/coronavirus-will-devastate-aboriginal-communities-if-we-dont-act-now-133766">chronic health conditions</a>. This makes us more vulnerable to contracting and dying from COVID-19.</p>
<p>Despite this, health services in regional, rural and remote areas with predominantly Aboriginal populations continue to be under-resourced by state and federal governments.</p>
<p>In addition, many people in western NSW communities are being turned away from health care facilities because they simply <a href="https://www.theguardian.com/australia-news/2021/aug/26/aboriginal-woman-turned-away-from-hospital-as-data-reveals-wilcannia-worst-hit-by-covid">lack capacity</a>.</p>
<p>In June, <a href="https://theconversation.com/the-covid-19-crisis-in-western-nsw-aboriginal-communities-is-a-nightmare-realised-166093">concerns were raised</a> about vaccination rates in First Nations communities in Australia. However, we still have <a href="https://theconversation.com/the-first-indigenous-covid-death-reminds-us-of-the-outsized-risk-nsw-communities-face-166888">lower vaccination rates</a> than the non-Indigenous NSW population.</p>
<p>There is indeed a level of vaccine hesitancy in the community. Inconsistent and sometimes inaccessible health messaging has contributed to understandable mistrust and fear. </p>
<p>However, First Nations peoples are among the most <a href="https://bmcpublichealth.biomedcentral.com/articles/10.1186/s12889-015-2052-3">over-researched</a> groups of people in the world. So, vaccine hesitancy can also be due to the long history in Australia of government trying to control our communities. </p>
<p>It certainly doesn’t help when white people continue to interfere with Indigenous health through the spread of false claims about COVID-19.</p>
<p>For instance, a self-proclaimed Indigenous prayer group in Western Australia <a href="https://theconversation.com/politics-with-michelle-grattan-pat-turner-on-covid-and-god-botherers-stalking-indigenous-communities-167115">spread misinformation</a> that God will protect against COVID-19. This group turned out to be a white man from Brisbane.</p>
<p>And in the NSW community in Wilcannia, which has been hard hit by a recent wave of COVID-19 infections, First Nations people have been targeted by a group spruiking the benefits of <a href="https://www.theguardian.com/australia-news/2021/sep/09/indigenous-australians-in-covid-hit-wilcannia-targeted-by-ivermectin-spruiker?CMP=soc_567&fbclid=IwAR1z9vYnTpAqISmMTfsrZtFj4IVyh91-eQK3k0ApnCXX5JVW6WSjjsNHA2I">ivermectin</a>.</p>
<p>Both occurrences feel reminiscent of colonial missionary days, where white people regarded First Nations peoples as barbarian savages who needed controlling (mind and body), civilising, and educating in white, European ways.</p>
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<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/politics-with-michelle-grattan-pat-turner-on-covid-and-god-botherers-stalking-indigenous-communities-167115">Politics with Michelle Grattan: Pat Turner on COVID – and god botherers – stalking Indigenous communities</a>
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<h2>Where to from here</h2>
<p>We need to find ways to disrupt health systems currently excluding First Nations people. </p>
<p>Community self-determination is essential and Aboriginal community-controlled responses must remain a <a href="https://theconversation.com/why-self-determination-is-vital-for-indigenous-communities-to-beat-coronavirus-137611">priority</a>.</p>
<p>The government has made efforts recently alongside the National Aboriginal Community Controlled Health Organisation to <a href="https://www.naccho.org.au/news/boosting-covid-19-vaccination-support-for-indigenous-australians?utm_medium=email&_hsmi=159964715&_hsenc=p2ANqtz-_JcGU0sCCK9wCsuYHC4TSMId8CsL2ZgcemADP5WK64QoNAqWJWUpIAHARpfK6n-EWaNkOQEzLp2Gq-GKC1mDmGKS_RaTjvi19qAkgGIydlbP064E8&utm_content=159964715&utm_source=hs_email">increase COVID vaccinations</a> in communities across Australia. This is a positive start, but more must be done.</p>
<p>There is talk of the borders re-opening and the country opening up after vaccination rates <a href="https://www.abc.net.au/news/2021-07-30/national-cabinet-four-phase-plan-out-of-covid-pandemic/100339314">exceed 75-80% of the adult population</a>.
A Freedom Day, if you will. </p>
<p>So, when is our mob’s “Freedom Day”? Besides our ignored cries for sovereignty and self-determination, we cannot be left to die due to low vaccination rates while the rest of the country is deemed “safe”. </p>
<p>Whiteness needs to stop being the baseline from which health services originate. Unless there is a move to strengths-based strategies for vaccinating at-risk populations, such as First Nations communities, we will remain more likely to get sicker and die sooner.</p><img src="https://counter.theconversation.com/content/167701/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kelly Menzel 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>Predominantly white perspectives in health practice and policy development can exclude First Nations people in some health services. This is proving evident during the COVID-19 global pandemic.Kelly Menzel, Assistant Professor - First Nations Health, Bond UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1673482021-09-16T05:52:14Z2021-09-16T05:52:14ZCOVID in Wilcannia: a national disgrace we all saw coming<figure><img src="https://images.theconversation.com/files/419712/original/file-20210907-27-1tvloa.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">The town of Wilcannia in the far outback of New South Wales on the banks of the Darling river.</span> <span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/town-wilcannia-far-outback-new-south-1820784710">shutterstock</a></span></figcaption></figure><p>The COVID-19 crisis in Wilcannia demonstrates how entrenched neglect, combined with a global pandemic, have created a perfect storm impacting the most marginalised people in society.</p>
<p>The treatment of the Barkindji people of Wilcannia is appalling by anyone’s standards and should be unacceptable to every Australian. The stories flooding out of Wilcannia of mistreatment of Aboriginal people should make every person stand up and demand immediate action.</p>
<p>The government needs to take immediate action to address the conditions in which the people in Wilcannia are forced to live, and by providing vaccinations immediately to all those who want to be vaccinated. </p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/politics-with-michelle-grattan-pat-turner-on-covid-and-god-botherers-stalking-indigenous-communities-167115">Politics with Michelle Grattan: Pat Turner on COVID – and god botherers – stalking Indigenous communities</a>
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<h2>Not enough healthcare, too much police involvement</h2>
<p>As part of my research, I spoke to community members over the phone to listen to their experiences of this breakout. Here are just a few stories told to me by the people of Wilcannia:</p>
<ul>
<li><p>a young mother who was made to sit outside a hospital on a cold night, before being sent home due to under-resourcing</p></li>
<li><p>a woman who had police arrive on her doorstep to inform her she had tested positive to COVID-19, and they must take her to the isolation unit. There was no phone call from NSW Health, just police arriving to take her to isolation. Her elderly mother, who is on dialysis, was taken to another town</p></li>
<li><p>Aboriginal people with mental illness or disorders, who require regular treatment and medication, being picked up in police vans and taken to the hospital because they “may” have COVID-19. The people of Wilcannia told me they were told this is because police vans are “easier” to clean.</p></li>
</ul>
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<p>The police or the defence force themselves cannot be blamed. They are doing all they can to assist, much of which NSW Health should be resourced to do. Without the police and the defence force, Wilcannia would be in a much worse situation. However, we need a health and community response, not a law and order response.</p>
<p>Reports have surfaced Aboriginal people in Wilcannia are being fined <a href="https://www.sbs.com.au/nitv/article/2021/08/23/causing-stress-and-anxiety-aboriginal-people-far-west-nsw-copping-hefty-covid">up to $5,000</a> for leaving home to get food. Some of the people being fined are already living on meagre incomes and having to pay those fines will cause significant distress and further financial problems, further entrenching disadvantage. </p>
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<h2>Neglect of Aboriginal people has led us here</h2>
<p>Overcrowded and poor-quality housing already results in <a href="https://apo.org.au/node/310467">poor health outcomes</a>. The effects of overcrowded and poor quality housing during a viral pandemic cannot be overstated.</p>
<p>Aboriginal people have been isolating <a href="https://www.abc.net.au/news/2021-08-30/barkaa-shares-message-as-wilcannia-sees-rising-cases/100412432">in tents</a> during cold desert nights to try to protect their families. They do not choose to live in overcrowded and poor-quality housing; that is all that is available. </p>
<p>NSW Health have since supplied <a href="https://www.abc.net.au/news/2021-09-05/nsw-wilcannia-motorhomes-isolation-hub/100434846">30 motor homes</a> for people diagnosed with COVID so they can isolate away from their families.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-first-indigenous-covid-death-reminds-us-of-the-outsized-risk-nsw-communities-face-166888">The first Indigenous COVID death reminds us of the outsized risk NSW communities face</a>
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</em>
</p>
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<p>The situation in Wilcannia did not just happen overnight, nor was it unforeseen. The <a href="https://www.abc.net.au/news/2021-08-26/covid-delta-unvaccinated-indigenous-communities-outbreak/100406682">neglect of Aboriginal people</a> by current and successive governments has led us to this point. </p>
<p>Furthermore, <a href="https://www.abc.net.au/news/2021-08-31/letter-warned-government-of-covid-disaster-in-wilcannia/100420052">Aboriginal health services predicted</a> last year that if COVID-19 entered Aboriginal communities, it would be disastrous. Instead of governments taking responsibility for their failures, some have blamed the people suffering the consequences of their failure.</p>
<p>For example, the government demonised the family and community who attended a funeral, making false statements and allegations, despite the funeral occurring <a href="https://www.sbs.com.au/nitv/article/2021/08/21/wilcannia-residents-livid-after-remote-funeral-compared-sydney-lockdown-party">before</a> restrictions and lockdowns outside of the Greater Sydney Region. Those who made negative statements about the funeral attendance have <a href="https://www.abc.net.au/news/2021-08-23/hazzard-says-he-regrets-wilcannia-funeral-comments/100399910">expressed regret</a>, but it’s too little too late.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/the-covid-19-crisis-in-western-nsw-aboriginal-communities-is-a-nightmare-realised-166093">The COVID-19 crisis in western NSW Aboriginal communities is a nightmare realised</a>
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</em>
</p>
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<p>Aboriginal people were classified as 1B priority for the vaccines, but in many places, the vaccines were simply not available. This was either because services on the ground did not have the capacity to deliver or there just were not enough vaccines. Many Aboriginal people across the state of NSW have reported <a href="https://www.abc.net.au/news/2021-08-27/awabakal-medical-service-vaccine-indigenous-community/100410252">long waiting lists</a> to get vaccinated. </p>
<p>It must also be noted that those Aboriginal people <a href="https://www.ntnews.com.au/news/alice-springs/nearly-40-per-cent-of-aboriginal-clients-reject-covid-jab-amid-vaccination-blitz-in-central-australia/news-story/9cfc285236c4d80e7e90a6346d300266">wary of vaccines</a> have good reason, based in over 200 years of history, not to trust what the government says. </p>
<p>However, we do not need to go back that far to understand this crisis. We only need to look at the government’s failure to secure enough (timely) vaccines for these vulnerable communities.</p>
<h2>What has to happen now?</h2>
<p>The government firstly must address the immediate needs of the community, by ensuring adequate and appropriate housing for people to isolate in, tents and motor homes are not appropriate in this situation. Vaccinations must be urgently administered and everyone who wants to be vaccinated must be able to do so without a waiting list. </p>
<p>More doctors and nurses need to be sent to regional areas affected by the virus. Social workers must also be sent to ensure people have access to adequate and appropriate health care, food and accommodation as well as programs to allow people to deal with issues worsened by the pandemic and to maintain mental and cultural well-being during times of isolation and lock down.</p><img src="https://counter.theconversation.com/content/167348/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Susan Green receives funding from ARC research funding. She is affiliated with CSU as an academic, AASW, as the Aboriginal and Torres Strait Islander Board member and Visual Dreaming as a board member. </span></em></p>The COVID-19 crisis in Wilcannia demonstrates how entrenched neglect has led to a community devastated by the global pandemic.Susan Green, Professor in Indigenous Australian Studies and GCWLCH Co-ordinator, Charles Sturt UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1648442021-08-05T17:56:43Z2021-08-05T17:56:43ZCOVID-19 caused a global setback in reproductive and sexual health rights, especially for women<figure><img src="https://images.theconversation.com/files/412290/original/file-20210720-25-9qizql.jpeg?ixlib=rb-1.1.0&rect=14%2C2%2C784%2C591&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Measures to combat COVID-19 have affected sexual and reproductive health care around the globe, including maternal and newborn care, birth control and access to abortion.</span> <span class="attribution"><a class="source" href="https://www.usherbrooke.ca/medecine/faculte/cidis/projets/clefs/">Université de Sherbrooke, Centre interdisciplinaire de développement international en santé (CIDIS)</a>, <span class="license">Author provided</span></span></figcaption></figure><p>The exceptional measures governments and health authorities used during the COVID-19 pandemic, such as lockdowns, quarantine or reorganizing health services, <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS-continuity-survey-2021.1">directly affected the full realization of sexual and reproductive health and rights</a>. This was particularly the case for women and girls. These impacts are felt at many levels and require a major rethinking of international health development in order to make this issue a global priority.</p>
<h2>Access to birth control</h2>
<p>Access to birth control is one of the sexual and reproductive health issues that has been most impacted by the pandemic. According to the <a href="https://www.who.int/publications/i/item/WHO-2019-nCoV-EHS_continuity-survey-2020.1">World Health Organization</a>, family planning and birth control have been severely disrupted during the pandemic, with seven out of 10 countries affected. </p>
<p><a href="https://www.unfpa.org/press/new-unfpa-projections-predict-calamitous-impact-womens-health-covid-19-pandemic-continues">According to the United Nations Population Fund (UNFPA)</a>, in 114 low/middle-income countries, more than 47 million women are unable to access contraceptives. With each three-month extension of the measures, up to two million more women would be unable to have access to modern birth control methods.</p>
<p>Confinement measures also <a href="https://www.guttmacher.org/print/article/2020/08/bad-worse-covid-19-pandemic-risks-further-undermining-adolescents-sexual-and">disrupted contraceptive supply chains and the ability to access health facilities</a>. Because of the focus on essential supplies to combat COVID-19, sexual and reproductive health-related products <a href="https://doi.org/10.1080/13625187.2020.1777398">became inaccessible or out of stock</a>, directly impeding sexual and reproductive health and rights for millions of women and girls. </p>
<figure class="align-center ">
<img alt="Infographic with two statistics: 650,000 additional unintended pregnancies in India, and 3.5 million additional unintended pregnancies in South Asia" src="https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=99&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=99&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=99&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=124&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=124&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414678/original/file-20210804-24-14ltum4.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=124&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19; UNICEF: Direct and indirect effects of the COVID-19 pandemic and response in South Asia.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Access to sexual health services</h2>
<p>The impacts of COVID-19 are also felt on access to sexual and reproductive health services, including on prenatal care, maternal and newborn health services, care related to sexually transmitted infections or sexual health counselling. In the United States, <a href="https://www.guttmacher.org/report/early-impacts-covid-19-pandemic-findings-2020-guttmacher-survey-reproductive-health#figure2">one in three women</a> reported having to delay or cancel a visit to a sexual and reproductive health provider, or had difficulty obtaining birth control. Closures of sexual and reproductive health clinics placed a disproportionate burden on women and girls with sexual and reproductive health needs. </p>
