Journal articles on the topic 'Immigrants Medical care Western Australia Perth'

Brachyspira pilosicoli is an anaerobic spirochaete that colonizes the large intestine of humans and various species of animals and birds. The spirochaete is an important enteric pathogen of pigs and poultry, but its pathogenic potential in humans is less clear. In the current study, the occurrence of B. pilosicoli in faecal samples from 766 individuals in two different population groups in Perth, Western Australia, was investigated by selective anaerobic culture. Of 586 individuals who were long-term residents of Perth, including children, elderly patients in care and in hospital and individuals with gastrointestinal disease, only one was culture positive. This person had a history of diverticulitis. In comparison, faeces from 17 of 180 (9.4 %) Indonesians who were short- or medium-term visitors to Perth were positive for B. pilosicoli. The culture-positive individuals had been in the city for between 10 days and 4.5 years (median 5 months). Resampling of subsets of the Indonesians indicated that all negative people remained negative and that some positive individuals remained positive after 5 months. Two individuals had pairs of isolates recovered after 4 and 5 months that had the same PFGE types, whilst another individual had isolates with two different PFGE types that were identified 2 months apart. Individuals who were culture-positive were likely to have been either colonized in Indonesia before arriving in Perth or infected in Perth following contact with other culture-positive Indonesians with whom they socialized. Colonization with B. pilosicoli was not significantly associated with clinical signs at the time the individuals were tested, although faeces with wet-clay consistency were 1.5 times more likely (confidence interval 0.55–4.6) than normal faeces to contain B. pilosicoli.

Abstract Background There has been concern that patients with malignant disease from remote and regional country areas may have adverse outcomes compared with those from cities. Western Australia (WA) with an area of 2,526,786 square kilometers, is one third the size of Australia. It has a population of 2.6 million of which 92% live in the capital city Perth and the southwest corner. In WA, multiple myeloma is managed in tertiary public hospitals and private physician practice located in Perth. While oral based immunomodulators and alkylators are readily delivered in the regional areas, patients travel to Perth for parenteral chemotherapy and stem cell transplantation. The WA state government subsidizes transport and accommodation for patients from regional areas to travel to Perth for treatment and clinical review via the Patient Assisted Travel Scheme (PATS). Telehealth through video conferencing is also used for review of patients on oral-based anti-myeloma treatment or during surveillance periods to avoid expensive and time-consuming travel to Perth. The Royal Flying Doctor Service (RFDS), a non-profit medical organization, provides prompt transfer of unwell patients from regional and remote areas of WA to Perth. Pathology services in remote regions are provided by the publicly funded PathWest organization. Method We retrospectively reviewed the survival outcomes of patients with multiple myeloma in the WA public healthcare system. Patients diagnosed between 2008 to 2017 were included (n=569). Staging information was extracted from the laboratory information system and the cytogenetic database in PathWest. Patient demographics, complications requiring admission, mortality and follow-up data were extracted from the public hospital patient management systems. Patients were segregated into regional or metropolitan by their residential address postcodes. Patients diagnosed and/or followed-up in the private sector were excluded. Survival was analyzed by Kaplan-Meier curves, Log-rank test and Cox proportional hazards model. Result Median age at diagnosis was 67 years old (range 29 to 98), with 56% above 65 years. 56% were males, 44% were females. Overall median survival was 46 months (95%CI:41,52). 1-year, 3-years and 5-years survival rates were 80%, 56% and 30% respectively. 25% (n=143) of patients resided in regional areas. No statistically significant difference in overall survival time between patients from metropolitan and regional areas was identified (p=0.2): 47 months (95% CI:43,54) and 42 months (95% CI: 33,54) respectively. Subgroup analysis also did not find any significant difference in overall survival of each R-ISS staging between metropolitan and regional areas. Discussion This retrospective study provides real-life survival data of of an Australian-based population in a state with a large land mass and low population density outside the capital city. The overall survival of patients living in regional areas was not significantly different from those living in the capital city. This gives credence to the benefit of the WA government supported regional network of travel, accommodation and Telehealth conferencing overcoming the distance barrier in the provision of comprehensive medical care in the management of a hematological malignancy. Figure. Figure. Disclosures No relevant conflicts of interest to declare.

Background and Objective: The overuse of antibiotics in the community is a primary cause of antibiotic resistance. Community pharmacists are the most accessible health professionals and so they are in an ideal position to implement interventions to ensure the appropriate use of antibiotics. This study aimed to explore the role of community pharmacists in the optimization of antibiotic prescribing and utilization. Method: Four focus groups were conducted with community pharmacists in Perth, Western Australia. Audio-recorded data were compared with field notes, transcribed, and thematically analyzed. Results: There were twenty-four participants in four focus group sessions. Four main themes were identified: patient perceptions and behaviors, prescribing behaviors, pharmacists’ roles and responsibilities, and health care system interventions in relation to antibiotic utilization. A number of interventions that could be implemented by community pharmacists were identified. In addition to interventions that are currently in place in Australia, forward dispensing, improved interprofessional collaboration, an expansion of current prescribing role, and vaccination capabilities were also suggested. Conclusions: This study indicated that current scope of pharmacists’ roles has room for more intervention strategies aimed at improving antibiotic prescribing and utilization in the community.

Objective This study investigated the link between socioeconomic status and unplanned dental presentations at the Perth Children’s Hospital (PCH), as well as the link between the socioeconomic status of unplanned dental patients and any previous admissions to the PCH. Methods Records of 351 unplanned visits to the PCH were collected, including reason for attendance (infection, trauma, other), the patient’s residential location (suburb) and the history of any previous presentations at the PCH. The socioeconomic status of each patient was based on the Index of Relative Socio-Economic Disadvantage, divided into quintiles. Geographic information systems (GIS) were used to spatially map the residential locations of the patients with unplanned dental presentations. QGIS was used to map and geocode the data. Analysis of variance and Chi-squared tests were used to determine associations between subgroups and other variables. Results ‘Unplanned dental presentation’ in this study refers to patients who present without an appointment, including by referral from the emergency department of the PCH or outside the PCH. Approximately two-thirds of unplanned dental presentation among patients from low socioeconomic groups were for dental infection, whereas the major reason for presentation among patients from higher socioeconomic groups was trauma. More than half the patients in low socioeconomic groups had at least one previous presentation at the PCH due to other medical issues. Conclusion Children from low socioeconomic groups, or from outside of Perth, were more likely to present with dental infections, which are mostly preventable at the primary care level; these patients often presented a more significant burden to the health system. Public health interventions should aim to promote preventive oral health care, especially for children from low socioeconomic groups. What is known about the topic? In Western Australia, the most common dental problems requiring hospitalisation among children is dental caries, and children from the lowest socioeconomic backgrounds have the highest prevalence of dental hospitalisations. What does this paper add? Children from lower socioeconomic backgrounds were more likely to have an unplanned presentation at the only tertiary children’s hospital in Western Australia due to dental infection. What are the implications for practitioners? Improved access to public dental services, especially in low socioeconomic areas, and the development of more strategies to reduce unplanned dental presentations at a tertiary hospital are needed.

Background: Although the poor health of people experiencing homelessness is increasingly recognised in health discourse, there is a dearth of research that has quantified the nature and magnitude of chronic health issues and morbidity among people experiencing homelessness, particularly in the Australian context. Methods: Analysis of the medical records of 2068 “active” patients registered with a specialist homeless health service in Perth, Western Australia as of 31 December 2019. Results: Overall, 67.8% of patients had at least one chronic physical health condition, 67.5% had at least one mental health condition, and 61.6% had at least one alcohol or other drug (AOD) use disorder. Nearly half (47.8%) had a dual diagnosis of mental health and AOD use issues, and over a third (38.1%) were tri-morbid (mental health, AOD and physical health condition). Three-quarters (74.9%) were multimorbid or had at least two long-term conditions (LTCs), and on average, each patient had 3.3 LTCs. Conclusions: The study findings have substantial implications from both a health risk and healthcare treatment perspective for people experiencing homeless. The pervasiveness of preventable health conditions among people experiencing homelessness also highlights the imperative to improve the accessibility of public health programs and screening to reduce their morbidity and premature mortality.

The Drug and Alcohol Withdrawal Network (DAWN) is a home-based withdrawal service based in Perth, Western Australia. Literature on outcomes, costs and client attitudes towards this type of home-based detoxification in Australia is sparse. Therefore, this study assessed these factors for clients enrolled over a 5-year period (July 2011–June 2016). Client experience was explored through semi-structured interviews with 10 clients. Over the study period, 1800 clients (54% male, mean age 38 years) were assessed, and there were 2045 episodes of care. Although most first-episode clients (52%) listed alcohol as the primary drug of concern, the proportion listing methamphetamine increased from 4% in 2011–12 to 23% in 2015–16. In 94% (n = 639) of withdrawal detoxification episodes with completed surveys, clients used their ‘drug of primary concern’ most days or more often at baseline; this had reduced to 23% (n = 149) at the conclusion of detoxification. Five-year direct costs were A$4.8 million. Clients valued the person-centred holistic approach to care, including linking with other health providers. Barriers included low awareness of the program and difficulties finding an appropriate support person. Further exploration of cost-effectiveness would substantiate the apparently lower per client cost, assuming medical suitability for both programs, for home-based relative to inpatient withdrawal.