<p>School closures (a measure widely implemented globally) have also led to <a href="https://resourcecentre.savethechildren.net/node/18201/pdf/global_girlhood_report_2020_africa_version_2.pdf">reduced access to information and sexuality education, mostly for girls</a>. Not returning to school exposed these girls to lack of information and resources, high-risk teenage pregnancy and death (as Save the Children reports that <a href="https://doi.org/10.1016/S0140-6736(20)32112-7">childbirth is the leading cause of death globally for girls aged 15-19</a>).</p>
<p>Even modest barriers to sexual and reproductive health services can have major health effects. For example, the consequences of a 10-per-cent drop in pregnancy-related health coverage can be <a href="https://www.guttmacher.org/journals/ipsrh/2020/04/estimates-potential-impact-covid-19-pandemic-sexual-and-reproductive-health">disastrous for women and newborns</a>: 1.7 million women who give birth and 2.6 million newborns will suffer serious complications and not receive needed care.</p>
<h2>Access to abortion</h2>
<p>During the pandemic, access to abortion was declared in many states and health jurisdictions a “<a href="http://doi.org/10.1056/NEJMp2008006">non-essential” service</a>, hindering access for millions of women and girls. In May 2020, <a href="https://www.ohchr.org/en/NewsEvents/Pages/DisplayNews.aspx?NewsID=25907&LangID=E">the Office of the United Nations High Commissioner for Human Rights</a> reported that some U.S. states were using the COVID-19 emergency situation to restrict access to abortion. In Italy, health <a href="https://www.hrw.org/news/2020/07/30/italy-covid-19-exacerbates-obstacles-legal-abortion">facilities have also suspended abortion-related services</a> or reassigned gynecological staff to anti-COVID-19 care, exacerbating barriers to legal abortion.</p>
<figure class="align-center ">
<img alt="Infographic with four statistics: 1 million unsafe abortions in India, 14-52% increase in maternal deaths in South Asia, 200% increase in maternal deaths in Nepal, 2,600 excess maternal deaths in India" src="https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=213&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=213&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=213&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=268&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=268&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414680/original/file-20210804-5434-10jyqmb.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=268&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19; Ipas: COVID-19 restrictions compromised abortion access for 1.85 M women in India; The Kathmandu Post 5/27/2020: a 200 per cent increase in maternal mortality since the lockdown began; Marie Stopes International: Resilience, Adaptation and Action: MSI’s Response to COVID-19.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Increase in gender-based violence</h2>
<p><a href="https://www.guttmacher.org/article/2020/08/bad-worse-covid-19-pandemic-risks-further-undermining-adolescents-sexual-and">Violence has also been exacerbated by the health crisis</a>, leading to an increase in gender-based violence threatening well-being and health. <a href="https://www.unfpa.org/fr/press/les-nouvelles-projections-de-lunfpa-pr%C3%A9voient-des-r%C3%A9percussions-d%C3%A9sastreuses-sur-la-sant%C3%A9-des">The UNFPA</a> has estimated, for example, that a six-month lockdown results in 31 million additional cases of gender-based violence. An additional 15 million cases would be added for each three-month extension.</p>
<p>Children are particularly impacted. <a href="https://www.wvi.org/sites/default/files/2020-05/Aftershocks%20FINAL%20VERSION_0.pdf">Save the Children</a> estimated in May 2020 that in the three months following their implementation, the stay-at-home guidelines resulted in a 20 per cent to 32 per cent increase in physical, sexual and emotional abuse of children. This means 85 million more girls and boys affected worldwide only for June, July and August 2020.</p>
<figure class="align-center ">
<img alt="Infographic with two statistics: 30-33% increase in domestic violence, 50% increase in gender-based violence" src="https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=98&fit=crop&dpr=1 600w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=98&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=98&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=123&fit=crop&dpr=1 754w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=123&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/414686/original/file-20210804-23-smsflr.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=123&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Sources: UN Policy Brief: The Impact of COVID-19 on Women; African Union (CUAWGDD): La violence basée sur le genre en Afrique durant la pandémie de COVID-19.</span>
<span class="attribution"><span class="license">Author provided</span></span>
</figcaption>
</figure>
<h2>Recommendations</h2>
<p>Progress on sexual and reproductive health and rights is a long-term endeavour that cannot afford to pause, even in a pandemic.</p>
<p>Millions of women and girls are affected globally — more than those affected by COVID-19. According to the <a href="https://www.guttmacher.org/fact-sheet/investing-sexual-and-reproductive-health-low-and-middle-income-countries">Guttmacher Institute</a>, there were for example, in 2020, 218 million women with unmet need for modern birth control method, 111 million unintended pregnancies, 30 million unplanned births and 35 million unsafe abortions, and this is only for low- and middle-income countries, compared to <a href="https://www.who.int/publications/m/item/weekly-epidemiological-update---29-december-2020">around 80 million cases of COVID-19 globally in 2020</a>. </p>
<p>The international community must mobilize with the same force as it did for the current pandemic. Sexual and reproductive health and rights must become a global priority.</p>
<p>To do so, we must:</p>
<ol>
<li><p>Establish a guaranteed base of sexual and reproductive health services that cannot be suspended, even in the event of a major crisis. This would help ensure a minimum supply of services, with continued funding, so that hard-won gains in sexual and reproductive health and rights are not lost.</p></li>
<li><p>Implement a gender and intersectional analysis for all health policies to assess short-, medium- and long-term effects in order to be sure that the negative impact of other health emergencies does not outweigh the expected policy benefits.</p></li>
<li><p>Continue to invest in international health development projects and ensure a significant budget to support the continuity of services despite other health emergencies and crises such as COVID-19.</p></li>
<li><p>Establish a specialization within the police and security services on gender-based violence so that people, especially women, can obtain support and protection without delay, even during emergency situations.</p></li>
</ol>
<p>The impact of the COVID-19 pandemic on the achievement of sexual and reproductive health and rights are multidimensional, direct and indirect, unevenly distributed internationally, and felt around the world. These impacts interact and intersect with other gender and/or economic and social inequalities that existed before the pandemic, adding to the complexity of the issue and the difficulties of responding adequately. The international community must make this a priority.</p><img src="https://counter.theconversation.com/content/164844/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>François Couturier receives funding from Global Affairs Canada. </span></em></p><p class="fine-print"><em><span><a href="mailto:michele.nicole.rietmann@usherbrooke.ca">michele.nicole.rietmann@usherbrooke.ca</a> receives funding from Global Affairs Canada (GAC). </span></em></p><p class="fine-print"><em><span><a href="mailto:sarah.stecko@usherbrooke.ca">sarah.stecko@usherbrooke.ca</a> receives funding from Global Affairs Canada - GAC. </span></em></p><p class="fine-print"><em><span>Gabriel Blouin-Genest, Natalia Torres Orozco, and Rosalie Émond-Tremblay 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>The exceptional measures deployed around the world during the COVID-19 pandemic have impeded access to urgent services like birth control, abortion and maternal and newborn care.Gabriel Blouin-Genest, Associate professor, School of applied politics, University of Sherbrooke. Scientific codirector, CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke François Couturier, Professor, Scientific codirector, CIDIS (Centre interdisciplinaire de développement international en santé., Université de Sherbrooke Michèle Rietmann, Project manager and research professional, CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke Natalia Torres Orozco, Research Professional | LL.M, Applied International Law and Politics, Université de Sherbrooke Rosalie Émond-Tremblay, Auxiliaire de recherches, Université de Sherbrooke Sarah Stecko, Director of operations and partnerships - CIDIS (Centre interdisciplinaire de développement international en santé), Université de Sherbrooke Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1638922021-07-27T02:35:24Z2021-07-27T02:35:24ZYarns from the heart: the role of Aboriginal English in Indigenous health communication<p>Indigenous Australians experience poorer health outcomes than non-Indigenous Australians. They are sick more often, die younger and are at higher risk of serious health complications, including heart disease. </p>
<p>One way to improve health outcomes is through targeted health communication in local languages. </p>
<p>The COVID-19 pandemic has seen <a href="https://www.languageonthemove.com/why-its-important-to-use-indigenous-languages-in-health-communication">increased attention given to the use of Indigenous languages</a> in health settings around the world, including Australia.</p>
<p>Many COVID-19 resources have been developed in partnership with local communities, including in widely-spoken Australian Aboriginal languages such as <a href="https://theconversation.com/explainer-the-largest-language-spoken-exclusively-in-australia-kriol-56286">Kriol</a>. Other <a href="http://lyfelanguages.com/">initiatives</a> have inspired new Indigenous health professionals to effectively communicate complex medical terminology and concepts to communities.</p>
<p>A frequent assumption among non-Indigenous people in Australia is that mainstream English media should work well for the almost 80% of Indigenous people in Australia for whom <a href="https://theconversation.com/10-ways-aboriginal-australians-made-english-their-own-128219">Aboriginal English</a> is their first language. </p>
<p>However, communities that use Aboriginal English as their language in daily interactions require health communication messages in the same language to be meaningful and accessible.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/were-not-all-in-this-together-messages-about-social-distancing-need-the-right-cultural-fit-135427">We're not all in this together. Messages about social distancing need the right cultural fit</a>
</strong>
</em>
</p>
<hr>
<h2>Exploring how to yarn about health</h2>
<p>In the past 18 months, we have been working with the <a href="https://www.heartfoundation.org.au/">Heart Foundation</a> on the production of two videos about heart health that were fully scripted and produced in Aboriginal English (the first of which can be <a href="https://www.youtube.com/watch?v=op1dNfMiz9s">viewed here</a>).</p>
<p>When we were initially approached, the brief was to create a video in “simple English” to ensure the health message would be available to First Nations communities across Western Australia. </p>
<figure>
<iframe width="440" height="260" src="https://www.youtube.com/embed/op1dNfMiz9s?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
</figure>
<p>However, Glenys Collard (one of the authors of this piece) says this is not the language of choice for most Aboriginal people:</p>
<blockquote>
<p>I never felt the need to want to learn or to speak mainstream Australian English; it didn’t come out my mouth easily. None of the people that I loved or looked up to in my life spoke mainstream Australian English. It didn’t feel right to me to speak differently to the rest of my family and friends. I wouldn’t have been able to truly respectfully represent my people. </p>
</blockquote>
<p>Both of the videos we created include a host of features that characterise Aboriginal English: the words “mob”, “fellas”, “crook” and “youse” are only some examples. The videos were also designed to include communication between a group of First Nations people gathered together outdoors. The entire video <a href="https://becauselanguage.com/11-aboriginal-english-yarning/">is presented as a yarn</a>. </p>
<p>The practice of yarning is a form of conversation and storytelling that includes repetition as a way to emphasise what is important in the message. The video features repetition and use of familiar language as a way to warm the audience up to the medical message. These features made it possible to communicate important medical information in a culturally safe way.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/10-ways-aboriginal-australians-made-english-their-own-128219">10 ways Aboriginal Australians made English their own</a>
</strong>
</em>
</p>
<hr>
<p>The work we completed on these videos gave us a unique opportunity to use our experience and linguistic expertise to create materials the community can relate to. We used a yarning style to present messages about attending heart health checks and the potential signs of a heart attack. </p>
<p>The scripting process was slightly different from what it would have been if the script had been written in Australian English. Collaboration, inclusion and Indigenous leadership were essential to its success.</p>
<h2>The benefits of this research</h2>
<p>We received positive feedback on these videos. To evaluate the success of the project, the Heart Foundation administered a survey to various Indigenous communities across Australia. A consistent comment during this consultation was that the people in the video “talk like us.” </p>
<p>This initiative has created opportunities for Indigenous health professionals to communicate complex terminology to their Indigenous patients in medical consultations. However, these efforts to create culturally and linguistically inclusive resources have not been available for all communities. </p>
<p>Language is fundamental to a sense of identity. Producing a video in Aboriginal English allows First Nations communities to relate to media directly and to feel the messaging is intended for them. </p>
<p>This is especially important during the global pandemic, when some Aboriginal Australians were feeling apprehensive about vaccination.</p>
<p>Organisations wishing to work this way will need to ensure First Nations people with the relevant expertise join the project from the beginning and become fundamental players in the planning and design stages. Organisations must also ensure that remunerated positions are created to complete this important work.</p>
<p>In producing these videos, we hope to have contributed to addressing the lack of Aboriginal English from medical media and to emphasise the importance of collaborative work. Working across cultures on materials the community will relate to is one more way to safeguard Indigenous health and well-being.</p><img src="https://counter.theconversation.com/content/163892/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Celeste Rodriguez Louro receives funding from the Australian Research Council.</span></em></p><p class="fine-print"><em><span>Glenys Dale Collard is affiliated with University of Western Australia and Mallee Aboriginal Corporation.</span></em></p>Indigenous people in Australia experience poorer health outcomes than non-Indigenous Australians. So it’s crucial health messaging is delivered in culturally appropriate ways.Celeste Rodriguez Louro, Senior Lecturer and ARC DECRA Fellow, Discipline of Linguistics, The University of Western AustraliaGlenys Dale Collard, Honorary Research Fellow and associate, The University of Western AustraliaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1619942021-06-14T17:59:34Z2021-06-14T17:59:34ZWhy is access to medically assisted death a legislated right, but access to palliative care isn’t?<figure><img src="https://images.theconversation.com/files/405982/original/file-20210611-17-yjynd9.jpg?ixlib=rb-1.1.0&rect=739%2C8%2C4564%2C3101&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Getting a referral to palliative care can be a complicated process.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>John started his first appointment in the Neuropalliative Care Clinic with, “I want to talk about MAID.” In our clinic, his request for medical assistance in dying is common. As legislated by government, I referred him to the MAID navigator. I had one request: that John wait to make his MAID decision until after seeing a community palliative care physician. </p>
<p>At his next appointment, John informed us he had withdrawn his MAID request because his primary symptom —pain — was now well controlled after our suggestions and those of the community palliative care doctor. John lived for two more years, during which he became closer with his daughter and continued to enjoy the company of his siblings.</p>
<p>John is not unusual. Neurologic illness accounts for 18 per cent of deaths in the Canada but <a href="https://doi.org/10.1016/j.parkreldis.2020.06.011">rarely has palliative care involvement</a>. By contrast, <a href="https://doi.org/10.25318/1310039401-eng">cancer accounts for 20 to 30 per cent of deaths</a>, but typically receives <a href="https://doi.org/10.1177%2F0269216317727157">75 per cent of palliative care</a>. </p>
<p>Part of the challenge is that palliative care services are often hospital-based, but most people who could benefit get their care in the community. Similarly, patients have recently refused palliative care <a href="https://www.virtualhospice.ca/Assets/MAiD_Report_Final_October_15_2018_20181218165246.pdf">in the belief that is the same as MAID</a>. In 2017, <a href="https://www.canada.ca/en/health-canada/services/publications/health-system-services/medical-assistance-dying-interim-report-april-2019.html">MAID accounted for 1.07 per cent</a> of deaths in Canada, increasing to <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying-annual-report-2019.html">two per cent in 2019</a>.</p>
<p>In June 2016, the <a href="https://www.canada.ca/en/health-canada/services/medical-assistance-dying.html#a1">passed legislation that gave all eligible Canadians the right to request MAID</a>. Colleges of Physicians and Surgeons required physicians to refer people who request MAID to services or arrange for a physician who would make the referral. </p>
<figure class="align-center ">
<img alt="A male doctor consulting with an older female patient" src="https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405983/original/file-20210611-19-cwcl3g.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">
<figcaption>
<span class="caption">The workforce for palliative care is inadequate to meet the needs for Canadians with chronic burdensome illnesses.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>Since then, every province and territory devoted resources to navigate requests and assessments for MAID. Typically, provinces have a <a href="https://www.albertahealthservices.ca/info/Page13497.aspx">website for self-referral</a>, easily found by internet search and/or dedicated health-care staff to help navigate the MAID process or inform those who are MAID-curious. </p>
<h2>Complicated referrals</h2>
<p>By contrast, the referral process for palliative care is often convoluted. Many provincial web pages simply give a definition of palliative care (some confuse the issue by including the MAID navigation site) but do not provide a central access point for physicians or nurses. Referral forms (where available) are complex, which creates another barrier to access. Many palliative care programs have an unofficial prognosis of three to six months’ life expectancy for services, despite research demonstrating that early palliative care <a href="https://doi.org/10.1056/nejmoa1000678">improves outcomes and in fact, can prolong life</a>. </p>
<p>What is the disconnect? Health-care providers are an unexpected barrier as they often cling to the belief that palliative care is for the imminently dying or means to give up hope. <a href="https://doi.org/10.1177/0269216313502372">For the public, palliative care means dying soon</a>.</p>
<p>But <a href="https://www.who.int/news-room/fact-sheets/detail/palliative-care">modern palliative care</a> is about living well now, meeting patients’ goals and finding meaning in life. For John, we helped him set goals, focused on the positive in his life, like his better relationships with his children and ongoing closeness with his siblings. His sharp sense of humour emerged despite communication challenges.</p>
<p>Additionally, many palliative care programs exist in the oncology (cancer) department and thus, their focus is cancer-based. Twenty per cent of people die from cancer, but <a href="https://doi.org/10.1177%2F0269216313502372">receive 75 per cent of palliative care services</a>. Current training for palliative care physicians requires exposure to other patient populations like heart failure, kidney failure and neurologic illnesses, but health-care systems are slow to change. </p>
<figure class="align-center ">
<img alt="A man in a hospital bed and a woman holding his hand, listening to a doctor whose back is to the camera." src="https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/405984/original/file-20210611-17-auakb9.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">
<figcaption>
<span class="caption">Placing as much importance on palliative care as we do on MAID might make navigation to palliative care less difficult.</span>
<span class="attribution"><span class="source">(shutterstock)</span></span>
</figcaption>
</figure>
<p>And finally, the workforce for palliative care is inadequate to meet the needs for Canadians with chronic burdensome illnesses.</p>
<h2>Making palliative care more accessible</h2>
<p>The solution requires a multi-faceted approach. All health-care providers need to have general palliative care skills because, in the way we all learn to control blood pressure and read a basic electrocardiogram, palliative care is part of good medical care. </p>
<p>At a systems level, placing as much importance on palliative care as we do on MAID might make navigation to palliative care less difficult for patients and clinicians. Given the broader applicability of palliative care, it is time for palliative care to become an independent department. Up to 28 per cent of Canadians will be seniors, which means <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/aging-chronic-diseases-profile-canadian-seniors-executive-summary.html">more people with multiple, chronic conditions that could benefit from a palliative approach</a>.</p>
<p>Building the palliative care workforce is essential. The palliative care workforce in Canada is <a href="https://surveys.cma.ca/en/viewer?file=%2fdocuments%2fSurveyPDF%2fCMA_Survey_Workforce2017_Q6i_FPfocus-e.pdf#phrase=false">estimated to be 773 doctors for a population of 39 million</a>. Once the palliative care workforce is established, educating the public that palliative care includes a holistic approach to wellness and meaning in life can help re-frame and increase acceptance.</p>
<p>There are more people like John who should connect with a palliative care team before walking down the road to MAID. Let palliative care help you live well, now.</p><img src="https://counter.theconversation.com/content/161994/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janis M. Miyasaki receives funding from Patient Centered Outcomes Research Institute, US; NINDS. Vice President of the American Academy of Neurology; Board Member, International Neuropalliative Care Society. </span></em></p>Palliative care is about living well and meeting patients’ goals, but referral can be more complex than access to medical assistance in dying (MAID). Palliative care should be as accessible as MAID.Janis M. Miyasaki, Professor, Department of Medicine, University of AlbertaLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1605862021-06-07T15:30:53Z2021-06-07T15:30:53ZInuit cancer patients often face difficult decisions without support far from home<figure><img src="https://images.theconversation.com/files/403662/original/file-20210531-15-1dkejwq.jpeg?ixlib=rb-1.1.0&rect=187%2C162%2C3838%2C2854&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Inuit in the Qikiqtaaluk (Baffin) region must travel long distances south to receive specialized health-care services.</span> <span class="attribution"><span class="source">(Janet Jull)</span>, <span class="license">Author provided</span></span></figcaption></figure><p>Inuit are resilient. They have demonstrated self-determination and the ability to navigate and adapt to harsh and changing environments.</p>
<p>Inuit live in many locations including urban environments, although most Inuit in Canada live in the traditional territory called <a href="https://www.itk.ca/about-canadian-inuit/">Inuit Nunangat</a>. Inuit who live in Inuit Nunangat must travel long distances south to receive specialized health-care services, such as cancer care, obstetrics and dialysis.</p>
<p>They must navigate complex health systems in major urban centres, often with little or no personal support. These circumstances <a href="https://dx.doi.org/10.3747%2Fco.26.4729">limit the opportunities of Inuit community members</a> to participate in their health decisions.</p>
<p>When people have opportunities to participate with their health-care providers and to share what is important to them in their health decisions, it is called <a href="https://www.kingsfund.org.uk/publications/making-shared-decision-making-reality">shared decision making</a>. Shared decision making is identified as a <a href="https://doi.org/10.1016/j.zefq.2011.04.004">high standard of person-centred care, and supports positive health outcomes</a>.</p>
<p>We are members of a team of Inuit and non-Inuit community service providers and academic health-care researchers who are working on a research project we call “Not Deciding Alone.”</p>
<p>Our focus is on <a href="https://theconversation.com/an-inuit-approach-to-cancer-care-promotes-self-determination-and-reconciliation-116900">enhancing opportunities for Inuit to participate in decisions about their health care</a> through the shared decision-making model. Our research approach applies the guiding principles of Inuit Qaujimajatuqangit, a system of knowledge and beliefs used to serve the common good through collaborative decision making. <a href="https://www.ccnsa-nccah.ca/docs/health/FS-InuitQaujimajatuqangitWellnessNunavut-Tagalik-EN.pdf">Inuit Qaujimajatuqangit</a> are grounded in caring for and respecting others, and are the <a href="https://www.gov.nu.ca/sites/default/files/files/Inuit%20Qaujimajatuqangit%20ENG.pdf">foundation for a strengths-based approach</a> to promote Inuit self-determination and self-reliance.</p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A town in a snowy landscape with a plane flying overhead." src="https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=450&fit=crop&dpr=1 600w, https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=450&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=450&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=566&fit=crop&dpr=1 754w, https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=566&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/403661/original/file-20210531-15-1b8obly.jpeg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=566&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px"></a>
<figcaption>
<span class="caption">For patients from the Qikiqtaaluk (Baffin) region, the journey to receive cancer care involves negotiating a complex health system and travelling thousands of kilometres to large cities in Ontario.</span>
<span class="attribution"><span class="source">(Janet Jull)</span>, <span class="license">Author provided</span></span>
</figcaption>
</figure>
<p>Like many First Nations and Métis populations, Inuit face a <a href="https://www.nccih.ca/495/An_Overview_of_Aboriginal_Health_in_Canada.nccih?id=101">high and worsening health burden</a> in relation to others across Canada. Ineffective policies perpetuate these health and social inequities.</p>
<p>Research can help people (community members, health-care providers, policy and decision makers) to <a href="https://journals.sagepub.com/doi/10.2190/986L-LHQ6-2VTE-YRRN">identify, understand and address</a> <a href="https://www.who.int/healthsystems/topics/equity/en/">health inequities</a>, that is, differences in health that are unnecessary, avoidable and unjust. We aim to build evidence that Inuit can use to improve their experience in the health system.</p>
<h2>Learning about the health-care journey</h2>
<p><a href="https://doi.org/10.1186/s12913-021-06303-9">We conducted a study to understand the experiences of Inuit</a> who travel from remote to urban settings for cancer care. For participants in our study from the Qikiqtaaluk (Baffin) region, the journey to receive cancer care involves negotiating complex health systems and travelling thousands of kilometres from very remote geographic areas to large cities in Ontario.</p>
<p>Our study shows that the journey to receive health care consists of a series of connected events that we describe as a “decision chain.” Participants described themselves as directed, with little or no support, and as seeking opportunities to collaborate with others on the journey to receive health care.</p>
<p>There is a travel burden to access health care for <a href="http://dx.doi.org/10.1136/bmjopen-2019-030885">people who live in the northern regions of Canada</a>. For many Inuit, decisions about <a href="https://doi.org/10.3747/co.22.2421">accessing health care also involve decisions about commuting or moving</a> from remote communities to a major urban centre in the south and leaving dependents, their home, employment and other community roles. The alternative is to opt out of treatment.</p>
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<em>
<strong>
Read more:
<a href="https://theconversation.com/an-inuit-approach-to-cancer-care-promotes-self-determination-and-reconciliation-116900">An Inuit approach to cancer care promotes self-determination and reconciliation</a>
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</em>
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<p>While all who live in remote areas of Canada are confronted with difficult decisions related to health-care access, the decision-making of Inuit (and other Indigenous people) is further complicated by factors related to health care. These factors include limited community health resources. For example, in some regions of Canada such as Nunavut, there is limited access or a lack of <a href="https://www.cancer.ca/en/prevention-and-screening/reduce-cancer-risk/find-cancer-early/screening-for-cancer/?region=on">organized cancer screening programs</a>.</p>
<p>As a result, people need to have an awareness of cancer symptoms and act as self-advocates. In addition, they must rely on a local health system that faces challenges of <a href="https://doi.org/10.1080/22423982.2019.1571384">health-care provider recruitment and retention</a>, and high patient caseloads. Many Inuit must also access and navigate health care in their second language, another health-care challenge and barrier to equitable access and uptake of health care.</p>
<p>Indigenous peoples’ history of <a href="https://www.cancercareontario.ca/sites/ccocancercare/files/assets/InuitRiskFactorsReport.pdf">negative experiences with the health-care system</a> also impact <a href="https://engage.gov.bc.ca/app/uploads/sites/613/2020/11/In-Plain-Sight-Summary-Report.pdf">decisions to seek treatment</a>. Inuit have painful memories about the removal of family members for <a href="http://www.trc.ca/assets/pdf/Honouring_the_Truth_Reconciling_for_the_Future_July_23_2015.pdf">tuberculosis treatment</a> to hospitals and sanatoria located in <a href="https://www.rcaanc-cirnac.gc.ca/eng/1552073111368/1552073153674">unknown southern regions of Canada in the 1950–60s</a>. Inuit must also deal with the <a href="https://www.thecanadianencyclopedia.ca/en/article/inuit-experiences-at-residential-school">intergenerational trauma</a> of <a href="http://www.trc.ca/assets/pdf/Volume_2_Inuit_and_Northern_English_Web.pdf">residential schools</a></p>
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<iframe width="440" height="260" src="https://www.youtube.com/embed/UGSWIa5vCH0?wmode=transparent&start=0" frameborder="0" allowfullscreen=""></iframe>
<figcaption><span class="caption">Lillian Elias: A Residential School Survivor’s Story.</span></figcaption>
</figure>
<h2>Support on the health-care journey</h2>
<p>People who live in remote areas are identified as being at risk to experience stress because, to receive care, they must leave their family and community supports to <a href="https://bcpsqc.ca/resource/journey-mapping-in-cancer-care/">travel to the location of care</a>. Research with Indigenous populations who live in remote areas shows that <a href="https://doi.org/10.1186/1472-6963-13-83">health-care systems do not accommodate</a> the <a href="https://doi.org/10.1186/s12913-016-1665-2">context and logistic complexity</a> of <a href="https://doi.org/10.1186/1472-6963-8-31">health-care access</a>. Inuit have also been identified to be at <a href="https://www.nationalobserver.com/2018/03/05/news/philpott-wants-see-health-care-inuit-inuit">increased risk of harms</a> during their <a href="https://nationalpost.com/news/the-mmiw-inquiry-drew-from-98-earlier-reports-the-same-problems-and-unrealized-solutions-echo-through-them-all">transition to urban centres</a>.</p>
<p>The recommendations of the <a href="https://irc.inuvialuit.com/index.php/news/calls-justice-final-report-national-inquiry-missing-and-murdered-indigenous-women-and-girls">Missing and Murdered Indigenous Women and Girls Inquiry</a> (MMIWG) call on governments to plan and fund safe, sufficient and readily available transportation in towns and cities with particular consideration of the limited transportation available, especially in fly-in, northern and remote locations.</p>
<p>There is an urgent need to improve opportunities for Inuit to participate in their health decisions. With leadership from Inuit partners, our team is learning how health-care systems can better support collaboration among those who use, deliver and facilitate health care. Inuit need to know that they are not alone on the health-care journey.</p>
<p><em>We thank the Not Deciding Alone Team for their support and role in the important work that contributed to this article.</em></p><img src="https://counter.theconversation.com/content/160586/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Janet Jull receives funding from Canadian Institutes of Health Research. </span></em></p><p class="fine-print"><em><span>Inuit Medical Interpreter Team, Malaya Zehr, and Mamisarvik Healing Centre, Tungasuvvingat Inuit 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>Inuit living in their traditional territory must travel long distances — often with no personal support — for specialized health-care services like cancer care, obstetrics and dialysis.Janet Jull, Assistant Professor, School of Rehabilitation Therapy, Queen's University, OntarioInuit Medical Interpreter Team, Ottawa Health Services Network Inc.Malaya Zehr, Research Manager, School of Rehabilitation Therapy, Queen's University, OntarioMamisarvik Healing Centre, Tungasuvvingat Inuit, Ottawa, OntarioLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1554762021-03-23T16:09:06Z2021-03-23T16:09:06ZCOVID-19 and schizophrenia: A potentially deadly combination<figure><img src="https://images.theconversation.com/files/390066/original/file-20210317-23-x2rxis.jpg?ixlib=rb-1.1.0&rect=50%2C272%2C1901%2C1317&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Schizophrenia has been identified as a significant risk factor for dying of COVID-19.</span> <span class="attribution"><span class="source">(Canva)</span></span></figcaption></figure><p>People living with schizophrenia are uniquely vulnerable to COVID-19 and completely missing from Canada’s <a href="https://www.canada.ca/en/public-health/services/immunization/national-advisory-committee-on-immunization-naci/guidance-prioritization-key-populations-covid-19-vaccination.html">National Advisory Committee on Immunization’s recommendations</a> for vaccine distribution, which prioritizes seniors, front-line health-care workers and Indigenous communities in the first stage. </p>