Purpose – The purpose of this paper is to measure the levels of psychological distress in adults entering Western Australia (WA) as refugees through the Australian Humanitarian Programme. To determine if the introduction of mental health screening instruments impacts on the level of referrals for further psychological/psychiatric assessment and treatment. Design/methodology/approach – Participants were 300 consecutive consenting refugee adults attending the Humanitarian Entrant Health Service in Perth, WA. This service is government funded for the general health screening of refugees. The Kessler-10 (K10) and the World Health Organisation’s post-traumatic stress disorder (PTSD) screener were the principal outcome measures used. Findings – Refugees had a high rate of current probable PTSD (17.2 per cent) as measured with the PTSD screener and mean K10 scores were significantly higher than general population norms. The K10 showed high accuracy for discriminating those with or without probable PTSD. Being married and having more children increased the risk of probable PTSD. In regard to region of origin, refugees from Western and Southern Asia had significantly higher scores on both screeners followed by those from Africa with those from South-Eastern Asia having the lowest scores. Referral rate for psychiatric/psychological treatment was 18 per cent compared to 4.2 per cent in the year prior to the study. Practical implications – This study demonstrates increased psychological distress including a high rate of probable PTSD in a recently arrived multi-ethnic refugee population and also demonstrates significant variations based on region of origin. In addition, it supports the feasibility of using brief screening instruments to improve identification and referral of refugees with significant psychological distress in the context of a comprehensive general medical review. Originality/value – This was an Australian study conducted in a non-psychiatric setting. The outcomes of this study pertain to refugee mental health assessed in a general health setting. The implications of the study findings are of far reaching relevance, inclusive of primary care doctors and general physicians as well as mental health clinicians. In particular the authors note that the findings of this study are to the authors’ knowledge unique in the refugee mental health literature as the participants are recently arrived refugees from diverse ethnic groups.

Objective: To describe the epidemiological and other characteristics of emergency department (ED) presentations diagnosed with acute upper respiratory infection (URI). Design and setting: A retrospective study of patients given an ED diagnosis of acute URI from July 2000 to July 2003 at any of the four metropolitan teaching hospitals in Perth, Western Australia. Results: Acute URI accounted for 3.6% (95% CI, 3.5?3.7) of ED presentations, and 80.7% (95% CI, 80.1?81.3) of these were aged less than 15 years. The most common diagnosis was acute upper respiratory infections of multiple and unspecified sites, followed by croup and acute tonsillitis. Of those with croup, 76.0% (95% CI, 74.7?77.3) presented at night, 67.6% (95% CI, 66.2?69.0) were male and the number of presentations with croup was highest in June 2002. The number of diagnoses of acute tonsillitis did not display a great deal of variation from month to month. Overall, hospital admission was 12.3% (95% CI, 11.8?12.8), with a median length of hospital stay of 1 day (IQR 1.0?2.0). An increase in comorbidity, residing in the most disadvantaged areas, and being a re-presentation increased the odds of being admitted. Conclusion: Further investigation is needed into whether alternative medical care services would be appropriate and acceptable for patients with less severe acute URIs.

IntroductionPreconception carrier screening (PCS) identifies couples at risk of having children with recessive genetic conditions. New technologies have enabled affordable sequencing for multiple disorders simultaneously, including identifying carrier status for many recessive diseases. The aim of the study was to identify the most effective way of delivering PCS in Western Australia (WA) through the public health system.Methods and analysisThis is a multicentre cohort pilot study of 250 couples who have used PCS, conducted at three sites: (1) Genetic Services of Western Australia, (2) a private genetic counselling practice in Perth and (3) participating general practice group practices in the Busselton region of WA. The primary outcome of the pilot study was to evaluate the feasibility of implementing the comprehensive PCS programme in the WA healthcare system. Secondary outcome measures included evaluation of the psychosocial impact of couples, such as reproductive autonomy; identification of areas within the health system that had difficulties in implementing the programme and evaluation of tools developed during the study.Ethics and disseminationApproval was provided by the Women and Newborn Health Service Human Research Ethics Committee (HREC) at King Edward Memorial Hospital for Women (RGS0000000946) and the University of Western Australia (UWA) HREC (RA/4/20/4258). Participants may choose to withdraw at any time. Withdrawal will in no way affect participating couples' medical care. Study couples will be redirected to another participating health professional for consultation or counselling in the event of a health professional withdrawing. All evaluation data will be deidentified and stored in a password-protected database in UWA. In addition, all hard copy data collected will be kept in a locked cabinet within a secure building. All electronic data will be stored in a password-protected, backed-up location in the UWA Institutional Research Data Store. All evaluative results will be published as separate manuscripts, and selected results will be presented at conferences.

Ms Dhu, an Aboriginal woman belonging to the Yamatji nation, died in police custody in South Hedland, Western Australia, in 2014 within 48 hours of being incarcerated for failing to pay fines. The coroner’s report found that both the police force and medical institution failed to discharge the duty of care owed to Ms Dhu, as their behaviour fell below what was expected of someone in their position. However, the coronial inquiry was unable to account for the ways in which state power and possessive sovereignty is invested in the deaths of Indigenous peoples. This article connects Ms Dhu’s life and death to forms of gendered, institutional and structural racism endemic to the Australian settler state. We then turn to examine the possibilities of justice for Ms Dhu through aesthetic attempts to memorialize her in public spaces of the city of Perth, which carry a promise of justice through their ability to challenge the settler-colonial logic that made possible Ms Dhu’s invisible suffering and the lack of accountability for her death.

Background: The prevalence of psychological and behavioral disturbances among older adults living in residential care facilities is high, and it has been shown previously that people with such symptoms have poorer health outcomes. This study was designed to assess the efficacy of an early psychiatric intervention on the 12-month health outcomes of older adults admitted to residential care facilities in Perth, Western Australia. We hypothesized that subjects in the intervention group would have better mental and physical health outcomes than controls.Methods: The study was designed as a randomized, single-blinded, controlled trial. All subjects aged 65 years or over admitted to one of the 22/26 participating residential care facilities of the Inner City area of Perth were approached to join the study and were allocated randomly to the intervention or usual care group. Demographic and clinical information (including medications and use of physical restraint) was gathered systematically from all participants at baseline, and at 6 and 12 months. At each assessment, the Geriatric Depression Scale (GDS), the Health of the Nation Outcome Scales for older adults (HoNOS 65+), the Mini-mental State Examination (MMSE) and the Neuropsychiatric Inventory (NPI) were administered. Subjects in the intervention group who screened positive at the baseline assessment for psychiatric morbidity were reviewed within a 2-week period by the Inner City Mental Health Service of Older Adults (ICMHSOA). If clinically appropriate, mental health services were introduced without the involvement of the research team.Results: One hundred and six subjects and their next of kin consented to participate in the study (53 in each group). Mental health screening and early referral to a psychogeriatric service did not significantly change the average number of medical contacts, self-rated health, use of psychotropic or PRN medication, use of physical restraint, 12-month mortality, or mental health outcomes, as measured by the GDS-15, HoNOS 65+ and NPI (p>0.05 for all relevant outcomes).Conclusion: Systematic mental health screening of older adults admitted to residential care facilities and early clinical intervention does not change 12-month health outcomes. More effective interventions to improve the health outcomes of older adults with psychological and behavioral disturbances admitted to residential care facilities are needed.

Objectives The aim of the present study was to provide descriptive planning data for a hospital-based Aboriginal Health Liaison Officer (AHLO) program, specifically quantifying episodes of care and outcomes within 28 days after discharge. Methods A follow-up study of Aboriginal in-patient hospital episodes was undertaken using person-based linked administrative data from four South Metropolitan hospitals in Perth, Western Australia (2006–11). Outcomes included 28-day deaths, emergency department (ED) presentations and in-patient re-admissions. Results There were 8041 eligible index admissions among 5113 individuals, with episode volumes increasing by 31% over the study period. Among patients 25 years and older, the highest ranking comorbidities included injury (47%), drug and alcohol disorders (41%), heart disease (40%), infection (40%), mental illness (31%) and diabetes (31%). Most events (96%) ended in a regular discharge. Within 28 days, 24% of events resulted in ED presentations and 20% resulted in hospital re-admissions. Emergency readmissions (13%) were twice as likely as booked re-admissions (7%). Stratified analyses showed poorer outcomes for older people, and for emergency and tertiary hospital admissions. Conclusions Future planning must address the greater service volumes anticipated. The high prevalence of comorbidities requires intensive case management to address case complexity. These data will inform the refinement of the AHLO program to improve in-patient experiences and outcomes. What is known about the topic? The health gap between Aboriginal and non-Aboriginal Australians is well documented. Aboriginal people have significantly higher hospital utilisation rates, as well as higher rates of complications, comorbidities and discharges against medical advice (DAMA). Aboriginal patients receive most of their specialist services in hospital; however, detailed person-based analyses are limited and planning is often based on crude data. What does this paper add? This is the first analysis of linked data focusing on Aboriginal patient flows and volume and 28-day health system outcomes following hospital admission for all causes in a large metropolitan setting. Because the data were linked, admissions belonging to a single episode of care were combined, ensuring that transfers were not counted as re-admissions. Linkage also allowed follow up across time. The results highlight the main disease groups for which Aboriginal patients are admitted, how this varies by age and the high proportion of patients returning to (any) hospital within 28 days, either through EDs or as booked (pre-arranged) admissions. These data aid in the planning of hospital-based Aboriginal health liaison services. What are the implications for practitioners? The paper outlines the complexity with which many Aboriginal patients present to hospital and the risk of DAMA and re-admission. Clinical and organisational strategies can be put in place in hospitals to address these risks and ensure improved continuity of care with community-based primary health services. The Western Australian South Metropolitan Health Service is reviewing these data and will monitor the impact of the hospital-based AHLO program.