<p>Those with schizophrenia are almost three times more likely to die from COVID-19 than those without the serious mental illness, making it second only to age as a risk factor for mortality, according to <a href="http://doi.org/10.1001/jamapsychiatry.2020.4442">a study in <em>JAMA Psychiatry</em></a>. </p>
<p>The study included more than 7,000 adults with confirmed COVID-19 in a large New York health system. It found that a pre-existing diagnosis of schizophrenia was significantly associated with an increased risk of death, even after adjusting for other demographic and medical risk factors. </p>
<p>In fact, schizophrenia was found to be a distinct, and more deadly COVID-19 risk factor than heart, lung and kidney disease — even while it is well-established that those with schizophrenia often also have multiple co-morbid conditions, such as <a href="http://doi.org/10.1080/15412555.2019.1572730">COPD</a> or <a href="https://doi.org/10.1155/2015/969182">diabetes</a>, that put them at further risk, say advocates.</p>
<p>The study authors suggest that the mechanism for their findings is not fully understood. But they suspect schizophrenia and its treatment trigger immune system changes that increase COVID-19 susceptibility beyond levels created by medication side-effects and barriers to accessing medical care and social supports, such as stigma and poverty. </p>
<h2>Stigma and inequity</h2>
<p>The results of the study trouble psychiatrist Dr. Saadia Sediqzadah, who worries that the more than <a href="https://www.canada.ca/en/public-health/services/publications/diseases-conditions/schizophrenia-canada.html">300,000 Canadians</a> living with schizophrenia already experience significant health disparities. </p>
<figure class="align-center zoomable">
<a href="https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="A bottle of anti-psychotic medication beside a tray of pills." src="https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390236/original/file-20210317-21-1anxfbv.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">Common side-effects of anti-psychotic medications can contribute to the risk of severe COVID-19.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Michelle Siu</span></span>
</figcaption>
</figure>
<p>Sediqzadah works at St. Michael’s Hospital in Toronto, and with <a href="http://www.icha-toronto.ca">Inner City Health Associates</a> to provide care in homeless shelters, and witnesses how people with schizophrenia are at greater risk, medically and due to social inequities and stigma.</p>
<p>She says the side-effects of anti-psychotic medications often include things like weight gain and increased risk of diabetes. “As important as they may be to treat delusions and hallucinations — they also unfortunately put people at risk for the very diseases that put someone at risk of having severe COVID,” says Sediqzadah. </p>
<p>She also notes that for a variety of reasons, an overwhelming number of <a href="https://dx.doi.org/10.3389%2Ffpsyt.2018.00711">people with schizophrenia also smoke</a>, putting them at higher risk of respiratory illness.</p>
<p>Sediqzadah says that from a “more upstream perspective we also know that people with schizophrenia are over-represented in populations where social distancing is just basically impossible.” </p>
<p>Psychotic illnesses are <a href="https://www.cfp.ca/content/62/3/215.full">common in the prison population</a> and in <a href="https://doi.org/10.1186/1471-2458-12-787">people experiencing homelessness</a>, where infection prevention and control are difficult to maintain. </p>
<p>And even those with housing <a href="https://www.mentalhealthcommission.ca/sites/default/files/PrimaryCare_Turning_the_Key_Full_ENG_0_1.pdf">frequently live in rooming houses or other forms of supportive living</a>.</p>
<p>Unstable or congregate living translates into <a href="https://doi.org/10.1002/wps.20806">higher incidence of COVID-19</a> infection for this population. </p>
<h2>Barriers to care</h2>
<p>Sediqzadah also worries that increased COVID-19 mortality for people with schizophrenia could be related to poor access to care. </p>
<figure class="align-right zoomable">
<a href="https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=1000&fit=clip"><img alt="Gloved hands preparing a dose of the Pfizer-BioNTech COVID-19 vaccine" src="https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=780&fit=crop&dpr=1 600w, https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=780&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=780&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=980&fit=crop&dpr=1 754w, https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=980&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/390237/original/file-20210317-13-hekni2.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=980&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 high risk for severe COVID-19 in people with schizophrenia should make them a high priority group for vaccination.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>“They don’t get the best access to health care first and foremost. And secondly, when they present to the emergency department, there’s always a concern on my end about diagnostic overshadowing in the sense that when the average person who may not have a psychotic illness presents with a health concern, their health concern is taken a lot more seriously than someone with a psychotic illness,” says Sediqzadah.</p>
<p>Not only is there a health-care bias against people with schizophrenia presenting with health concerns — which affects outcomes for serious medical conditions — Sediqzadah notes a symptom of schizophrenia itself can also be a barrier.</p>
<p>“They’re doubly hit because they also have challenges with insight to go and seek care for health conditions,” she says.</p>
<p>She explains that changes to a person’s insight as a result of their psychotic illness “compromises their access to treatment for schizophrenia in and of itself, because they don’t think it’s necessarily a problem and then that also extends to accessing health care generally” — even for cancers or other significant illnesses.</p>
<h2>Logistic challenges and outreach</h2>
<p>Chris Summerville, the chief executive officer of the <a href="https://schizophrenia.ca">Schizophrenia Society of Canada</a>, also highlights barriers to care. He finds that many people with schizophrenia struggle to find a primary care provider, which limits their access to information about prevention and treatment of COVID-19.</p>
<p>“Family members are calling us and our calls have increased about 50 per cent. And family members are looking for a primary health-care provider, and asking ‘do you know how do I convince my son to go get the COVID-19 shot?’” says Summerville.</p>
<p>But he has not seen any action yet on prioritizing this population.</p>
<p>Sediqzadah says she also hopes that people with schizophrenia will be made a priority sooner rather than later. She thinks that it will be challenging logistically to track and identify those with serious mental illness, but she thinks this population could be reached indirectly: </p>
<p>“Doing outreach to shelters, outreach on the streets … and bringing the vaccine out to people who are incarcerated. By virtue of doing that, you will vaccinate a lot of people with severe mental illnesses.”</p><img src="https://counter.theconversation.com/content/155476/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Kaleigh Alkenbrack receives funding from Canadian Mental Health Association (CMHA) Niagara.</span></em></p>People with schizophrenia are almost three times more likely to die from COVID-19 than those without the serious mental illness, making it second only to age as a risk factor for mortality.Kaleigh Alkenbrack, Physician, Dalla Lana Fellow in Global Journalism, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1547062021-03-08T21:16:49Z2021-03-08T21:16:49ZMass COVID-19 immunization: Ensuring equitable access to vaccination<figure><img src="https://images.theconversation.com/files/385489/original/file-20210222-23-1vulc7d.jpg?ixlib=rb-1.1.0&rect=89%2C62%2C2905%2C1881&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Premier Scott Moe speaks after a media tour of the COVID-19 mass immunization clinic and drive-thru immunization space in Regina on Feb. 18, 2021. The province also has mobile immunization vehicles to distribute the vaccine to remote communities. </span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Michael Bell</span></span></figcaption></figure><p>There are very few things as logistically complex as the task that is now getting underway: <a href="https://theconversation.com/covid-19-vaccine-rollout-why-a-mask-and-social-distancing-are-still-needed-even-if-you-get-the-shot-152351">universal public immunization against COVID-19</a> to as many as 70-85 per cent of the population as quickly as possible, to achieve herd immunity.</p>
<p>So what will success look like?</p>
<p>As a team of researchers dedicated to investigating how health and social systems can help achieve health equity, we have been working to understand the factors that determine vaccine uptake, and what public health systems can do to lower the barriers to immunization in general.</p>
<p>One particularly important metric by which we can measure the efficiency and effectiveness of our public health system is ensuring everyone has access to vaccinations in their own community.</p>
<h2>Mass public immunizations</h2>
<p>At its core, immunization is a service provided to every resident in a community. As a service, a mass immunization program is simple enough to imagine. </p>
<p>Much like a Boxing Day sale at a store (during non-pandemic periods), everyone lines up for their shot, first-come, first-served, with hopefully enough supply for everyone.</p>
<p>Our current situation, however, is far from straightforward. </p>
<p>For one, <a href="https://theconversation.com/the-roots-of-canadas-covid-19-vaccine-shortage-go-back-decades-154792">we do not have enough supply for everyone</a> yet. It’s also not just one vaccine, it is <a href="https://theconversation.com/how-pharma-can-build-trust-in-covid-19-vaccines-transparency-on-trials-and-side-effects-150270">at least three for now, each with its own storage and distribution requirements</a>.</p>
<p>Second, we can’t deliver vaccines in a centralized location where everyone comes to get their shots. It would likely be dangerous to do so in terms of proximity between people in crowds, but such clinics would also not be equally accessible to all residents.</p>
<h2>Access and universalism</h2>
<figure class="align-center ">
<img alt="Close-up of a woman's shoulder being injected by a health-care worker out of frame" src="https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=552&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=552&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385491/original/file-20210222-23-1t3hzn9.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=552&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Amanda Parsons, a registered nurse on staff at the Northwood Care facility, administers a dose of the Moderna vaccine to Ann Hicks, 77, in Halifax on Jan. 11, 2021. In a bid to control COVID-19, the federal government plans to make free vaccines available to everyone who lives in Canada over the course of 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
</figcaption>
</figure>
<p>Mass immunization clinics will not necessarily provide the most equitable level of access to a COVID-19 vaccine. As with any health-care service, effective immunization strategies will depend on two perspectives: A patient perspective and the public health perspective. </p>
<p><a href="https://dx.doi.org/10.1186%2F1475-9276-12-18">Factors affecting access on the patient side</a> include:</p>
<ul>
<li>the patient’s ability to understand and trust health services </li>
<li>the patient’s values and culture</li>
<li>the patient’s built and social environment </li>
<li>the level of available socio-economic resources </li>
<li>ability to engage with health care and participate in treatment decisions</li>
</ul>
<p>On the public health side, health services must be approachable, acceptable, available, accommodating, affordable and appropriate to be truly accessible to every patient.</p>
<p>Regarding mass immunization clinics, not everyone has access to transportation, especially when <a href="https://theconversation.com/giving-up-public-transit-during-the-coronavirus-is-a-luxury-many-canadians-cant-afford-138875">public transit has been reduced because of the pandemic</a>. And many don’t have the luxury to wait in line all day. They may have multiple jobs or lack social support or financial resources to help with child care.</p>
<p>If we’re not careful, we may see the emergence of an “<a href="https://doi.org/10.2105/ajph.2007.114777">inequality paradox</a>,” where universal programs inadvertently reach privileged populations, and nothing much changes for disadvantaged populations. </p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/covid-19-vaccine-rollout-why-a-mask-and-social-distancing-are-still-needed-even-if-you-get-the-shot-152351">COVID-19 vaccine rollout: Why a mask and social distancing are still needed, even if you get the shot</a>
</strong>
</em>
</p>
<hr>
<p>We have seen programs such as vaccine campaigns increase inequities in health outcomes rather than reduce it. For example, in Calgary, despite the universal H1N1 immunization campaign, those who provide services to homeless people reported that <a href="https://www.homelesshub.ca/sites/default/files/attachments/LessonsfromH1N1-Chapter_4.pdf">the clinics ran counter to the needs of those experiencing homelessness</a>. For example, clinics were held in the evening, when those living in shelters with strict evening sign-in times could not attend. </p>
<p>At the same time, while mass immunization clinics were rationing doses, <a href="https://www.cbc.ca/news/canada/calgary/calgary-flames-skip-flu-vaccine-lineups-1.809497">the Calgary Flames received special treatment and earlier dedicated doses</a>.</p>
<p>Our research on the <a href="https://harvest.usask.ca/handle/10388/12051">measles, mumps and rubella immunization uptake in Calgary during the 2014 measles outbreak</a> also showed that mass immunization campaigns favoured children who live in neighbourhoods that had the highest income and highest rates of home-ownership. </p>
<p>This is something we need to avoid as we may inadvertently create social groups with persistent and longer-term vulnerability to COVID-19.</p>
<h2>Needs-based approach</h2>
<figure class="align-center ">
<img alt="Shot from above of people waiting in line 6 feet apart" src="https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=419&fit=crop&dpr=1 600w, https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=419&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=419&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=527&fit=crop&dpr=1 754w, https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=527&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/385490/original/file-20210222-13-t657xw.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=527&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Health-care workers wait in line at a COVID-19 vaccine clinic in Toronto on Jan. 7, 2021.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>“<a href="http://www.healthscotland.com/documents/24296.aspx">Proportionate universalism</a>” is a model of program design that prioritizes building provisions into a universal program to account for various levels of patient access needs.</p>
<p>The proportionate universalism approach looks more closely at removing patient- and system-level barriers, community by community and social group by social group. For example, in Saskatoon during the H1N1 pandemic, <a href="https://nccdh.ca/images/uploads/Saskatoon_EN_Feb_20.pdf">public health teams deployed small clinics</a> throughout the neighbourhoods where transportation was a problem, and used a <a href="https://healthstandards.org/leading-practice/primary-health-bus-reaches-under-served-populations/">health bus to take the vaccine to communities</a>. </p>
<p>This approach can also include adapting education materials and communications about the vaccine and clinics to varying levels of literacy and language needs. </p>
<p>Conducting mass immunizations against COVID-19 in centralized locations, while convenient in principle, will not achieve immunization equity unless specific steps are taken to remove barriers to access. It might also exacerbate inequities. Equity needs to be the core principle of immunization, and enacting it needs to be planned in detail.</p><img src="https://counter.theconversation.com/content/154706/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Thilina Bandara has received funding from the Natural Sciences and Engineering Research Council, Canadian Institutes of Health Research, the Government of Saskatchewan and the Saskatchewan Health Research Foundation. He is a board member for the National Collaborating Centre for Determinants of Health and the Saskatchewan Public Health Association.</span></em></p><p class="fine-print"><em><span>Cory Neudorf receives funding from the Canadian Institutes for Health Research, the Saskatchewan Health Research Foundation. He is affiliated with the Urban Public Health Network, and serves on advisory boards and committees with the Public Health Agency of Canada, the Canadian Institute for Health Information, the Canadian Public Health Association. </span></em></p><p class="fine-print"><em><span>Nazeem Muhajarine receives funding from Canadian Institutes of Health Research, Social Sciences and Humanities Research Council of Canada, and Global Affairs Canada. He leads several studies on risk behaviour, mitigation and perceptions related to the COVID-19 pandemic, and mental health. He serves on an expert advisory panel on COVID-19 immunization, and is theme lead, Epidemiology and Public Health at CanCOVID.
</span></em></p>One important metric by which we can measure the success of our public health system: Ensuring everyone has access to immunization in their community.Thilina Bandara, Research Scientist and Adjunct Professor, Community Health and Epidemiology, University of SaskatchewanCory Neudorf, Professor, Department of Community Health and Epidemiology, College of Medicine, University of SaskatchewanNazeem Muhajarine, Professor, Department of Community Health and Epidemiology and Director, Saskatchewan Population Health and Evaluation Research Unit, University of SaskatchewanLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1547412021-02-15T13:12:38Z2021-02-15T13:12:38ZPeople with disabilities put at risk by COVID-19 triage and vaccine priorities<figure><img src="https://images.theconversation.com/files/383957/original/file-20210212-17-1mpvoqc.jpg?ixlib=rb-1.1.0&rect=45%2C5%2C3788%2C2138&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">While people with certain disabilities are already at higher risk for severe COVID-19, that risk is increased by elements within the health-care system.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>There are two big stories on either end of the COVID spectrum right now. Both are about line-ups and priorities. Both impact disabled people. And both say so much about who matters.</p>
<p>The first story is about vaccines. Canada has overlooked disabled individuals and their essential caregivers as a priority group in its COVID-19 vaccine distribution plan.</p>
<p>In contrast <a href="https://www.porticonetwork.ca/web/hcardd/news/-/blogs/research-evidence-regarding-covid-19-and-developmental-disabilities">to other countries</a> which clearly indicate that people with disabilities or certain types of disabilities are high priority, Canada has yet to give this guidance. The only exceptions are <a href="https://www2.gov.bc.ca/gov/content/safety/emergency-preparedness-response-recovery/covid-19-provincial-support/vaccines?">British Columbia</a> and <a href="https://www.saskatchewan.ca/government/health-care-administration-and-provider-resources/treatment-procedures-and-guidelines/emerging-public-health-issues/2019-novel-coronavirus/covid-19-vaccine/vaccine-delivery-phases">Saskatchewan</a>, which both list “adults with very significant developmental disabilities that increase risk” as people who are “clinically extremely vulnerable.” </p>
<p>The second story concerns triage protocols, which have been in the news recently with increasing demand for critical care resources and reduced <a href="https://www.theglobeandmail.com/canada/article-how-doctors-in-quebec-ontario-will-decide-who-gets-care-if-coronavirus/">ICU capacity in Ontario and Québec</a>. When the demand for intensive care exceeds supply, people who become very ill will have to be prioritized for life-saving treatments. </p>
<p>Triage protocols released in the spring were discriminatory toward disabled individuals. Steps were taken in <a href="https://www.cbc.ca/news/canada/montreal/covid-quebec-icu-priority-guidelines-1.5836092">Québec to improve its protocol</a> but changes in Ontario have yet to be made public.</p>
<h2>The back of the line</h2>
<p>This is not new. <a href="https://theconversation.com/coronavirus-crisis-shows-ableism-shapes-canadas-long-term-care-for-people-with-disabilities-137478">People with disabilities have been forgotten</a>, or told to stand near the back of the line for many things prior to and since the start of the pandemic, including accessible information, housing, education, <a href="https://theconversation.com/covid-19-financial-future-grim-for-canadians-with-disabilities-health-conditions-143168">employment, financial support</a> and health care. </p>
<p>In fact, if you read the news, it seems the only time disabled individuals may find their way to the “front of the line” relates to Bill C-7, concerning medical assistance in dying (MAID), discussed in the Senate this week.</p>
<hr>
<p>
<em>
<strong>
Read more:
<a href="https://theconversation.com/a-dangerous-path-why-expanding-access-to-medical-assistance-in-dying-keeps-us-up-at-night-153540">A dangerous path: Why expanding access to medical assistance in dying keeps us up at night</a>
</strong>
</em>
</p>
<hr>
<p>In a bold <a href="https://twitter.com/NightShiftMD/status/1353121263582121987">tweet</a> recently, emergency room physician and medical reporter Brian Goldman suggested that it would be more efficient for the health-care system to avoid triaging people with disabilities by prioritizing them instead. </p>
<p><div data-react-class="Tweet" data-react-props="{"tweetId":"1353121263582121987"}"></div></p>
<p>There is truth to this. A <a href="https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronaviruscovid19relateddeathsbydisabilitystatusenglandandwales/24januaryto20november2020">United Kingdom-based analysis</a> found that disabled adults in the U.K., representing 17 per cent of the population, accounted for 59 per cent of COVID-19 deaths. If we know that a group is more likely to get ill or do worse when they fall ill, they should be vaccinated sooner.</p>
<p>But I want to dispel the notion that it is something about people with disabilities that puts them at increased risk. <a href="https://doi.org/10.1080/15265161.2020.1779396">We know from research</a> that certain health conditions more common in disabled adults make contracting COVID-19 more deadly. However, there are also common mistakes made in health care that contribute to this problem:</p>
<ul>
<li><p>There are attitudes within the health system that lead to discriminatory behaviours when it comes to how we care for people with disabilities. In a <a href="https://doi.org/10.1377/hlthaff.2020.01452">recent study based in the United States</a>, four out of five doctors <a href="https://www.statnews.com/2021/02/01/large-majority-of-doctors-hold-misconceptions-about-people-with-disabilities-survey-finds/">perceived the quality of life of people with severe disabilities as worse than other patients</a>.</p></li>
<li><p>Pandemic restrictions and inaccessible health-care information have made health-care navigation for many disabled people even more complicated, <a href="https://doi.org/10.1016/j.dhjo.2021.101066">especially those less able to manage digital solutions</a>. This means that not everyone can access needed health care in a timely manner.</p></li>
<li><p>We recognize symptoms of COVID-19 too late because of communication challenges, because they present differently and because we mis-attribute illness symptoms to a person’s disability (“<a href="https://www.patientsafetyinstitute.ca/en/NewsAlerts/News/Pages/SHIFTTalks-Diagnostic-Overshadowing-in-the-ED-2018-04-04.aspx">diagnostic overshadowing</a>”).</p></li>
<li><p>Despite <a href="https://www.canada.ca/en/public-health/services/diseases/2019-novel-coronavirus-infection/guidance-documents/people-with-disabilities.html">federal guidance</a> to the contrary, we prevent essential care partners from being present in hospital to assist with assessing, diagnosing and treating illness, COVID-19 related and otherwise. Not only does this lead to problematic care, it can <a href="https://www.peacearchnews.com/news/policy-change-sparked-by-death-of-disabled-south-surrey-woman-will-save-lives/">lead to preventable deaths</a>.</p></li>
</ul>
<figure class="align-center ">
<img alt="A woman with a developmental disability getting an injection" src="https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/383958/original/file-20210212-13-wccny.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">
<figcaption>
<span class="caption">Higher-risk groups, such as people with disabilities, should be priorities for vaccine distribution.</span>
<span class="attribution"><span class="source">(Shutterstock)</span></span>
</figcaption>
</figure>
<p>So, while we continue to advocate regarding vaccine prioritization and triage protocols, let’s also:</p>
<ul>
<li><p>Ensure disabled people are knowledgeable and empowered to do all they can to prevent getting COVID-19, or any illnesses requiring intensive health care at this time, by giving them the health, financial and social supports they need to stay well.</p></li>
<li><p>Adapt protocols in hospital and community so disabled people can be easily tested for COVID-19, and can isolate and be treated. Everyone can play a role in this — patients, caregivers, and importantly, health-care providers and administrators.</p></li>
<li><p>Make sure that disabled individuals who require an <a href="https://www.cfhi-fcass.ca/what-we-do/enhance-capacity-and-capability/essential-together">essential care partner</a> to provide physical, psychological and emotional support are able to have them present in all health-care settings.</p></li>
<li><p>Put structures in place to reduce ableism in health care. Health-care providers, it’s time we take a close look at ourselves in terms of our attitudes and behaviour toward disability, call out discrimination when we see it, and take action.</p></li>
</ul>
<p>Disabled people matter and this pandemic has only accentuated the sad reality that as a country, we fail to act like this is the case. Whether we are talking about vaccine distribution or triage protocols, we need to work together to make sure they are prioritized while, at the same time, address the issues that put them at risk.</p><img src="https://counter.theconversation.com/content/154741/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Yona Lunsky receives research funding from the Canadian Institutes of Health Research and the Azrieli Foundation focused on the mental health of people with developmental disabilities and their families. </span></em></p>People with disabilities are overlooked for COVID-19 vaccine distribution and triage protocols. We need to make this group a priority and address issues that put them at risk.Yona Lunsky, Professor, Department of Psychiatry, Director, Azrieli Adult Neurodevelopmental Centre, CAMH, University of TorontoLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1459342020-10-26T17:07:38Z2020-10-26T17:07:38ZCollateral damage: The unmet health-care needs of non-COVID-19 patients<figure><img src="https://images.theconversation.com/files/364847/original/file-20201021-13-f5ye61.jpg?ixlib=rb-1.1.0&rect=35%2C0%2C2959%2C1998&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">With more health resources devoted to COVID-19, non-COVID patients may have unmet health-care needs, which predict poorer health in the future.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>As the second wave of COVID-19 has now officially hit Central Canada (<a href="https://www.cbc.ca/news/canada/montreal/quebec-second-covid-wave-presents-challegne-1.5734599">Québec</a> and <a href="https://news.ontario.ca/en/release/58602/ontario-releases-updated-covid-19-modelling-for-second-wave">Ontario</a>), we can expect health-care system resources to again be disproportionally demanded by COVID-19 patients. Addressing the direct health implications of the pandemic is <a href="https://www.sciencemag.org/news/2020/07/brain-fog-heart-damage-covid-19-s-lingering-problems-alarm-scientists">clearly necessary</a>, but doing so may come at an indirect cost for non-COVID patients who may struggle to access needed care. </p>
<p>Meeting those unmet health-care needs calls for policy actions such as better data, alignment of physicians’ billings with telemedicine, including extended hours, and ensuring all Canadians have a regular point of care.</p>
<p>I am a health economist and health policy researcher, and in my work, I regularly analyze how the organization of health-care systems influence health care and health outcomes. In a recently <a href="https://doi.org/10.1017/S1744133120000250">published article</a>, my co-author Ian Allan and I studied the evolution of unmet health-care needs in Canada since the early 2000s. We found a remarkable stability over a period of 14 years of the groups reporting comparatively more unmet health-care needs: women, those in poorer health and those without a regular doctor.</p>
<h2>Unmet needs</h2>
<p>Unmet health-care needs reflect an inadequacy between the needs perceived by people seeking health care (the patients, or those trying to become someone’s patient), and the actual health-care services received, making it a measure of <a href="https://doi.org/10.1016/j.socscimed.2009.10.027">lack of accessibility of care</a>. While they tend to be self-reported, unmet health-care needs are a commonly used and a valid measure, since higher unmet health-care needs in the present <a href="https://doi.org/10.1002/hec.3877">predict poorer health in the future</a>. And these unmet health-care needs are poised to grow during the COVID-19 pandemic.</p>
<p>The negative implications of the COVID-19 pandemic for women are wide-ranging, including the fact that <a href="https://melbourneinstitute.unimelb.edu.au/__data/assets/pdf_file/0006/3387039/ri2020n10.pdf">industries hit hardest</a> tend to employ more women, or that the lion’s share of <a href="https://www.ifs.org.uk/publications/14860">household responsibilities</a> during and after lockdown still fell on women. </p>
<p>Unfortunately, women in Canada are also more likely than men to report unmet health-care needs. We also found that over time, there has been an increasing share of women reporting unmet needs due to system reasons. Excessive wait times and areas where care is not available are examples of systemic causes that could be addressed by health policy.</p>
<figure class="align-center ">
<img alt="An ECG printout, stethoscope, eyeglasses and medication." src="https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364006/original/file-20201016-21-gs173f.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">
<figcaption>
<span class="caption">People with chronic conditions who are not getting regular care during the pandemic are at risk of becoming more seriously ill.</span>
<span class="attribution"><span class="source">(Unsplash)</span></span>
</figcaption>
</figure>
<p>Individuals in poorer health, like those with chronic conditions, face a double-edged sword with COVID-19. On one hand, they are more likely to <a href="https://www.mayoclinic.org/diseases-conditions/coronavirus/in-depth/coronavirus-who-is-at-risk/art-20483301">develop severe forms of COVID-19</a> if they become infected. This gives them incentive to limit social exposure, including contacts with health-care providers and clinic environments. On the other hand, these individuals are likely to become more seriously ill if their conditions are not <a href="https://bmcfampract.biomedcentral.com/articles/10.1186/s12875-017-0692-3">properly managed and monitored</a>, which requires contacts with the health-care system. </p>
<p>Again, individuals in poorer health report consistently higher unmet health-care needs than their healthier counterparts, which means they are more at risk of insufficient care during the COVID pandemic.</p>
<p>For those two above subgroups, and for others too, having a regular doctor helps ensure individuals get the health care they need. But Canada does not compare well to <a href="https://www.healthaffairs.org/doi/10.1377/hlthaff.2013.0879">other industrialized countries</a> when it comes to timely access to health-care services. </p>
<p>Lack of access to care is often linked to Canada’s high level of unattached patients (those with no regular family physician or other primary care providers). About <a href="https://www150.statcan.gc.ca/n1/pub/82-625-x/2019001/article/00001-eng.htm">15 per cent of Canadians</a> are in this situation. Even worse, in Québec, the province hardest hit by COVID-19, <a href="https://yourhealthsystem.cihi.ca/hsp/inbrief?lang=en#!/indicators/074/has-a-regular-health-care-provider/;mapC1;mapLevel2;provinceC4000;trend();/">close to 22 per cent</a> have no regular provider of care.</p>
<h2>Targeted solutions</h2>
<p>Targeting these subgroups should be part of the <a href="https://www.sciencedirect.com/science/article/pii/S2211883720300940?via%3Dihub">policy package</a> to address the implications of COVID-19. Ensuring that all Canadians have a regular provider of care shall also <a href="https://liberal.ca/liberals-move-forward-to-boost-investments-in-health-care-and-make-sure-all-canadians-have-a-family-doctor/">stay high on the policy and political agendas</a>, even though it is not absolutely necessary for the <a href="https://doi.org/10.1111/1475-6773.13059">primary care provider to be a physician</a>. </p>
<p>Efforts to address this issue, like the creation of a <a href="https://www.longwoods.com/content/25555/centralized-waiting-lists-for-unattached-patients-in-primary-care-learning-from-an-intervention-imp">centralized waiting list</a>, have shown mixed effectiveness. During COVID-19, accelerating formal enrolment with a family physician for those on a <a href="https://www.ramq.gouv.qc.ca/SiteCollectionDocuments/professionnels/infolettres/2020/info015-20.pdf">centralized waiting list in Québec</a> goes in the right direction. But this will work only if patients can attend the clinic.</p>
<figure class="align-center ">
<img alt="A woman in casual clothes on a sofa consulting with a doctor on her laptop." src="https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=464&fit=crop&dpr=1 600w, https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=464&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=464&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=582&fit=crop&dpr=1 754w, https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=582&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/364004/original/file-20201016-23-4jddfs.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=582&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">The use of telemedicine has increased during the pandemic.</span>
<span class="attribution"><span class="source">(Pexels/Canva)</span></span>
</figcaption>
</figure>
<p>The use of telemedicine has jumped during the pandemic, and while this may have helped those with chronic conditions, one issue is that there has been variation across provinces in incorporating telemedicine procedures <a href="https://www.cihi.ca/en/physician-billing-codes-in-response-to-covid-19">in doctors’ billing schedules</a>. In Ontario, the other hard hit province, more <a href="https://www.theglobeandmail.com/canada/article-doctors-association-says-help-from-government-is-not-enough-to-2/">complications around the billings</a> may have put some clinics in difficult financial situation and in turn affected access to care. And the telemedicine approach is likely to support women’s better access to care only if it is coupled with after-hours and weekend access, due to their typically higher familial responsibilities.</p>