BackgroundEvidence is emerging that surgery in the neonatal period is associated with increased risk of suboptimal neurodevelopmental outcomes (SNDO). The aim of this study was to describe neurodevelopmental outcomes (at 1 year) of neonatal surgery for congenital gastrointestinal surgical conditions (CGSC) and to explore risk factors.MethodsRetrospective study (2005–2014) of infants born ≥34 weeks gestation with CGSC and admitted to the surgical neonatal intensive care unit of Perth Children’s Hospital, Western Australia. Clinical details and 1-year developmental outcomes based on Griffiths Mental Developmental Assessment Scales were collated from the database and by reviewing the medical records of study infants. SNDO was defined as one or more of the following: a general quotient less than 88 (ie, >1 SD below mean), cerebral palsy, blindness or sensorineural deafness. Univariable and multivariable logistic regression analyses were carried out to explore risk factors for SNDO. A total of 413 infants were included, of which 13 died. Median gestation was 37.6 weeks (IQR: 36.4–39.1). Information on developmental outcomes was available from 262 out of 400 survivors. A total of 43/262 (16.4%) had SNDO. On univariable analysis, lower z scores for birth weight, prolonged duration of antibiotics, increased episodes of general anaesthesia and prolonged duration of hospital stay were associated with SNDO. On multivariable analysis, lower z scores for birth weight and prolonged hospital stay were associated with increased risk of SNDO.ConclusionsLate preterm and term infants undergoing neonatal surgery for CGSC may be at risk for SNDO. Studies with longer duration of follow-up are needed to further evaluate the role of potentially modifiable risk factors on their neurodevelopmental outcomes.

Objective: The Alcohol Use Disorders Identification Test (AUDIT) has been developed to screen for hazardous and harmful alcohol consumption. It has been used among a variety of primary care, general population and general hospital populations. However, with the exception of one study undertaken by the author and colleagues, the use of the AUDIT in general hospital psychiatric patients has not been reported. This paper reports on a substudy of this larger study whose aim was to determine the frequency of hazardous alcohol use and dependence among patients admitted to the psychiatric units of general hospitals in Perth, Western Australia, and discusses major reasons for non-AUDIT screening among this group. Method: In a 12-month period 990 patients aged 18–64 years and residing in the Perth metropolitan area were admitted to the psychiatric unit of the two hospitals. Using the AUDIT alcohol use in patients with four major types of psychiatric disorder, namely mood, adjustment, anxiety and psychotic disorders, was assessed. Results: Of the 834 admissions targeted for AUDIT screening 263 were not screened. This non-screening represented 27–42% of patients in each of the major diagnostic categories. There was no significant difference in the proportion of patients screened versus not screened for mood, adjustment or schizophrenia/psychosis. There were however, significantly fewer patients with anxiety disorder screened compared with mood disorder. Those non-screened patients in major psychiatric groups had significantly shorter hospital stays than their diagnostic counterparts who were screened. The major reason for non-screening in all groups was due to patients leaving the psychiatric facility before they could be accessed. This included discharge before screening, transfer to another psychiatric facility and short admission. To a lesser extent cognitive dysfunction accounted for non-screening among major diagnostic groups. Conclusions: Failure to screen patients was largely due to short hospital stays. Screening was impeded by the brief window period, commonly 1 or 2 days, between the absence of acute psychiatric sequelae and discharge. This situation contrasts dramatically to the medical or surgical admission where major sequelae are largely resolved in 2–3 days and AUDIT screening can take place over the remaining 3–4 days prior to discharge. To be effective in the general hospital psychiatric setting, alcohol screening needs to be incorporated into the routine ward assessment procedures. The brevity of the AUDIT makes this possible. This would maximize the time available to implement an intervention programme to those found to be consuming alcohol at a hazardous or harmful level.

The values of filial piety have strongly influenced the care of older people in traditional Chinese societies. Changes in family structure and relationships have occurred and in recent decades, transnational migration has become a factor in how filial piety is perceived and practiced in contemporary translocal Chinese families. Through the use of in-depth interviews, this pilot study explores transnational family patterns, elder care practices, attitudes towards filial piety, and opinions of the medical systems in Taiwan and Australia among 14 Taiwanese families who have lived in Australia for over 20 years. The study finds that despite immigration, filial piety remains an important value for these families. Most participants have/had provided care to their aged parents at the site of immigration and back home, and some of these parents were immigrants who had returned to Taiwan in their old age. Participants generally felt that older people are better looked after in Taiwan than in Australia, as Taiwan has a better healthcare system, and hired caregivers are more readily available. Elders’ expectations of filial piety from their children varied among participants, but all were prepared for a weakening of filiality and ongoing changes in intergenerational relations while living in a Western country. 傳統中國社會的老人照顧，受到孝道價值觀的影響很深。因為家庭結構及成員關係的改變，特別是近三十年來移民國外人口的增加，對當代華人家庭對孝道的認知與實踐產生了新的影響。本研究透過深入訪談居住澳洲二十年以上的台灣移民，探索跨國家庭類型、照顧年長父母的方式、對孝道的看法，以及台灣及澳洲兩地醫療體系的差異。研究發現雖然移民海外，盡孝道仍是重要的家庭價值。大部分的受訪者都曾為長者提供資源或參與照顧，無論是在澳洲或在台灣。年長父母也曾經在成年子女居住澳洲期間前往探視、短期逗留或移民。他們大部分都已回流台灣，原因是在台灣的年長者會得到較好的照顧，台灣的健保制度較適合年長者的需要，而且可以僱用外傭幫忙。已定居澳洲的台灣移民，對孝道的看法雖有差異，但對自己的成年子女是否能在環境不同的西方國家盡孝道，均有所保留。 (This article is in English.)

Abstract Objectives The purpose of this study was to characterise neonatal Staphylococcus aureus (SA) sepsis in Western Australia (WA) between 2001 and 2020 at the sole tertiary neonatal intensive care unit (NICU), examine risk factors for sepsis in the cohort, and compare short- and long-term outcomes to control infants without any sepsis. Methods Retrospective cohort study at the Neonatal Directorate at King Edward Memorial Hospital (KEMH) and Perth Children’s Hospital, using electronic databases and patient medical records. Results The overall incidence of SA sepsis was 0.10 per 1000 live births (62/614207). From 2001 to 2010 the incidence was 0.13/1000 live births, reducing to 0.07/1000 live births from 2011 to 2020. SA was most frequently isolated from endotracheal aspirates, and infants with SA sepsis had longer median duration of ventilatory support than those without any sepsis (31 days vs 18 days respectively, p < 0.001). In our cohort, SA sepsis was associated with worse neurodevelopmental outcomes compared to infants without any sepsis. Conclusions The incidence of neonatal SA sepsis has reduced over the last 20 years, suggesting potential effectiveness of the preventative interventions implemented. Endotracheal tube (ETT) colonisation and prolonged ventilation may be under-recognised as potential sources of SA infection. Our study suggests SA sepsis may negatively impact neurodevelopmental outcomes.

IntroductionMajor trauma patients are often perceived as being young males injured by high energy transfer mechanisms. The aim of this study was to describe the demographics of major trauma patients who were transported to hospital by ambulance.MethodsThis is a retrospective cohort study of adult major trauma (injury severity score >15) patients transported to hospital by St John Western Australia emergency ambulance in metropolitan Perth, between 1 January 2013 and 31 December 2016. To describe the cohort, median and interquartile range (IQR) were used for continuous variables and counts and percentages for categorical variables. Differences between mechanism of injury groups were assessed using the Kruskal-Wallis test. Trauma deaths were defined as early (declared deceased within 24 hours) or late (declared deceased within 30 days). ResultsA total of 1625 patients were included. The median age was 51 years (IQR 30-75) and 1158 (71%) were male. Falls from standing were the most common mechanism of injury (n=460, 28%) followed by motor vehicle crashes (n=259, 16%). Falls from standing were responsible for the majority of early (n=45/175, 26%) and late deaths (n=69/158, 44%). A large number of early deaths also resulted from motorbike crashes (n=32/175, 18%) with a median age of 34 years (IQR 21-46, p<0.001). ConclusionMajor trauma is not only a disease of the young. More than half of the cohort was more than 51 years of age and the most common cause was a fall from standing. Pre-hospital care must evolve to address the needs of a changing trauma patient demographic.

BASTARDYAll children born before matrimony, or so long after the death of the husband as to render it impossible that the child could be begotten by him, are bastards.– Cro. Jac. 451William Toone: The Magistrates Manual, 1817 (66)On 4 September 1832, the body of a newborn baby boy was found washed up on the shore at the port town of Fremantle, Western Australia. As the result of an inquest into the child’s suspicious death, a 20-year-old, unmarried woman named Mary Summerland was accused of concealing his birth. In October 2014, 25-year-old Irish backpacker Caroline Quinn faced court in Perth, Western Australia, over claims that she concealed the birth of her stillborn child after giving birth in the remote north west town of Halls Creek during May of the same year. Both women denied the existence of their children, both appear to have given birth to their “illegitimate” babies alone, and both women claimed that they did not know that they had ever been pregnant at all. In addition, both women hid the body of their dead child for several days while the people they lived with or were close to, did not appear to notice that the mother of the child had had a baby. In neither case did any person associated with either woman seek to look for the missing child after it had been born.Despite occurring 182 years apart, the striking similarities between these cases could lead to the assumption that it is almost as if there were a written script of behaviour that would explain the actions of both young women. Close examination of the laws surrounding child murder, infanticide and concealment of birth reveals evidence of similar behaviours being enacted by women as far back as the 1600s (and earlier), and all are shaped in response to the legal frameworks that prosecuted women who gave birth outside of marriage.This article traces the history of child murder law from its formation in England in the 1600s and explores how early moral assumptions concerning unmarried mothers echoed through the lived experiences of women who killed their illegitimate babies in colonial Western Australia, and continue to resonate in the treatment of, and legal response to, women accused of similar crimes in the present day. The Unlicensed ChildThe unlicensed child is a term coined by Swain and Howe to more accurately define the social matrix faced by single women and their children in Australia. The term seeks to emphasise the repressive and controlling religious, legal and social pressures that acted on Australian women who had children outside marriage until the mid-1970s (xxi, 1, 92, 94). For the purposes of this article, I extend Swain and Howe’s term the unlicensed child to coin the term the unlicensed mother. Following on from Swain and Howe’s definition, if the children of unmarried mothers did not have a license to be born, it is essential to acknowledge that their mothers did not have a license to give birth. Women who had children without social and legal sanction gave birth within a society that did not allocate them “permission” to be mothers, something that the corporeality of pregnancy made it impossible for them not to be. Their own bodies—and the bodies of the babies growing inside them—betrayed them. Unlicensed mothers were punished socially, religiously, legally and financially, and their children were considered sinful and inferior to children who had married parents simply because they had been born (Scheper-Hughes 410). This unspoken lack of authorisation to experience the unavoidably innate physicality of pregnancy, birth and motherhood, in turn implies that, until recently unmarried mothers did not have license to be mothers. Two MothersAll that remains of the “case” of Mary Summerland is a file archived at the State Records Office of Western Australia under the title CONS 3472, Item 10: Rex V Mary Summerland. Yet revealed within those sparse documents is a story echoed by the events surrounding Caroline Quinn nearly two hundred years later. In September 1832, Mary Summerland was an unmarried domestic servant living and working in Fremantle when the body of a baby was found lying on a beach very close to the settlement. Western Australia had only been colonized by the British in 1829. The discovery of the body of an infant in such a tiny village (colonial Fremantle had a population of only 436 women and girls out of 1341 non-Aboriginal emigrants) (Gardiner) set in motion an inquest that resulted in Mary Summerland being investigated over the suspicious death of the child.The records suggest that Mary may have given birth, apparently alone, over a week prior to the corpse of the baby being discovered, yet no one in Fremantle, including her employer and her family, appeared to have noticed that Mary might have been pregnant, or that she had given birth to a child. When Mary Summerland was eventually accused of giving birth to the baby, she strongly denied that she had ever been pregnant, and denied being the mother of the child. It is not known how her infant ended up being disposed of in the ocean. It is also not known if Mary was eventually charged with concealment or child murder, but in either scenario, the case against her was dismissed as “no true bill” when she faced her trial. The details publically available on the case of Caroline Quinn are also sparse. Even the sex of her child has not been revealed in any of the media coverage of the event. Yet examination of the limited details available on her charge of “concealment of birth” reveal similarities between her behaviours and those of Mary Summerland.In May 2014 Caroline Quinn had been “travelling with friends in the Kimberly region of Western Australia” (Lee), and, just as Mary did, Caroline claims she “did not realise that she was pregnant” when she went into labour (Independent.ie). She appears, like Mary Summerland, to have given birth alone, and also like Mary, when her child died due to unexplained circumstances she hid the corpse for several days. Also echoing Mary’s story, no person in the sparsely populated Hall’s Creek community (the town has a populace of 1,211) or any friends in Caroline’s circle of acquaintances appears to have noticed her pregnancy, nor did they realise that she had given birth to a baby until the body of the child was discovered hidden in a hotel room several days after her or his birth. The media records are unclear as to whether Caroline revealed her condition to her friends or whether they “discovered” the body without her assistance. The case was not brought to the attention of authorities until Caroline’s friends took her to receive medical attention at the local hospital and staff there notified the police.Media coverage of the death of Caroline Quinn’s baby suggests her child was stillborn or died soon after birth. As of 13 August 2014 Caroline was granted leave by the Chief Magistrate to return home to Ireland while she awaited her trial, as “without trivialising the matter, nothing more serious was alleged than the concealing of the birth” (Collins, "Irish Woman"). Caroline Quinn was not required to return to Australia to appear at her trial and when the case was presented at the Perth Magistrates Court on Thursday 2 October, all charges against her were dropped as the prosecutor felt “it was not in the public interest” to proceed with legal action (Collins, "Case").Statutory MarginalisationTo understand the similarities between the behaviours of, and legal and medical response to, Mary Summerland and Caroline Quinn, it is important to situate the deaths of their children within the wider context of child murder, concealment of birth and “bastardy” law. Tracing the development of these methods of law-making clarifies the parallels between much of the child murder, infanticide and concealment of birth narrative that has occurred in Western Australia since non-Aboriginal settlement.Despite the isolated nature of Western Australia, the nearly 400 years since the law was formed in England, and the extremely remote rural locations where both these women lived and worked, their stories are remarkably alike. It is almost as if there were a written script and each member of the cast knew what role to play: both Mary and Caroline knew to hide their pregnancies, to deny the overwhelmingly traumatic experience of giving birth alone, and to conceal the corpses of their babies. The fathers of their children appear to have cut off any connection to the women or their child. The family, friends, or employers of the parents of the dead babies knew to pretend that they did not know that the mother was pregnant or who the father was. The police and medical officers knew to charge these women and to collect evidence that could be used to simultaneously meet the needs of the both prosecution and the defence when the cases were brought to trial.In reference to Mary Summerland’s case, in colonial Western Australia when a woman gave birth to an infant who died under suspicious circumstances, she could be prosecuted with two charges: “child murder” and/or “concealment of birth”. It is suggestive that Mary may have been charged with both. The laws regarding these two offences were focused almost exclusively on the deaths of unlicensed children and were so deeply interconnected they are difficult to untangle. For Probyn, shame pierces the centre of who we think we are, “what makes it remarkable is that it reveals with precision our values, hopes and aspirations, beyond the generalities of good manners and cultured norms” (x). Dipping into the streams of legal and medical discourse that flow back to the seventeenth century highlights the pervasiveness of discourses marginalising single women and their children. This situates Mary Summerland and Caroline Quinn within a ‘burden on society’ narrative of guilt, blame and shame that has been in circulation for over 500 years, and continues to resonate in the present (Coull).An Act to Prevent the Destroying and Murthering of Bastard ChildrenIn England prior to the 17th century, penalties for extramarital sex, the birth and/or maintenance of unlicensed children or for committing child murder were expressed through church courts (Damme 2-6; Rapaport 548; Butler 61; Hoffer and Hull 3-4). Discussion of how the punishment of child murder left the religious sphere and came to be regulated by secular laws that were focused exclusively on the unlicensed mother points to two main arguments: firstly, the patriarchal response to unlicensed (particularly female) sexuality; and secondly, a moral panic regarding a perceived rise in unlicensed pregnancies in women of the lower classes, and the resulting financial burden placed on local parishes to support unwanted, unlicensed children (Rapaport 532, 48-52; McMahon XVII, 126-29; Osborne 49; Meyer 3-8 of 14). In many respects, as Meyer suggests, “the legal system subtly encouraged neonaticide through its nearly universally negative treatment of bastard children” (240).The first of these “personal control laws” (Hoffer and Hull 13) was the Old Poor Law created by Henry VIII in 1533, and put in place to regulate all members of English society who needed to rely on the financial assistance of the parish to survive. Prior to 1533, “by custom the children of the rich depended on their relations, while the ‘fatherless