<h2>Gaps in data</h2>
<p>Overall, the effects of delayed care cannot be underestimated. For example, non-urgent procedures and elective surgeries in Ontario have been <a href="https://www.cihi.ca/en/covid-19-intervention-timeline-in-canada">postponed for more than two months</a>, with the queue building up as new and postponed patients seek care. </p>
<p>One issue is that in Canada, we do not know exactly how much care has been postponed or foregone. Other countries like <a href="https://www.lemonde.fr/sciences/article/2020/07/13/diagnostics-prise-en-charge-traitements-le-coronavirus-a-des-effets-sanitaires-collateraux-tres-larges_6046098_1650684.html">France</a> and <a href="https://www.commonwealthfund.org/publications/2020/aug/impact-covid-19-pandemic-outpatient-visits-changing-patterns-care-newest">the United States</a> are able to report this information publicly. </p>
<p>While <a href="https://www.ices.on.ca/About-ICES/Collaborations-and-Partnerships/HDRN-DASH">progress is made</a> on the data front, and more <a href="https://news.ontario.ca/en/release/58314/ontario-quebec-summit-strengthens-ties-between-the-two-provinces">co-ordination across provinces</a> is on the way, what Canada needs is a better health data infrastructure and reporting system, <a href="https://theconversation.com/a-national-health-data-infrastructure-could-manage-pandemics-with-less-disruption-140407">not only for managing the pandemic</a>, but also for ensuring everyone’s health-care needs are met.</p><img src="https://counter.theconversation.com/content/145934/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Mehdi Ammi receives funding from the Canadian Institutes of Health Research. He has received funding from the Social Sciences and Humanities Research Council and the Canadian Research Data Centre Network. </span></em></p>With COVID-19 placing heavy demands on the health-care system, non-COVID patients may struggle to access care, putting women, people in poor health and those without a regular doctor at risk.Mehdi Ammi, Associate Professor of Health Economics and Policy, Carleton UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1371152020-05-11T13:49:37Z2020-05-11T13:49:37ZChildren with disabilities face health risks, disruption and marginalization under coronavirus<figure><img src="https://images.theconversation.com/files/332425/original/file-20200504-83779-9q5o48.jpg?ixlib=rb-1.1.0&rect=77%2C99%2C5971%2C4803&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Because support from specialized professionals and technologies is often accessed through schools, families of children with disabilities may find childcare and education particularly challenging during COVID-19 school closures.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>COVID-19 has been disruptive to all families, but the effects of school closures, medical equipment shortages and social distancing are further amplified for families of children with disabilities.</p>
<p>As an assistant professor in the School of Rehabilitation Science at McMaster University, a CanChild Scientist and adjunct scientist at Bloorview Research Institute, I study children’s rehabilitation services including family-centred care, ethics, access and equity. I’m concerned about the challenges that children with disabilities and their families face during COVID-19, and can offer some ideas for taking prompt action and promoting allyship.</p>
<h2>Concerns about care and COVID-19 risks</h2>
<p>People with disabilities may experience <a href="https://www.thenation.com/article/society/immunocompromised-children-coronavirus/">serious complications or death due to COVID-19</a>, however this group was <a href="https://www.cbc.ca/news/canada/edmonton/covid-disability-protective-equipment-alberta-1.5537181">missed in messaging</a> about <a href="https://theconversation.com/people-with-a-disability-are-more-likely-to-die-from-coronavirus-but-we-can-reduce-this-risk-134383">at-risk populations</a>. They may also experience negative outcomes due to <a href="https://doi.org/10.1016/S2468-2667(20)30076-1">reduced quality of care</a>. Public screening facilities may be inaccessible or increase exposure for children and families. </p>
<p>Parents who have COVID-19 may lack the specialized child-care supports needed to isolate from their child. If a child contracts COVID-19 or otherwise requires hospitalization, <a href="https://www.cbc.ca/news/canada/british-columbia/woman-disability-dies-white-rock-hospital-covid-19-1.5543468">parents and personal support workers (PSW) may be denied hospital entry</a>. We must recognize that <a href="https://medium.com/@franco.carnevale/covid-19-pandemic-measures-ethical-consequences-of-barring-families-from-hospitals-and-long-term-951b812e7f49">caregivers provide communication and care support, improving care and protecting patients</a>.</p>
<p>Worldwide alarm was raised about the discriminatory nature of guidelines that may <a href="https://www.nytimes.com/2020/03/23/opinion/coronavirus-ventilators-triage-disability.html">limit acute care and resources for people with disabilities who have COVID-19</a> if hospitals become overwhelmed. <a href="https://www.vox.com/first-person/2020/4/4/21204261/coronavirus-covid-19-disabled-people-disabilities-triage">People who use ventilators are worried</a> and may avoid health care for fear that their ventilators may be given to someone else during an equipment shortage. Some people with disabilities in the United Kingdom were sent <a href="https://www.theguardian.com/commentisfree/2020/apr/09/nice-guidelines-coronavirus-pandemic-disabled">do not resuscitate (DNR) forms</a> during the pandemic. Learning and developmental disabilities have been given as reasons for some DNR orders. </p>
<p>These practices are unethical and devalue the lives of people with disabilities. In Canada, <a href="https://archdisabilitylaw.ca/covid-19-and-disability-recommendations-to-the-canadian-government-from-disability-related-organizations-in-canada-march-24-2020/">disability organizations have made recommendations</a> to promote the <a href="https://www.cbc.ca/news/opinion/opinion-disabled-covid-19-triage-orders-1.5532137">rights of people with disabilities</a>. Consultation in policy and guideline development should include people with disabilities and disability organizations to guard against ableist beliefs. </p>
<h2>Home-based family concerns</h2>
<p>Many children with disabilities require medication, personal protective equipment (PPE, such as gloves and masks), home care, respite and rehabilitation services. These resources are scarce or unavailable given <a href="https://www.disabilityscoop.com/2020/04/23/kids-who-rely-on-ventilators-cant-get-enough-supplies-putting-their-lives-at-risk/28216/">PPE shortages in communities</a>, <a href="https://www.thestar.com/news/gta/2020/04/13/activists-fear-for-safety-of-people-with-disabilities-after-funding-for-mobility-and-medical-devices-deemed-non-essential.html">delayed or cancelled dispensing of medical equipment</a>, cancellation of respite and group programs and the <a href="https://time.com/5826098/coronavirus-people-with-disabilities">potential for staffing shortages</a>. </p>
<p>Even if PSWs or home nurses are available, families may suspend the service to <a href="https://www.linkedin.com/pulse/one-covid-19-response-needed-most-never-came-ariana-a-jalfen">limit exposure to COVID-19 when staff are providing service in multiple homes</a>. The lack of supports and resources, paired with extra care responsibilities during COVID-19, may compound the <a href="https://doi.org/10.1080/08916930802354948">physical and mental health challenges already experienced by many parents of children with disabilities</a>.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=444&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=444&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=444&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=558&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=558&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332459/original/file-20200504-83745-1ts3q98.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=558&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Six-year-old Peyton Denette is helped by her mom Kristy Denette as she works remotely with speech-language pathologist Olivia Chiu (on screen) from her home in Mississauga, Ont. Like many other children, Denette must adapt to online learning due to COVID-19.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Nathan Denette</span></span>
</figcaption>
</figure>
<p>With school closures, <a href="https://www.todaysparent.com/blogs/opinion/why-is-no-one-talking-about-how-unsustainable-this-is-for-working-parents/">parents are struggling to manage children’s education while balancing childcare and work</a> demands. This may be particularly hard for parents of children with disabilities because learning and school participation are often supported by a team of <a href="https://www.cbc.ca/radio/checkup/pandemic-home-schooling-families-children-special-needs-1.5522119">professionals such as educational assistants and speech-language pathologists, and by specialized technology</a>. Some of these supports have been discontinued, while others have been moved online.</p>
<p>Some children with disabilities will <a href="https://theconversation.com/ontarios-high-school-e-learning-still-hasnt-addressed-students-with-special-needs-121612">face greater challenges with online learning</a> if there are inadequate accommodations while for others, online learning is simply not an option. Families of children with disabilities are also <a href="https://www.canchild.ca/system/tenon/assets/attachments/000/000/619/original/ChildhoodDisabilityintheContextofPoverty_CanChild.pdf">more likely to experience socio-economic disadvantage</a>, including less access to the <a href="https://acorncanada.org/sites/default/files//Digital%20Economy%20Report%20Final.pdf">internet and technology</a>. </p>
<p>We must consider the accessibility of remote learning and <a href="https://www.youtube.com/watch?feature=share&v=jgxRoaAU6F0&fbclid=IwAR0Q3LRDeBeor3WnSqTBYl4oviGtCtHX3Egy1TycbFj5-EWQAyyiPTiy3sA&app=desktop">rehabilitation services, such as speech therapy</a>, as well as the stress placed on families of children with disabilities when remote and in-home supports and resources are not available.</p>
<h2>Group living environments</h2>
<p>People with disabilities of all ages who are cared for in group environments, such as facilities specifically for people with disabilities or long-term care (LTC) homes, face heightened risks for contracting COVID-19. <a href="https://www.thestar.com/news/gta/2020/04/28/fifth-covid-19-resident-death-at-participation-house-in-markham.html">Participation House, in Markham, Ont., is a devastating case</a>, where people with disabilities living in supportive housing have nearly all contracted COVID-19 and six people had died as of April 28, 2020. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=438&fit=crop&dpr=1 600w, https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=438&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=438&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=550&fit=crop&dpr=1 754w, https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=550&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/332464/original/file-20200504-83775-5kyo4i.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=550&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Participation House in Markham, Ont., on April 15, 2020.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Frank Gunn</span></span>
</figcaption>
</figure>
<p><a href="https://www.cp24.com/news/mom-pleads-with-workers-to-return-to-markham-facility-for-vulnerable-adults-after-daughter-hospitalized-1.4894795">Staffing shortages</a> and their tremendous impact on residents and their families is alarming. The spread and death rate of COVID-19 in Canada’s LTC homes is dire, accounting for <a href="https://www.thestar.com/politics/federal/2020/05/07/82-of-canadas-covid-19-deaths-have-been-in-long-term-care.html">over 80 per cent the COVID-19 related deaths in Canada</a>. </p>
<p>This disproportionately affects people with disabilities, given that in 2016 over <a href="https://globalnews.ca/news/2843104/more-than-2900-ontarians-with-developmental-disabilities-live-in-long-term-care-facilities/">2,900 people with disabilities lived in LTC homes, more than half of whom were under 65 years old</a>. This pandemic has highlighted the gaping cracks in the care and living supports for people with disabilities and their families that must be attended to now and after this crisis has passed.</p>
<h2>Mental health concerns</h2>
<p><a href="https://doi.org/10.1001/jamainternmed.2020.1562">Mental health challenges</a> such as loneliness, depression and anxiety are some of the anticipated consequences of COVID-19. Specific attention should be paid to the mental health needs of children with disabilities. Children with neuromotor disabilities such as cerebral palsy are <a href="https://www.cps.ca/en/documents/position/mental-health-problems-neuromotor-disabilities">more likely than others to have mental health symptoms</a>, which may be exacerbated during the pandemic. The well-being of children with intellectual or language disabilities <a href="https://theconversation.com/how-coronavirus-could-affect-the-wellbeing-of-people-with-intellectual-disabilities-133540">may be negatively affected due to difficulties understanding the pandemic</a> and the need for precautions such as staying indoors. </p>
<p><a href="https://nationalpost.com/pmn/news-pmn/canada-news-pmn/disabled-canadians-feel-excluded-from-covid-19-messaging">COVID-19 information has not consistently been shared in accessible formats</a> (such as closed captioning and sign language interpretation), further marginalizing people with disabilities and increasing their health risks. The mental health of children with disabilities may be improved if information is made accessible to promote understanding and coping. For example, closed captioned videos explaining concepts such as social distancing.</p>
<p><a href="http://somatosphere.net/2020/structural-silencing.html">Strategies used by children with disabilities</a> to promote mental health may not currently be available, such as routines and social supports in schools and recreations programs. Children and families living with disability are often more socially isolated than others. Therefore, it can be difficult to create opportunities to interact with others, especially those that rely on language (for example, video chats). </p>
<p>Another threat during social isolation is <a href="https://www.doi.org/10.1001/jamainternmed.2020.1562">increased risk for abuse</a>, with children who have disabilities already experiencing <a href="http://citeseerx.ist.psu.edu/viewdoc/download?doi=10.1.1.460.1007&rep=rep1&type=pdf">higher rates of abuse and neglect than other children</a>. If mental illness is <a href="https://www.cbc.ca/news/canada/british-columbia/months-isolation-mental-health-covid-1.5521649">the next wave of the pandemic</a>, specific attention needs to be paid to the mental health of children with disabilities who may be in need of protection. </p>
<h2>What should I do?</h2>
<p>Raise concerns about children with disabilities and their families and advocate for: </p>
<ol>
<li><p>Inclusion of people with disabilities in policy development. </p></li>
<li><p>Ensuring human and equipment resources are available for home and centre-based care. </p></li>
<li><p>Accessible information.</p></li>
<li><p>Promotion of social inclusion to advance mental health and child safety.</p></li>
</ol><img src="https://counter.theconversation.com/content/137115/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Michelle Phoenix received previous funding from the Canadian Institutes of Health Research and the Canadian Child Health Clinician Scientist Program. She is a CanChild Scientist, Adjunct Scientist with Holland Bloorview Kids Rehabilitation Hospital, and Academic Member with the College of Audiologists and Speech-Language Pathologists of Ontario. </span></em></p>COVID-19 has left children with disabilities and their families lacking services, at risk for physical and mental health issues, and fearful of discriminatory choices for treating critical illness.Michelle Phoenix, Assistant Professor School of Rehabilitation Science, CanChild Scientist, McMaster UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1307792020-03-04T21:13:21Z2020-03-04T21:13:21ZFuelling a crisis: Lack of treatment for opioid use in Canada’s prisons and jails<figure><img src="https://images.theconversation.com/files/318731/original/file-20200304-66106-13763lm.jpg?ixlib=rb-1.1.0&rect=287%2C8%2C5703%2C3979&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">Incarcerated people are often denied access to treatment for opioid use disorder. This October 2016 file photo shows corrections officer opening the door to a cell in the segregation unit at the Fraser Valley Institution for Women in Abbotsford, B.C. during a media tour.</span> <span class="attribution"><span class="source">THE CANADIAN PRESS/Darryl Dyck</span></span></figcaption></figure><p>The opioid overdose crisis has <a href="https://health-infobase.canada.ca/sutance-related-harms/opioids">killed almost 14,000 Canadians since 2016</a>. </p>
<p>One flashpoint of this crisis is Canada’s correctional facilities. <a href="https://www.csc-scc.gc.ca/research/sr-18-02-en.shtml">Opioid-related deaths are increasing</a> among incarcerated people. Post-release, their prospects are even worse: in the two weeks after release, a prisoner’s risk of overdose is <a href="https://doi.org/10.9778/cmajo.20150098">more than 50 times higher</a> than in the general population. <a href="https://doi.org/10.1371/journal.pone.0157512">One in 10 of all overdose deaths</a> is a prisoner released in the past year. </p>
<p>Despite this, our prisons and jails often delay or deny access to evidence-based treatments for opioid use disorder and fail to ensure appropriate supports on release.</p>
<h2>Opioid agonist therapy</h2>
<p>Governments have brought <a href="https://www.cbc.ca/news/canada/toronto/ontario-opioid-class-action-suit-1.5394066">class-action lawsuits against pharmaceutical companies</a> and <a href="https://www.justice.gov/opa/pr/second-appalachian-region-prescription-opioid-strikeforce-takedown-results-charges-against-13">prosecuted overprescribing doctors</a>. Canada’s federal government is <a href="https://www.canada.ca/en/health-canada/services/substance-use/problematic-prescription-drug-use/opioids/responding-canada-opioid-crisis.html">taking action on opioids</a>. </p>