poor’ relied on the charity of the monastic institutions and the municipalities” (Teichman 60-61). Its implementation marks the historical point where the state began to take responsibility for maintenance of the poor away from the church by holding communities responsible for “the problem of destitution” (Teichman 60-61; Meyer 243).The establishment of the poor law system of relief created a hierarchy of poverty in which some poor people, such as those suffering from sickness or those who were old, were seen as worthy of receiving support, while others, who were destitute as a result of “debauchery” or other self-inflicted means were seen as undeserving and sent to a house of correction or common gaol. Underprivileged, unlicensed mothers and their children were seen to be part of the category of recipients unfit for help (Jackson 31). Burdens on SocietyIt was in response to the narrative of poor unlicensed women and their children being undeserving fiscal burdens on law abiding, financially stretched community members that in 1576 a law targeted specifically at holding genetic parents responsible for the financial maintenance of unlicensed children entered the secular courts for the first time. Called the Elizabethan Poor Law it was enacted in response to the concerns of local parishes who felt that, due to the expenses exacted by the poor laws, they were being burdened with the care of a greatly increased number of unlicensed children (Jackson 30; Meyer 5-6; Teichman 61). While the 1576 legislation prosecuted both parents of unlicensed children, McMahon interprets the law as being created in response to a blend of moral and economic forces, undergirded by a deep, collective fear of illegitimacy (McMahon 128). By the 1570s “unwed mothers were routinely whipped and sent to prison” (Meyer 242) and “guardians of the poor” could force unlicensed mothers to wear a “badge” (Teichman 63). Yet surprisingly, while parishes felt that numbers of unlicensed children were increasing, no concomitant rise was actually recorded (McMahon 128).The most damning evidence of the failure of this law, was the surging incidence of infanticide following its implementation (Rapaport 548-49; Hoffer and Hull 11-13). After 1576 the number of women prosecuted for infanticide increased by 225 percent. Convictions resulting in unlicensed mothers being executed also rose (Meyer 246; Hoffer and Hull 8, 18).Infanticide IncreasesBy 1624 the level of infanticide in local communities was deemed to be so great An Act to Prevent the Destroying and Murthering of Bastard Children was created. The Act made child murder a “sex-specific crime”, focused exclusively on the unlicensed mother, who if found guilty of the offence was punished by death. Probyn suggests that “shame is intimately social” (77) and indeed, the wording of An Act to Prevent highlights the remarkably similar behaviours enacted by single women desperate to avoid the shame and criminal implication linked to the social position of unlicensed mother: Whereas many lewd Women that have been delivered of Bastard Children, to avoyd their shame and to escape punishment [my italics], doe secretlie bury, or conceale the Death of their Children, and after if the child be found dead the said Women doe alleadge that the said Children were borne dead;…For the preventing therefore of this great Mischiefe…if any Woman…be delivered of any issue of the Body, Male or Female, which being born alive, should by the Lawes of this Realm be a bastard, and that she endeavour privatlie either by drowning or secret burying thereof, or any other way, either by herselfe of the procuring of others, soe to conceale the Death thereof, as that it may not come to light, whether it be borne alive or not, but be concealed, in every such Case the Mother so offending shall suffer Death… (Davies 214; O'Donovan 259; Law Reform Commission of Western Australia 104; Osborne 49; Rose 1-2; Rapaport 548). An Act to Prevent also “contained an extraordinary provision which was a reversion of the ordinary common law presumption of dead birth” (Davies 214), removing the burden of proof from the prosecution and placing it on the defence (Francus 133; McMahon 128; Meyer 2 of 14). The implication being that if the dead body of a newborn, unlicensed baby was found hidden, it was automatically assumed that the child had been murdered by their mother (Law Reform Commission of Western Australia 104; Osborne 49; Rapaport 549-50; Francus 133). This made the Act unusual in that “the offence involved was the concealment of death rather than the death itself” (O'Donovan 259). The only way an unlicensed mother charged with child murder was able to avoid capital punishment was to produce at least one witness to give evidence that the child was “borne dead” (Law Reform Commission of Western Australia 104; Meyer 238; McMahon 126-27).Remarkable SimilaritiesClearly, the objective of An Act to Prevent was not simply to preserve infant life. It is suggestive that it was enacted in response to women wishing to avoid the legal, social, corporal and religious punishment highlighted by the implementation of the poor law legislation enacted throughout earlier centuries. It is also suggestive that these pressures were so powerful that threat of death if found guilty of killing their neonate baby was not enough to deter women from concealing their unlicensed pregnancies and committing child murder. Strikingly analogous to the behaviours of Mary Summerland in 19th century colonial Western Australia, and Caroline Quinn in 2014, the self-preservation implicit in the “strategies of secrecy” (Gowing 87) surrounding unlicensed birth and child murder often left the mother of a dead baby as the only witness to her baby’s death (McMahon xvii 49-50).An Act to Prevent set in motion the legislation that was eventually used to prosecute Mary Summerland in colonial Western Australia (Jackson 7, Davies, 213) and remnants of it still linger in the present where they have been incorporated into the ‘concealment of birth law’ that prosecuted Caroline Quinn (Legal Online TLA [10.1.182]).Changing the ‘Script’Shame runs like a viral code through the centuries to resonate within the legal response to women who committed infanticide in colonial Western Australia. It continues on through the behaviours of, and legal responses to, the story of Caroline Quinn and her child. As Probyn observes, “shame reminds us about the promises we keep to ourselves” in turn revealing our desire for belonging and elements of our deepest fears (p. x). While Caroline may live in a society that no longer outwardly condemns women who give birth outside of marriage, it is fascinating that the suite of behaviours manifested in response to her pregnancy and the birth of her child—by herself, her friends, and the wider community—can be linked to the narratives surrounding the formation of “child murder” and “concealment” law nearly 400 years earlier. Caroline’s narrative also encompasses similar behaviours enacted by Mary Summerland in 1832, in particular that Caroline knew to say that her child was “born dead” and that she had merely concealed her or his body—nothing more. This behaviour appears to have secured the release of both women as although both Mary and Caroline faced criminal investigation, neither was convicted of any crime. Yet, neither of these women or their small communities were alone in their responses. My research has uncovered 55 cases linked to child murder in Western Australia and the people involved in all of these incidences share unusually similar behaviours (Gardiner). Perhaps, it is only through the wider community becoming aware of the resonance of child murder law echoing through the centuries, that certain women who are pregnant with unwanted children will be able to write a different script for themselves, and their “unlicensed” children. ReferencesButler, Sara, M. "A Case of Indifference? Child Murder in Later Medieval England." Journal of Women's History 19.4 (2007): 59-82. Collins, Padraig. "Case against Irish Woman for Concealing Birth Dropped." The Irish Times 2 Oct. 2014. ---. "Irish Woman Held for Hiding Birth in Australia Allowed Return Home." The Irish Times 13 Aug. 2014. Coull, Kim. “The Womb Artist – A Novel: Translating Late Discovery Adoptee Pre-Verbal Trauma into Narrative”. Dissertation. Perth, WA: Edith Cowan University, 2014.Damme, Catherine. "Infanticide: The Worth of an Infant under Law." Medical History 22.1 (1978): 1-24. Davies, D.S. "Child-Killing in English Law." The Modern Law Review 1.3 (1937): 203-23. Dickinson, J.R., and J.A. Sharpe. "Infanticide in Early Modern England: The Court of Great Sessions at Chester, 1650-1800." Infanticide: Historical Perspectives on Child Murder and Concealment, 1550-2000. Ed. Mark Jackson. Hants: Ashgate, 2002. 35-51.Francus, Marilyn. "Monstrous Mothers, Monstrous Societies: Infanticide and the Rule of Law in Restoration and Eighteenth-Century England." Eighteenth-Century Life 21.2 (1997): 133-56. Gardiner, Amanda. "Sex, Death and Desperation: Infanticide, Neonaticide and Concealment of Birth in Colonial Western Australia." Dissertation. Perth, WA: Edith Cowan University, 2014.Gowing, Laura. "Secret Births and Infanticide in Seventeenth-Century England." Past & Present 156 (1997): 87-115. Hoffer, Peter C., and N.E.H. Hull. Murdering Mothers: Infanticide in England and New England 1558-1803. New York: New York University Press, 1984. Independent.ie. "Irish Woman Facing Up to Two Years in Jail for Concealing Death of Her Baby in Australia." 8 Aug. 2014. Law Reform Commission of Western Australia. "Chapter 3: Manslaughter and Other Homicide Offences." Review of the Law of Homicide: Final Report. Perth: Law Reform Commission of Western Australia, 2007. 85-117.Lee, Sally. "Irish Backpacker Charged over the Death of a Baby She Gave Birth to While Travelling in the Australia [sic] Outback." Daily Mail 8 Aug. 2014. Legal Online. "The Laws of Australia." Thomson Reuters 2010. McMahon, Vanessa. Murder in Shakespeare's England. London: Hambledon and London, 2004. Meyer, Jon'a. "Unintended Consequences for the Youngest Victims: The Role of Law in Encouraging Neonaticide from the Seventeenth to Nineteenth Centuries." Criminal Justice Studies 18.3 (2005): 237-54. O'Donovan, K. "The Medicalisation of Infanticide." Criminal Law Review (May 1984): 259-64. Osborne, Judith A. "The Crime of Infanticide: Throwing Out the Baby with the Bathwater." Canadian Journal of Family Law 6 (1987): 47-59. Rapaport, Elizabeth. "Mad Women and Desperate Girls: Infanticide and Child Murder in Law and Myth." Fordham Urban Law Journal 33.2 (2006): 527-69.Rose, Lionel. The Massacre of the Innocents: Infanticide in Britain, 1800-1939. London: Routledge & Kegan, 1986. Scheper-Hughes, Nancy. Death without Weeping: The Violence of Everyday Life in Brazil. Los Angeles: University of California Press, 1992. Swain, Shurlee, and Renate Howe. Single Mothers and Their Children: Disposal, Punishment and Survival in Australia. Cambridge: Cambridge University Press, 1995. Teichman, Jenny. Illegitimacy: An Examination of Bastardy. Oxford: Cornell University Press, 1982. Toone, William. The Magistrate's Manual: Or a Summary of the Duties and Powers of a Justice of the Peace. 2nd ed. London: Joseph Butterworth and Son, 1817.

“Human beings are not born once and for all on the day their mothers give birth to them [...] life obliges them over and over again to give birth to themselves.” (Garcia Marquez 165) Introduction The refugee experience is, at heart, one of rebirth. Just as becoming a new, distinctive being—biological birth—necessarily involves the physical separation of mother and infant, so becoming a refugee entails separation from a "mother country." This mother country may or may not be a recognised nation state; the point is that the refugee transitions from physical connectedness to separation, from insider to outsider, from endemic to alien. Like babies, refugees may have little control over the timing and conditions of their expulsion. Successful resettlement requires not one rebirth but multiple rebirths—resettlement is a lifelong process (Layton)—which in turn require hope, imagination, and energy. In rebirthing themselves over and over again, people who have fled or been forced from their homelands become both mother and child. They do not go through this rebirthing alone. A range of agencies and individuals may be there to assist, including immigration officials, settlement services, schools and teachers, employment agencies and employers, English as a Second Language (ESL) resources and instructors, health-care providers, counsellors, diasporic networks, neighbours, church groups, and other community organisations. The nature, intensity, and duration of these “midwives’” interventions—and when they occur and in what combinations—vary hugely from place to place and from person to person, but there is clear evidence that post-migration experiences have a significant impact on settlement outcomes (Fozdar and Hartley). This paper draws on qualitative research I did in 2012 in a regional town in New South Wales to illuminate some of the ways in which settlement aides ease, or impede, refugees’ rebirth as fully recognised and participating Australians. I begin by considering what it means to be resilient before tracing some of the dimensions of the resettlement process. In doing so, I draw on data from interviews and focus groups with former refugees, service providers, and other residents of the town I shall call Easthaven. First, though, a word about Easthaven. As is the case in many rural and regional parts of Australia, Easthaven’s population is strongly dominated by Anglo Celtic and Saxon ancestries: 2011 Census data show that more than 80 per cent of residents were born in Australia (compared with a national figure of 69.8 per cent) and about 90 per cent speak only English at home (76.8 per cent). Almost twice as many people identify as Aboriginal or Torres Strait Islander as the national figure of 2.5 per cent (Australian Bureau of Statistics). For several years Easthaven has been an official “Refugee Welcome Zone”, welcoming hundreds of refugees from diverse countries in Africa and the Middle East as well as from Myanmar. This reflects the Department of Immigration and Citizenship’s drive to settle a fifth of Australia’s 13,750 humanitarian entrants a year directly in regional areas. In Easthaven’s schools—which is where I focused my research—almost all of the ESL students are from refugee backgrounds. Defining Resilience Much of the research on human resilience is grounded in psychology, with a capacity to “bounce back” from adverse experiences cited in many definitions of resilience (e.g. American Psychological Association). Bouncing back implies a relatively quick process, and a return to a state or form similar to that which existed before the encounter with adversity. Yet resilience often requires sustained effort and significant changes in identity. As Jerome Rugaruza, a former UNHCR refugee, says of his journey from the Democratic Republic of Congo to Australia: All the steps begin in the burning village: you run with nothing to eat, no clothes. You just go. Then you get to the refugee camp […] You have a little bread and you thank god you are safe. Then after a few years in the camp, you think about a future for your children. You arrive in Australia and then you learn a new language, you learn to drive. There are so many steps and not everyone can do it. (Milsom) Not everyone can do it, but a large majority do. Research by Graeme Hugo, for example, shows that although humanitarian settlers in Australia face substantial barriers to employment and initially have much higher unemployment rates than other immigrants, for most nationality groups this difference has disappeared by the second generation: “This is consistent with the sacrifice (or investment) of the first generation and the efforts extended to attain higher levels of education and English proficiency, thereby reducing the barriers over time.” (Hugo 35). Ingrid Poulson writes that “resilience is not just about bouncing. Bouncing […] is only a reaction. Resilience is about rising—you rise above it, you rise to the occasion, you rise to the challenge. Rising is an active choice” (47; my emphasis) I see resilience as involving mental and physical grit, coupled with creativity, aspiration and, crucially, agency. Dimensions of Resettlement To return to the story of 41-year-old Jerome Rugaruza, as related in a recent newspaper article: He [Mr Rugaruza] describes the experience of being a newly arrived refugee as being like that of a newborn baby. “You need special care; you have to learn to speak [English], eat the different food, create relationships, connections”. (Milsom) This is a key dimension of resettlement: the adult becomes like an infant again, shifting from someone who knows how things work and how to get by to someone who is likely to be, for a while, dependent on others for even the most basic things—communication, food, shelter, clothing, and social contact. The “special care” that most refugee arrivals need initially (and sometimes for a long time) often results in their being seen as deficient—in knowledge, skills, dispositions, and capacities as well as material goods (Keddie; Uptin, Wright and Harwood). As Fozdar and Hartley note: “The tendency to use a deficit model in refugee resettlement devalues people and reinforces the view of the mainstream population that refugees are a liability” (27). Yet unlike newborns, humanitarian settlers come to their new countries with rich social networks and extensive histories of experience and learning—resources that are in fact vital to their rebirth. Sisay (all names are pseudonyms), a year 11 student of Ethiopian heritage who was born in Kenya, told me with feeling: I had a life back in Africa [her emphasis]. It was good. Well, I would go back there if there’s no problems, which—is a fact. And I came here for a better life—yeah, I have a better life, there’s good health care, free school, and good environment and all that. But what’s that without friends? A fellow student, Celine, who came to Australia five years ago from Burundi via Uganda, told me in a focus group: Some teachers are really good but I think some other teachers could be a little bit more encouraging and understanding of what we’ve gone through, because [they] just look at you like “You’re year 11 now, you should know this” […] It’s really discouraging when [the teachers say] in front of the class, “Oh, you shouldn’t do this subject because you haven’t done this this this this” […] It’s like they’re on purpose to tell you “you don’t have what it takes; just give up and do something else.” As Uptin, Wright and Harwood note, “schools not only have the power to position who is included in schooling (in culture and pedagogy) but also have the power to determine whether there is room and appreciation for diversity” (126). Both Sisay and Celine were disheartened by the fact they felt some of their teachers, and many of their peers, had little interest in or understanding of their lives before they came to Australia. The teachers’ low expectations of refugee-background students (Keddie, Uptin, Wright and Harwood) contrasted with the students’ and their families’ high expectations of themselves (Brown, Miller and Mitchell; Harris and Marlowe). When I asked Sisay about her post-school ambitions, she said: “I have a good idea of my future […] write a documentary. And I’m working on it.” Celine’s response was: “I know I’m gonna do medicine, be a doctor.” A third girl, Lily, who came to Australia from Myanmar three years ago, told me she wanted to be an accountant and had studied accounting at the local TAFE last year. Joseph, a father of three who resettled from South Sudan seven years ago, stressed how important getting a job was to successful settlement: [But] you have to get a certificate first to get a job. Even the job of cleaning—when I came here I was told that somebody has to go to have training in cleaning, to use the different chemicals to clean the ground and all that. But that is just sweeping and cleaning with water—you don’t need the [higher-level] skills. Simple jobs like this, we are not able to get them. In regional Australia, employment opportunities tend to be limited (Fozdar and Hartley); the unemployment rate in Easthaven is twice the national average. Opportunities to study are also more limited than in urban centres, and would-be students are not always eligible for financial assistance to gain or upgrade qualifications. Even when people do have appropriate qualifications, work experience, and language proficiency, the colour of their skin may still mean they miss out on a job. Tilbury and Colic-Peisker have documented the various ways in which employers deflect responsibility for racial discrimination, including the “common” strategy (658) of arguing that while the employer or organisation is not prejudiced, they have to discriminate because of their clients’ needs or expectations. I heard this strategy deployed in an interview with a local businesswoman, Catriona: We were advertising for a new technician. And one of the African refugees came to us and he’d had a lot of IT experience. And this is awful, but we felt we couldn't give him the job, because we send our technicians into people's houses, and we knew that if a black African guy rocked up at someone’s house to try and fix their computer, they would not always be welcomed in all—look, it would not be something that [Easthaven] was ready for yet. Colic-Peisker and Tilbury (Refugees and Employment) note that while Australia has strict anti-discrimination legislation, this legislation may be of little use to the people who, because of the way they look and sound (skin colour, dress, accent), are most likely to face prejudice and discrimination. The researchers found that perceived discrimination in the labour market affected humanitarian settlers’ sense of satisfaction with their new lives far more than, for example, racist remarks, which were generally shrugged off; the students I interviewed spoke of racism as “expected,” but “quite rare.” Most of the people Colic-Peisker and Tilbury surveyed reported finding Australians “friendly and accepting” (33). Even if there is no active