<p>But our divergent experiences as a physician, a legal academic and a formerly incarcerated harm reduction activist have taught us that much of the responsibility lies with government itself — specifically, its failure to provide prisoners with timely access to opioid agonist therapy (OAT) and ensure post-release continuity of treatment.</p>
<p>People incarcerated in Canada’s federal prisons and provincial-territorial jails are highly likely to have experienced <a href="https://doi.org/10.2105/AJPH.2018.304855">childhood trauma</a>, poverty and the corrosive effects of <a href="https://www.oci-bec.gc.ca/cnt/rpt/annrpt/annrpt20162017-eng.aspx#s6">racism</a> and <a href="https://www.oci-bec.gc.ca/cnt/comm/press/press20200121-eng.aspx">colonialism</a>. They are highly likely to struggle with <a href="https://doi.org/10.1111/add.13877">addictions</a> and <a href="https://www.cfp.ca/content/62/3/215">mental illness</a>. Incarcerated people, like many on the outside, use drugs as a form of coping.</p>
<p>OAT provides a medication (usually buprenorphine/naloxone or methadone) to prevent drug cravings and withdrawal symptoms. It is the <a href="https://doi.org/10.1503/cmaj.170958">first-line treatment for opioid use disorder</a> and the standard of community-based care across Canada. <a href="https://doi.org/10.1371/journal.pmed.1003002">OAT saves lives</a>, <a href="https://doi.org/10.1016/S0140-6736(16)30769-3">reduces HIV and hepatitis C transmission</a>, improves a host of social and psychological outcomes and is associated with a decreased risk of <a href="https://doi.org/10.1111/add.14059">future criminal charges</a> and <a href="https://www.csc-scc.gc.ca/research/005008-0322-eng.shtml">imprisonment</a>.</p>
<h2>Legal standards for health care</h2>
<p><a href="https://laws-lois.justice.gc.ca/eng/acts/C-44.6/index.html">Canadian</a> and <a href="https://undocs.org/A/RES/70/175">international</a> law obliges prisons to provide incarcerated people with health care at community standards. But <a href="https://doi.org/10.1016/j.drugalcdep.2018.09.003">research</a>, <a href="https://www.mcscs.jus.gov.on.ca/english/Deathinvestigations/Inquests/Verdictsandrecommendations/OCCInquestHWDC.html">coroners’ inquests</a> and <a href="https://cp-ep.org/wp-content/uploads/2019/09/JAIL-Hotline_Q1-Report_Final.pdf">prisoners’ rights groups</a> all tell a similar story: too often, people are not provided addictions treatment on admission, whether or not they were being treated in the community. This means they go into acute withdrawal and are at increased risk of use, relapse and overdose. </p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=439&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=439&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=439&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=551&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=551&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314418/original/file-20200210-109912-1agifo1.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=551&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Cells at the Central Nova Scotia Correctional Facility in Halifax in May 2018. File photo.</span>
<span class="attribution"><span class="source">THE CANADIAN PRESS/Andrew Vaughan</span></span>
</figcaption>
</figure>
<p>The result? Missed opportunities to provide care to people who desperately need it, and deaths with little oversight or accountability. While we pursue progressive solutions like <a href="https://www.ccsa.ca/sites/default/files/2019-04/CCSA-Decriminalization-Controlled-Substances-Policy-Brief-2018-en.pdf">decriminalization</a> and <a href="http://capud.ca/sites/default/files/2019-03/CAPUD%20safe%20supply%20English%20March%203%202019.pdf">safe supply</a>, we must urgently make OAT available to everyone incarcerated who would benefit.</p>
<p>In Nova Scotia, the provincial health authority is responsible for delivering health care in the province’s jails, rather than Correctional Services, as is common in other provinces. Nova Scotia’s jails have a blanket policy of<a href="https://www.cbc.ca/news/canada/nova-scotia/jail-medication-mental-health-methadone-withheld-1.3708938">not providing prisoners with OAT unless they are already on it when they arrive</a>. Those who are not on therapy suffer through withdrawal or find ways to keep using illicitly inside. This is a clear violation of the government’s legal obligation to provide equivalent health care in detention. </p>
<p>Provinces like Ontario, which have celebrated Nova Scotia’s wisdom in making correctional health care the responsibility of the Department of Health and Wellness instead of corrections, should take note: simply shifting responsibility is not enough to ensure sound policy.</p>
<h2>Feeding a crisis by limiting OAT</h2>
<p>As people who have lived or worked in prisons and with people who have been incarcerated, we have seen first-hand how limiting OAT in prison feeds the opioid crisis inside. It increases the demand for illicit drugs to be smuggled in or diverted. </p>
<p>In some institutions, those receiving OAT are subjected to a <a href="https://impactethics.ca/2019/11/19/methadone-access-in-prisons-stop-strip-searching/">daily strip search: a degrading and re-traumatizing practice</a>. Others who want the medication to prevent their own withdrawal symptoms target prisoners receiving OAT. People soon start diverting their medication, for instance by vomiting it up and straining it through a sock for someone else to use. If someone says no to a demand to divert their OAT, they may be subject to violence. </p>
<p><a href="https://www.cbc.ca/news/canada/nova-scotia/methadone-nova-scotia-jail-burnside-clayton-cromwell-1.3836706">If someone is caught diverting, their OAT is discontinued</a>, placing them at high risk of overdose. If treatment were not so intensely restricted, these adverse events could be reduced or eliminated.</p>
<figure class="align-right ">
<img alt="" src="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=237&fit=clip" srcset="https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=651&fit=crop&dpr=1 600w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=651&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=651&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=818&fit=crop&dpr=1 754w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=818&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/314420/original/file-20200210-109896-ezjwz5.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=754&h=818&fit=crop&dpr=3 2262w" sizes="(min-width: 1466px) 754px, (max-width: 599px) 100vw, (min-width: 600px) 600px, 237px">
<figcaption>
<span class="caption">Denying access to opioid agonist treatment using medications such as methadone (above) feeds the opioid crisis in prisons and jails.</span>
<span class="attribution"><span class="source">AP Photo/The Evening News, Chuck Branham</span></span>
</figcaption>
</figure>
<p>There are a few glimmers of hope. Rhode Island implemented a statewide correctional OAT program and saw a <a href="https://doi.org/10.1001/jamapsychiatry.2017.4614">60.5 per cent reduction in one-year overdose mortality after release</a>. In 2016, people incarcerated in British Columbia launched a <a href="https://www.theglobeandmail.com/news/british-columbia/bc-prisoners-get-addiction-therapy-after-settlement-in-charter-challenge/article29648890/">Charter challenge over policies limiting access to OAT in B.C. jails</a>; while that lawsuit settled, it contributed to increased access to the treatment. Access expanded further when the B.C. Ministry of Health took over provincial correctional health services in 2017. </p>
<p>But elsewhere, <a href="https://www.csc-scc.gc.ca/health/002006-2007-en.shtml">access to OAT in federal prisons</a> or provincial jails continues to be denied or unreasonably delayed. This has led B.C.’s Prisoners’ Legal Services to launch a <a href="https://prisonjustice.org/wp-content/uploads/2018/12/OST-rep-complaint-to-CHRC-20180604-narrative-1.pdf">representative human rights complaint on behalf of federal prisoners with opioid use disorder</a>, focused on access to OAT.</p>
<p>Federal, provincial and territorial governments need to step up and tackle the opioid epidemic at its flashpoint: our prisons and jails. Timely access to OAT for every incarcerated person who could benefit is required to turn the tide of death and ill health. Until we make these changes, Canada’s most vulnerable will continue to endure extraordinary suffering at the hands of our government and the body count will continue to rise.</p><img src="https://counter.theconversation.com/content/130779/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Claire Bodkin receives funding from the Canadian Research Initiative in Substance Misuse and is an employee of Hamilton Health Sciences. She is affiliated with the Prison Health Member Interest Group at the College of Family Physicians of Canada. Her views represent only her own opinions.</span></em></p><p class="fine-print"><em><span>Matthew Bonn is an employee of Mainline Needle Exchange as a Frontline Harm Reduction Support Worker. He is the Lead Peer in Peers Assisting & Lending Support (PALS) which is a Harm Reduction Prison Outreach Program funded by PHAC. He is also a Research Assistant with Dalhousie & SMU. Currently receives funding from Gilead & AbbVie for Hepatitis C Elimination. </span></em></p><p class="fine-print"><em><span>Sheila Wildeman is a Vice-Chair of East Coast Prison Justice Society and a member of Dalhousie's Health Law Institute. </span></em></p>Urgently needed treatment for opioid use disorder is often denied to incarcerated people, feeding the crisis in prisons and jails.Claire Bodkin, Resident Physician, Department of Family Medicine, McMaster UniversityMatthew Bonn, Frontline Harm Reduction Worker & Health Promotion Research Assistant, Dalhousie UniversitySheila Wildeman, Associate professor, Schulich School of Law, Dalhousie UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/1302782020-02-05T23:04:38Z2020-02-05T23:04:38ZA national licence for doctors in Canada: Is it really possible?<figure><img src="https://images.theconversation.com/files/313852/original/file-20200205-149757-jkr72y.jpg?ixlib=rb-1.1.0&rect=134%2C186%2C3217%2C2055&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A national licence to practice may be one way to help address the lack of doctors in some regions, and to encourage telemedicine consultations.</span> <span class="attribution"><span class="source">(Shutterstock)</span></span></figcaption></figure><p>In December 2019, just before the holiday season, Pontiac Hospital in Shawville, Qué., not too far from the Ontario border, <a href="https://www.cbc.ca/news/canada/ottawa/pontiac-hospital-shawville-obstetrics-closure-1.5394551">shut down its obstetric services</a> for 21 days. It was the 10th closure of its obstetric services since September. </p>
<p>These closures meant that without specialized staff, women who were ready to give birth had to go to another hospital, over an hour’s drive away. This came at a time when there is already <a href="https://www.ledroit.com/actualites/sante/encore-une-penurie-de-medecins-de-famille-en-outaouais-2976d62e747c7a373c7181ea4387e8c5">a shortage of family doctors in the Outaouais region</a>, which lies just north of Ottawa.</p>
<p>The causes of this shortage of family physicians are complex, and we should avoid magical thinking when looking for solutions. Yet these service interruptions raise a legitimate question: should a medical doctor who is fully licensed in Ontario be allowed to practise on the Québec side of the Ottawa River to help alleviate the shortage, without going through all the paperwork, costs and delays required to obtain a practice licence in Québec?</p>
<p>Many doctors think so, judging by the results of a survey conducted in 2019 by the Canadian Medical Association (CMA). Based on the answers provided by 7,000 of its members, <a href="https://www.cma.ca/canadian-physicians-support-national-licensure-and-increased-use-technology-improve-health-care">the CMA claims that “nine out of 10 physicians support the establishment of a national licence to practice and three quarters believe that this will improve access to health care”</a>.</p>
<p><a href="https://residentdoctors.ca/wp-content/uploads/2018/10/Infosheet-Portablelocumlicensureinitiative-EN-R2.pdf">Other Canadian medical stakeholders also appear to be in favour of such a measure</a>, citing the need to facilitate replacements (locums) for doctors in underserved regions as well as interprovincial medical teleconsultations.</p>
<figure class="align-center ">
<img alt="" src="https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&fit=clip" srcset="https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=600&h=400&fit=crop&dpr=1 600w, https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=600&h=400&fit=crop&dpr=2 1200w, https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=15&auto=format&w=600&h=400&fit=crop&dpr=3 1800w, https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=754&h=503&fit=crop&dpr=1 754w, https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.jpg?ixlib=rb-1.1.0&q=30&auto=format&w=754&h=503&fit=crop&dpr=2 1508w, https://images.theconversation.com/files/312158/original/file-20200127-81346-jny11r.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">
<figcaption>
<span class="caption">Remote consultations could be very useful in regions with shortages of family physicians.</span>
<span class="attribution"><a class="source" href="https://www.shutterstock.com/image-photo/female-doctor-working-two-computers-distance-1228571512">(Shutterstock)</a></span>
</figcaption>
</figure>
<p>This seems to be a reasonable proposition. But would it be possible, from a legal perspective, to implement a national licence for doctors and other health-care providers <a href="https://decisions.scc-csc.ca/scc-csc/scc-csc/en/item/6436/index.do?q=Lafferty+c.+Lincoln">considering that professional regulation falls under provincial jurisdiction</a>?</p>
<p>I have more than 20 years of academic and professional experience in health law and policy. I’m particularly interested in trying to improve the Canadian professional regulation framework on such issues, to address the challenges presented by issues like workforce shortages and new technologies.</p>
<h2>Similarities with securities</h2>
<p>A <a href="https://scc-csc.lexum.com/scc-csc/scc-csc/en/item/17355/index.do">2018 Supreme Court of Canada ruling</a> on securities regulation suggests what could be the legal basis for a national medical licence.</p>
<p>Although securities fall under provincial jurisdiction, the federal government and the governments of some provinces and territories have proposed a legislative system of co-operation. This includes a model statute that may be passed by the legislatures of the provinces and territories to regulate various aspects of the securities business, as well as a federal statute to prevent and manage systemic risk and to establish criminal offences relating to financial markets. A national securities regulator would be in charge of making this system work, under the supervision of a federal-provincial council of ministers.</p>
<p>Despite strong opposition from some provinces, the Supreme Court indicated that such a regime would respect provincial jurisdiction, since provinces would not be forced to join it. It also concluded that the intervention of the federal government would be justified, considering its own jurisdictions and the national issues involved.</p>
<p>This model is actually very similar to the one that has been put in place in Australia to establish a national licence for all health-care professionals, based on an <a href="https://www.ahpra.gov.au/About-AHPRA/Who-We-Are.aspx">intergovernmental agreement between the federal government, states and territories</a>.</p>
<p>With these precedents, it is plausible, from a legal point of view, to consider the possibility of implementing a national licensing system for doctors and other health-care providers in Canada.</p>
<h2>A professional passport</h2>
<p>Another solution, less well integrated but maybe easier to set up from a political and legal perspective, could be to establish a “national professional passport,” perhaps by improving the current <a href="https://www.cfta-alec.ca/labour-mobility/">labour mobility provisions of the Canadian Free Trade Agreement (CFTA)</a>.</p>
<p>This agreement between the federal, provincial and territorial governments commits them to put in place measures allowing people in regulated trades and professions to work anywhere in Canada, without having to comply with additional requirements related to training, experience, competencies, etc. </p>
<p>That said, the CFTA still allows certain provincial and territorial requirements to be maintained, like language proficiency in French or English, registration and permit fees, professional liability insurance and examinations relating to ethical aspects.</p>
<p>The idea of a national passport, based on the elimination or reduction of these obstacles, as well as on a greater administrative co-ordination between provincial regulatory authorities, <a href="http://fmrac.ca/wp-content/uploads/2018/04/Model-Standards-for-Medical-Registration-in-Canada-updated-February-2018.pdf">seems to be supported by the Federation of Medical Regulatory Authorities of Canada (FMRAC)</a>. </p>
<p><a href="https://www.theglobeandmail.com/canada/article-why-isnt-there-a-single-medical-licence-for-all-doctors-in-canada/">The idea would be to have something like a Nexus card</a> that would allow physicians to quickly meet the administrative requirements of a province or territory, and be authorized to practice there. This approach is also similar to what the Americans have been trying to implement for a few years, without complete success yet, with the “<a href="https://imlcc.org/">Interstate Medical Licensure Compact</a>”.</p>
<h2>Political will needed</h2>
<p>Although complex, the introduction of a national licensure or a national passport for doctors and other health-care professionals could be legally feasible, provided that there is sufficient political will.</p>
<p>However, there would be obstacles to overcome. Examples include some specific provincial requirements such as <a href="http://legisquebec.gouv.qc.ca/fr/ShowDoc/cs/C-11?langCont=en">French knowledge requirements in Quebec</a>, medicare coverage for services provided by out-of-province providers, scope of practice disparities, etc.</p>