discrimination on the basis of skin colour in employment, education, or housing, or overt racism in social situations, visible difference can still affect a person’s sense of belonging, as Joseph recounts: I think of myself as Australian, but my colour doesn’t [laughs] […] Unfortunately many, many Australians are expecting that Australia is a country of Europeans … There is no need for somebody to ask “Where do you come from?” and “Do you find Australia here safe?” and “Do you enjoy it?” Those kind of questions doesn’t encourage that we are together. This highlights another dimension of resettlement: the journey from feeling “at home” to feeling “foreign” to, eventually, feeling at home again in the host country (Colic-Peisker and Tilbury, Refugees and Employment). In the case of visibly different settlers, however, this last stage may never be completed. Whether the questions asked of Joseph are well intentioned or not, their effect may be the same: they position him as a “forever foreigner” (Park). A further dimension of resettlement—one already touched on—is the degree to which humanitarian settlers actively manage their “rebirth,” and are allowed and encouraged to do so. A key factor will be their mastery of English, and Easthaven’s ESL teachers are thus pivotal in the resettlement process. There is little doubt that many of these teachers have gone to great lengths to help this cohort of students, not only in terms of language acquisition but also social inclusion. However, in some cases what is initially supportive can, with time, begin to undermine refugees’ maturity into independent citizens. Sharon, an ESL teacher at one of the schools, told me how she and her colleagues would give their refugee-background students lifts to social events: But then maybe three years down the track they have a car and their dad can drive, but they still won’t take them […] We arrive to pick them up and they’re not ready, or there’s five fantastic cars in the driveway, and you pick up the student and they say “My dad’s car’s much bigger and better than yours” [laughs]. So there’s an expectation that we’ll do stuff for them, but we’ve created that [my emphasis]. Other support services may have more complex interests in keeping refugee settlers dependent. The more clients an agency has, the more services it provides, and the longer clients stay on its books, the more lucrative the contract for the agency. Thus financial and employment imperatives promote competition rather than collaboration between service providers (Fozdar and Hartley; Sidhu and Taylor) and may encourage assumptions about what sorts of services different individuals and groups want and need. Colic-Peisker and Tilbury (“‘Active’ and ‘Passive’ Resettlement”) have developed a typology of resettlement styles—“achievers,” “consumers,” “endurers,” and “victims”—but stress that a person’s style, while influenced by personality and pre-migration factors, is also shaped by the institutions and individuals they come into contact with: “The structure of settlement and welfare services may produce a victim mentality, leaving members of refugee communities inert and unable to see themselves as agents of change” (76). The prevailing narrative of “the traumatised refugee” is a key aspect of this dynamic (Colic-Peisker and Tilbury, “‘Active’ and ‘Passive’ Resettlement”; Fozdar and Hartley; Keddie). Service providers may make assumptions about what humanitarian settlers have gone through before arriving in Australia, how they have been affected by their experiences, and what must be done to “fix” them. Norah, a long-time caseworker, told me: I think you get some [providers] who go, “How could you have gone through something like that and not suffered? There must be—you must have to talk about this stuff” […] Where some [refugees] just come with the [attitude] “We’re all born into a situation; that was my situation, but I’m here now and now my focus is this.” She cited failure to consider cultural sensitivities around mental illness and to recognise that stress and anxiety during early resettlement are normal (Tilbury) as other problems in the sector: [Newly arrived refugees] go through the “happy to be here” [phase] and now “hang on, I’ve thumped to the bottom and I’m missing my own foods and smells and cultures and experiences”. I think sometimes we’re just too quick to try and slot people into a box. One factor that appears to be vital in fostering and sustaining resilience is social connection. Norah said her clients were “very good on the mobile phone” and had links “everywhere,” including to family and friends in their countries of birth, transition countries, and other parts of Australia. A 2011 report for DIAC, Settlement Outcomes of New Arrivals, found that humanitarian entrants to Australia were significantly more likely to be members of cultural and/or religious groups than other categories of immigrants (Australian Survey Research). I found many examples of efforts to build both bonding and bridging capital (Putnam) in Easthaven, and I offer two examples below. Several people told me about a dinner-dance that had been held a few weeks before one of my visits. The event was organised by an African women’s group, which had been formed—with funding assistance—several years before. The dinner-dance was advertised in the local newspaper and attracted strong interest from a broad cross-section of Easthaveners. To Debbie, a counsellor, the response signified a “real turnaround” in community relations and was a big boon to the women’s sense of belonging. Erica, a teacher, told me about a cultural exchange day she had organised between her bush school—where almost all of the children are Anglo Australian—and ESL students from one of the town schools: At the start of the day, my kids were looking at [the refugee-background students] and they were scared, they were saying to me, "I feel scared." And we shoved them all into this tiny little room […] and they had no choice but to sit practically on top of each other. And by the end of the day, they were hugging each other and braiding their hair and jumping and playing together. Like Uptin, Wright and Harwood, I found that the refugee-background students placed great importance on the social aspects of school. Sisay, the girl I introduced earlier in this paper, said: “It’s just all about friendship and someone to be there for you […] We try to be friends with them [the non-refugee students] sometimes but sometimes it just seems they don’t want it.” Conclusion A 2012 report on refugee settlement services in NSW concludes that the state “is not meeting its responsibility to humanitarian entrants as well as it could” (Audit Office of New South Wales 2); moreover, humanitarian settlers in NSW are doing less well on indicators such as housing and health than humanitarian settlers in other states (3). Evaluating the effectiveness of formal refugee-centred programs was not part of my research and is beyond the scope of this paper. Rather, I have sought to reveal some of the ways in which the attitudes, assumptions, and everyday practices of service providers and members of the broader community impact on refugees' settlement experience. What I heard repeatedly in the interviews I conducted was that it was emotional and practical support (Matthews; Tilbury), and being asked as well as told (about their hopes, needs, desires), that helped Easthaven’s refugee settlers bear themselves into fulfilling new lives. References Audit Office of New South Wales. Settling Humanitarian Entrants in New South Wales—Executive Summary. May 2012. 15 Aug. 2013 ‹http://www.audit.nsw.gov.au/ArticleDocuments/245/02_Humanitarian_Entrants_2012_Executive_Summary.pdf.aspx?Embed=Y>. Australian Bureau of Statistics. 2011 Census QuickStats. Mar. 2013. 11 Aug. 2013 ‹http://www.censusdata.abs.gov.au/census_services/getproduct/census/2011/quickstat/0>. Australian Survey Research. Settlement Outcomes of New Arrivals—Report of Findings. Apr. 2011. 15 Aug. 2013 ‹http://www.immi.gov.au/media/publications/research/_pdf/settlement-outcomes-new-arrivals.pdf>. Brown, Jill, Jenny Miller, and Jane Mitchell. “Interrupted Schooling and the Acquisition of Literacy: Experiences of Sudanese Refugees in Victorian Secondary Schools.” Australian Journal of Language and Literacy 29.2 (2006): 150-62. Colic-Peisker, Val, and Farida Tilbury. “‘Active’ and ‘Passive’ Resettlement: The Influence of Supporting Services and Refugees’ Own Resources on Resettlement Style.” International Migration 41.5 (2004): 61-91. ———. Refugees and Employment: The Effect of Visible Difference on Discrimination—Final Report. Perth: Centre for Social and Community Research, Murdoch University, 2007. Fozdar, Farida, and Lisa Hartley. “Refugee Resettlement in Australia: What We Know and Need To Know.” Refugee Survey Quarterly 4 Jun. 2013. 12 Aug. 2013 ‹http://rsq.oxfordjournals.org/search?fulltext=fozdar&submit=yes&x=0&y=0>. Garcia Marquez, Gabriel. Love in the Time of Cholera. London: Penguin Books, 1989. Harris, Vandra, and Jay Marlowe. “Hard Yards and High Hopes: The Educational Challenges of African Refugee University Students in Australia.” International Journal of Teaching and Learning in Higher Education 23.2 (2011): 186-96. Hugo, Graeme. A Significant Contribution: The Economic, Social and Civic Contributions of First and Second Generation Humanitarian Entrants—Summary of Findings. Canberra: Department of Immigration and Citizenship, 2011. Keddie, Amanda. “Pursuing Justice for Refugee Students: Addressing Issues of Cultural (Mis)recognition.” International Journal of Inclusive Education 16.12 (2012): 1295-1310. Layton, Robyn. "Building Capacity to Ensure the Inclusion of Vulnerable Groups." Creating Our Future conference, Adelaide, 28 Jul. 2012. Milsom, Rosemarie. “From Hard Luck Life to the Lucky Country.” Sydney Morning Herald 20 Jun. 2013. 12 Aug. 2013 ‹http://www.smh.com.au/national/from-hard-luck-life-to-the-lucky-country-20130619-2oixl.html>. Park, Gilbert C. “’Are We Real Americans?’: Cultural Production of Forever Foreigners at a Diversity Event.” Education and Urban Society 43.4 (2011): 451-67. Poulson, Ingrid. Rise. Sydney: Pan Macmillan Australia, 2008. Putnam, Robert D. Bowling Alone: The Collapse and Revival of American Community. New York: Simon & Schuster, 2000. Sidhu, Ravinder K., and Sandra Taylor. “The Trials and Tribulations of Partnerships in Refugee Settlement Services in Australia.” Journal of Education Policy 24.6 (2009): 655-72. Tilbury, Farida. “‘I Feel I Am a Bird without Wings’: Discourses of Sadness and Loss among East Africans in Western Australia.” Identities: Global Studies in Culture and Power 14.4 (2007): 433-58. ———, and Val Colic-Peisker. “Deflecting Responsibility in Employer Talk about Race Discrimination.” Discourse & Society 17.5 (2006): 651-76. Uptin, Jonnell, Jan Wright, and Valerie Harwood. “It Felt Like I Was a Black Dot on White Paper: Examining Young Former Refugees’ Experience of Entering Australian High Schools.” The Australian Educational Researcher 40.1 (2013): 125-37.