<p>Arguably, it is not a given that we can count on the level of federal-provincial co-operation that would be required to remove these obstacles. Let’s just consider that the pan‑Canadian securities regulation is <a href="https://www.lesoleil.com/actualite/justice-et-faits-divers/valeurs-mobilieres-quebec-nadherera-pas-a-la-commission-pancanadienne-e9e41fc0f2e1079d28567b3f2179c037">still facing a steady opposition from some provinces</a>, not to mention the issues raised by the prospect of a <a href="https://www.cbc.ca/news/politics/pharmacare-cost-analysis-premiers-hoskins-trudeau-1.5174601">national pharmacare program</a>. </p>
<h2>What about public protection?</h2>
<p>One thing that should be avoided if a national licensure or a national passport for health-care professionals were implemented, is weakening the public protection that professional regulation aims to support.</p>
<p>Filing a complaint or initiating a disciplinary process is not easy for most patients. It should not be made more complex when a problem occurs with an out-of-province professional providing services through teleconsultation or acting as a replacement. </p>
<p>Patients should still be allowed to rely on the local regulator, which would require closer co-operation between provincial regulatory authorities on disciplinary matters, as well as the harmonization of standards of practice and quality assessment of professionals.</p>
<p>Given all of these factors, establishing a national licensure for doctors and other health-care professionals would certainly not be a walk in the park from a legal and political perspective. To gather sufficient public support, this project should undoubtedly be designed first and foremost to meet the needs of patients and not just to reduce the administrative requirements for professionals.</p><img src="https://counter.theconversation.com/content/130278/count.gif" alt="La Conversation" width="1" height="1" />
<p class="fine-print"><em><span>In addition to his academic activities at Université de Sherbrooke and Université de Montréal, Marco Laverdière serves as the executive director and secretary of the Ordre des optométristes du Québec. / En plus de ses activités académiques à l'Université de Sherbrooke et à l'Université de Montréal, Marco Laverdière occupe les fonctions de directeur général et de secrétaire de l'Ordre des optométristes du Québec.</span></em></p>In Canada, regulation of professions usually falls under provincial jurisdiction, but there may be feasible models for a national licence for health-care professionals.Marco Laverdière, Avocat, enseignant et chercheur associé en droit et politiques de la santé / Lawyer, lecturer and research associate in Health Law and Policy, Université de Sherbrooke Licensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/643112016-09-14T21:18:31Z2016-09-14T21:18:31ZThe triple vulnerability of being poor and disabled in rural South Africa<figure><img src="https://images.theconversation.com/files/137589/original/image-20160913-4948-um4tr9.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">People with disabilities living in Madwaleni in the Eastern Cape have difficulty accessing healthcare. </span> <span class="attribution"><span class="source">Richard Vergunst</span></span></figcaption></figure><p>Over the last two decades the South African government has passed several pieces of legislation to ensure that people with disabilities are included in society and are able to access services such as health care.</p>
<p>This has included a <a href="http://www.gov.za/services/social-benefits/disability-grant">national disability grant</a> as well as regulations that all government buildings provide ramps so that people with disabilities can easily access them.</p>
<p>According to official statistics <a href="http://www.statssa.gov.za/?p=3180">7.5%</a> of South Africans live with disability. In the rest of the world, this figure sits at <a href="http://www.who.int/disabilities/world_report/2011/report/en/">15%</a>. It’s quite possible that the South African figure doesn’t reflect the full extent of disability in the country because of under-reporting. </p>
<p><a href="http://www.who.int/disabilities/world_report/2011/chapter3.pdf?ua=1">Global studies</a> show that the top three barriers stopping people with disabilities from using health facilities are cost, lack of services near to where they live and transportation.</p>
<p><a href="http://scholar.sun.ac.za/bitstream/handle/10019.1/98408/vergunst_access_2016.pdf?sequence=1">Our study</a> found that these three barriers were particularly acute for poor people with disabilities living in rural South Africa. This is because they experience a “triple vulnerability”: poverty, disability and rurality. They see themselves as less healthy compared to able bodied people and they have less access to health care.</p>
<h2>A community with very little</h2>
<p>Our study formed part of the international study <a href="http://www.sintef.no/Projectweb/Equitable">Equitable</a>. This looked at access to health care for people with disabilities, evaluating 16 sites in South Africa, Namibia, Malawi and Sudan.</p>
<p>Our part of the study centred on Madwaleni in the Eastern Cape, a largely rural and poor province in South Africa. We looked at the differences between people with and without disabilities when it came to accessing health care. </p>
<p>Madwaleni is made up of about 20 villages scattered around rugged hills, valleys, rivers and forests. The area lacks basic services like water and electricity and has poor infrastructure. Nearly 90% of the community is unemployed and there are low levels of literacy and education. There is a high incidence of communicable diseases and high mortality rates.</p>
<p>There is a hospital which handles cases in a 35km radius as well as eight smaller health care centres. Together they service the 120 000 people living in the area. </p>
<p>Poor people with disabilities have more problems going about their daily activities than those who are able bodied. Travelling around their communities, shopping, preparing food and doing household chores are more challenging. They also have problems furthering their education and getting jobs and often experience prejudice and discrimination.</p>
<p>In a rural, remote and impoverished communities these challenges are more amplified. The people with disabilities in these settings experience such issues more intensely. </p>
<h2>Physical barriers</h2>
<p>In Madwaleni the topography of the area, the natural environment and the terrain all contribute to the experiences of people with disabilities. Many have to manage hills, cross rivers or use gravel and uneven roads to access health care. </p>
<p>The distances are vast between the eight smaller health centres and the villages in the area. Travelling on foot is often not an option and taxis are expensive. The result is that people with disabilities receive health care less often and in turn feel that they have poorer physical and mental health.</p>
<p>In addition to transportation problems, there are other physical barriers. For example, participants recounted how they were unable to use overnight accommodation at health care centres and were not provided with the drugs and equipment they needed after their consultations. </p>
<h2>Bad attitudes</h2>
<p>In addition to these challenges, participants said they encountered negative attitudes from health care providers who treated them differently from other patients. </p>
<p>People with disabilities felt their preferred health care providers were not as accessible to them as their able bodied peers. They also did not receive the same level of service and were unhappy with health care personnel.</p>
<p>They communicated less with health care providers and as a result felt that they received less respect from these providers. This often meant that they were afforded less privacy during consultations when compared with able bodied patients. This meant that health care providers did not spend time explaining things to them. They also felt that they were less involved in their own treatment. </p>
<h2>Improving the situation</h2>
<p>Based on the site study in Madwaleni, there are several changes that could improve the way rural people with disabilities access health care. </p>
<p>Mobile health clinics would help. This would mean that people with disabilities could access health care services more regularly. </p>
<p>In addition, health care workers should be trained to better deal with people with disabilities so that attitudinal barriers can be addressed. </p>
<p>And lastly, the community needs to be educated about disability and how it can help create a more inclusive environment.</p><img src="https://counter.theconversation.com/content/64311/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>Richard Vergunst 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>Poor people with disabilities living in rural South Africa are particularly disadvantaged when it comes to accessing health care.Richard Vergunst, PhD Psychology Department, Stellenbosch UniversityLicensed as Creative Commons – attribution, no derivatives.tag:theconversation.com,2011:article/597672016-05-25T04:15:17Z2016-05-25T04:15:17ZMore Africans are accessing health care – but states still have work to do<figure><img src="https://images.theconversation.com/files/123783/original/image-20160524-25236-1diy5ec.jpg?ixlib=rb-1.1.0&q=45&auto=format&w=496&fit=clip" /><figcaption><span class="caption">A Malian mother waits to have her baby vaccinated. Though access to health care has improved, many people say their governments must do more.</span> <span class="attribution"><span class="source">Dominic Chavez/World Bank</span></span></figcaption></figure><p>People across Africa rank health as the second most important national problem they believe that governments should address. Only unemployment outranks it as an issue among ordinary citizens, and only education outstrips it as a funding priority.</p>
<p>These are the findings of <a href="http://afrobarometer-mande.msgfocus.com/c/1ix6ZjHnDvdGymYIgQy9q">a survey</a>, “Despite Gains, Barriers Keep Health Care High on Africa’s Priority List”, which was conducted across 36 African countries in 2014 and 2015. It is part of a series of public-attitude surveys about democracy, governance, economic conditions and related issues run by <a href="http://www.afrobarometer.org/">Afrobarometer</a>, a pan-African, non-partisan research network.</p>
<p>On average across the countries, just over half of those interviewed listed health care among their top two priorities. It ranked first or second in 31 of 36 countries. The only exceptions were Guinea, Kenya and Liberia, where it ranked third; and Lesotho and Nigeria, where it ranked fifth. </p>
<p>As part of the survey, census enumeration areas were assessed. In these areas, the study considered issues like access to health care, government performance and other matters that needed government action. In looking into these issues, the rural-urban breakdown was also considered.</p>
<p>We tracked health care in several of these countries over the past decade and found that the proportion of Africans going without medicine or medical care decreased from 58% in 2005/2006 to 48% in 2014/2015. Despite this decrease, citizens still perceived some challenges standing between themselves and universal health care. In many areas, these included:</p>
<ul>
<li><p>an absence of basic health-care facilities; </p></li>
<li><p>shortages of necessary medical care; </p></li>
<li><p>difficulty in obtaining care, which sometimes compels people to pay bribes; and</p></li>
<li><p>poor government performance in improving basic health services.</p></li>
</ul>
<h2>Accessing health care</h2>
<p>Field teams made on-the-ground observations of services and facilities in each census enumeration area they visited. They looked at whether the health centres were in the area or within easy walking distance and how difficult it was to access services once individuals got in touch with a health-care worker. </p>
<p>Almost two-thirds of the clinics were accessible or within walking distance.</p>
<p>According to our survey, Zimbabwe experienced the largest improvement: fewer people were unable to access health care in the country than was the case in the 2004/2005 survey. </p>
<p>In about <a href="http://www.who.int/countryfocus/cooperation_strategy/ccsbrief_zwe_en.pdf">2008</a> the Zimbabwean health sector was near collapse. Its infrastructure had deteriorated, investment was limited and health workers were poorly paid. There was a shortage of essential supplies and commodities. </p>
<p>But change came in the country when the Government of National Unity created the multi-donor <a href="http://www.acdi-cida.gc.ca/cidaweb/cpo.nsf/vWebSEn/23E646D4AB7FF8A9852579CD004F0D3C">Health Transition Fund</a> to support the Ministry of Health and Child Care. In 2013, the right to health was also affirmed in the new constitution. </p>
<p>On the other end, Benin recorded the greatest deterioration. Benin’s <a href="http://afrobarometer.org/sites/default/files/publications/Policy%20papers/ab_r6_policypaperno28_healthcare_reform_in_benin.pdf">public health-care system</a> has historically been underfunded and ill-equipped to meet the population’s health-care needs.</p>
<p>In 2009, the government of Benin embarked on a series of policy initiatives to increase public access to health services, especially for pregnant women, children under five and the poor.</p>
<p>Though the take-up of health services increased sharply, by 2014 public approval of the government’s efforts had dropped sharply, reflecting dissatisfaction with what was actually rolled out in terms of new government policies.</p>
<h2>Paying a bribe</h2>
<p>Corruption also featured in the survey but did not have a major impact on health care. In evaluating whether anybody went without medical care, we also looked at whether some interviewees paid bribes to get the help they needed. </p>
<p>But only one of every seven people who accessed health services paid a bribe or gave a health-care worker a gift to obtain the needed service.</p>
<p>Corruption was most pronounced in conflict-ridden Liberia. More than half of the Liberians interviewed said they had to pay bribes. There is a critical <a href="http://www.mohsw.gov.lr/documents/Health%20Sector%20Assessment_Report_Final_2015.pdf">health workforce shortage</a> in the country, compounded by high attrition.</p>
<p>Corruption was also common in Morocco, Sudan, Egypt and Cameroon. </p>
<p>In contrast, corruption levels were low in 11 of the 36 countries, where fewer than one in 20 respondents said they paid bribes. Botswana and Mauritius set the example, with only one reported case of bribery for health-care services between them. In Mauritius, this may be linked to the government’s <a href="http://www.who.int/countryfocus/cooperation_strategy/ccs_mus_en.pdf">heavy investment</a> to provide free health care. </p>
<h2>The urban-rural dynamic</h2>
<p><a href="http://www.annualreviews.org/doi/full/10.1146/annurev-publhealth-032315-021507">Research</a> has highlighted the differences in health care for urban and rural people. Our survey corroborated this. </p>
<p>We found that close to 75% of the urban zones had health clinics compared with only half of the rural zones. This made it harder and more expensive for rural residents to obtain care as it would include transport costs.</p>
<p>Urban dwellers were more likely than rural residents to say they found it difficult to get health-care services. This pattern was replicated in most of the countries, led by Mauritius, Zimbabwe and Burkina Faso. </p>
<p>The urban-rural gap was most pronounced in Morocco, Mali and Malawi, while there was an equal spread of clinics in the rural and urban areas of Sierra Leone and Cameroon.</p>
<h2>Government performance</h2>
<p>Close to half of the citizens interviewed said their government was performing “fairly badly” or “very badly” in improving basic health services. In 18 countries tracked since 2005, negative evaluations increased by 13 percentage points over the past decade, from 33% in 2005/2006 to 46% in 2014/2015.</p>
<p>While Afrobarometer does not ask respondents to explain their ratings of government performance, it seems reasonable to consider whether negative performance ratings may be related to: </p>
<ul>
<li><p>a lack of available health-care facilities; </p></li>
<li><p>the experience of going without medicine or medical care; </p></li>
<li><p>difficulties faced while seeking medical care; or </p></li>
<li><p>having to pay bribes to obtain medical care. </p></li>
</ul>
<p>Going without care, encountering difficulties, and having to pay a bribe all appeared to be strongly linked to negative ratings of government performance on health care. </p>
<p>Our survey showed that citizens did not rate government’s performance based on whether or not there was a health clinic in the zone. And there appeared to be no strong link between presence of health facilities and the frequency with which individuals went without care or experienced difficulties in obtaining care.</p>
<h2>Governments must take action</h2>
<p>Citizens’ perceptions suggest a number of barriers to health-care access and, ultimately, “health for all”.</p>
<p>Overall, citizen ratings of government efforts were fairly negative – significantly more negative than a decade ago. </p>
<p>The experiences and perceptions of health care varied widely by country. More specific data would be able to identify the most important difficulties patients encounter and factors that explain the negative public perceptions of government performance. </p>
<p>But citizens spoke clearly in saying that health care was one of their top priorities for government action.</p><img src="https://counter.theconversation.com/content/59767/count.gif" alt="The Conversation" width="1" height="1" />
<p class="fine-print"><em><span>The Afrobarometer survey was funded by USAID, Mo Ibrahim Foundation, DFID, World Bank and SIDA. </span></em></p><p class="fine-print"><em><span>The Afrobarometer survey was funded by USAID, Mo Ibrahim Foundation, DFID, World Bank and SIDA.</span></em></p><p class="fine-print"><em><span>Edem E. Selormey 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>Across the continent, citizens’ perceptions of health care show several barriers to access and better health for all.Daniel Armah-Attoh, Senior Research Officer and the Afrobarometer Project Manager for Anglophone West Africa, Centre for Democratic Development GhanaEdem E. Selormey, Senior Research Fellow, Centre for Democratic Development GhanaRichard Houessou, Afrobarometer Project Manager for Francophone West Africa, based at the Institute for Empirical Research in Political Economy (IREEP), African School of EconomicsLicensed as Creative Commons – attribution, no derivatives.