Prelude: 2020 in Words Each year the Australian National Dictionary Centre, based at the Australian National University (ANU), selects “a word or expression that has gained prominence in the Australian social landscape”. In 2020, “iso” took out first place, with “bubble” following close behind. On the Centre’s website, Senior Researcher Mark Gywnn explains that “iso” was selected not only for its flexibility, merrily combining with other words to create new compound words (for instance “being in iso”, doing “iso baking” and putting on “iso weight”), but also because it “stood out as a characteristically Aussie abbreviation” (Australian National Dictionary Centre). Alongside the flexibility of the word “iso” and its affinity with the Australian English tradition of producing and embracing diminutives, iso’s appeal might well be that it does not carry the associations that the word “bubble” has acquired in the time of COVID. While COVID-19 has put many of us in various forms of “iso”, the media imagery—and indeed experiences—of many older people living in residential aged care during COVID has shifted some of the associations of the word “bubble”, heightening its associations with fragility and adding vulnerability and helplessness into the mix. 2020 was not the first time “bubble” has appeared in the Australian word of the year list. In 2018 “Canberra bubble” took out the first spot. What interests us about bubble’s runner-up position behind “iso” in 2020’s word of the year is what this might also reveal about the way ideas of independence vs dependence, and youthfulness vs aged underlie and inflect new usages of these words. In the era of COVID-19, the buoyancy of “iso” is tied to its association with a particular kind of Aussie-youth-speak, while the sense of heaviness and negative resonances that now accompany the word bubble are tied to its associations with the experiences of those in aged care. In 2020 “bubble”—a word that has primarily been associated with children and the child-like (bubble baths, bubble tea)—took on new associations and overtones. As the pandemic unfolded, “bubble” also became intertwined with media depictions of and popular discourses around those in later life, many of whom experienced “iso” much more brutally than the easy-Aussie-speak of “iso” would convey. There is much less play—and a lot less mingling—in the Australian National Dictionary Centre description of new uses of the word “bubble”: “a district, region, or a group of people viewed as a closed system, isolating from other districts, regions, or groups as a public health measure to limit the spread of Covid-19”. There have been various kinds of “closed system[s]”, isolated groups and regions constructed in the management of the pandemic, but there is one group—and one kind of location—that has been “bubbled” in quite specific ways. While the sectioning off and isolating of older age people in the name of protecting their health has often been ineffectively—and in some places, disastrously—managed in terms of disease prevention, it has been very effective in reducing the rights and voices of those it acts in the name of. Speaking from Ireland but commenting on the situation in the UK and parts of Europe, Anne Fuchs and colleagues write that “the discursive homogenization and ‘frailing’ of the over 65s meant that people in this category were an object of public discourse rather than participants in the debate” (2). In many instances the “bubbling” of older people, particularly those in aged care residences, has served to both isolate and render largely voiceless the residents of these care homes. Although the global impact of COVID-19 on the aged has been significant, including across many affluent societies, it has been particularly disastrous in Australia. At the time of writing (1 January 2021), of the 909 COVID-related deaths in Australia to date, 693 have been of people aged 80 or over: in other words, more than 75% of COVID-related deaths in Australia have been of people over 80. According to the federal government’s records of COVID-19 deaths by age group and sex, 685 of these deaths have been of aged care residents. It is not surprising therefore that many speak of the heavy impact of COVID-19 on older people as a form of genocide. Public discourse and government policies and priorities around COVID-19 have thrown into relief and exacerbated some of the deeply troubling ways that older people, particularly those living in aged care residences, are not recognised or treated as “equal partners in our future” (Royal Commission into Aged Care 1). Both the management of and public discourse around COVID-19 have highlighted and escalated the forms of ageism, especially ageism around later life, that have become embedded in Australian culture. In late 2019 the Royal Commission into Aged Care Quality and Safety released its Interim Report, titled simply Neglect. In the Foreword, the commissioners write: the Australian community generally accepts that older people have earned the chance to enjoy their later years, after many decades of contribution and hard work. Yet the language of public discourse is not respectful towards older people. Rather, it is about burden, encumbrance, obligation and whether taxpayers can afford to pay for the dependence of older people. (Royal Commission into Aged Care 1) Written and released before the COVID-19 pandemic, the Interim Report highlighted the “fundamental fact that our aged care system essentially depersonalises older people” (Royal Commission into Aged Care 6) and identified many ways “the aged care system fails to meet the needs of our older, often very vulnerable, citizens” (Royal Commission into Aged Care 1). In 2020 we saw some of the effects of these failures in the often disastrous mismanagement of disease transmission prevention in many aged care residences in Australia. Equally troubling, the resulting deaths have at times been accompanied by a general acceptance of the loss of so many in later life to COVID-19. The fact that these deaths are often regarded as somehow more inevitable, or as less significant than the deaths of others, is an indication of how deeply “Australia has drifted into an ageist mindset that undervalues older people and limits their possibilities” (Royal Commission into Aged Care 1). It assumes that one’s later-life years are of less significance and value (to oneself, to the community) than one’s younger years. At various times in the pandemic, sizable parts of the global population have been variously asked, advised, or required by their governments to remain within their household or residential “bubble”. These COVID-related “bubbles” are more buoyant for some. Jackie Gulland has written a feminist analysis of the ways that the UK COVID-19 lockdown rules are premised on “neo-liberal assumptions about the family as autonomous and sufficient for the provision of reproductive labour” (330). In many places the requirement to stay within one’s “household bubble” both assumes that the home is safe for all, and that most care and dependency requirements are provided and received within a household. As Gulland’s essay demonstrates, the idea of the household bubble constructs an image or idea of who and what constitutes a household, and which relationships “count”. Drawing on critiques of neo-liberal and able-ist ideas about autonomy by feminist and disability scholars, Gulland “shows how the failure of policymakers to take account of interdependency has made lockdown more difficult for carers and those in receipt of care” (330). In this essay we look at some of the ways that the required and/or imagined COVID-19 bubbles for people in later life are thought of differently to the COVID-19 bubbles that younger, and mixed age, households are imagined as forming. This is particularly the case, we argue, for those in aged care residences. Younger and mixed age COVID bubbles often include extended or linked households (as we will discuss below in relation to the idea of the compassionate bubble) and function as a bubble that can link and enclose. In contrast, COVID bubbles in and for aged care and those in later life, work to isolate and separate. They function as bubbles that close off and shut out, as if placing the older person and older people behind glass (in some cases, quite literally). Likewise, while the COVID-19 bubbles for the “general” population (a category from which those in later life are often excluded) are regarded as temporary structures that will in time be dissolved to re-allow social movement and intermingling, the later life and aged care COVID-19 bubble is imagined very differently. This is because it is overlaid upon a pre-existing conception of later life—and in particular the fourth age—as itself a kind of bubbled existence, a fragile state held somewhat separate and apart from the general population and moving inexorably toward death—a bubble that pops. Bubbling the Fourth Age The idea that later life can be divided into different stages and ages has a long history, although the shape, meaning and valuing of different ages in later life is historically specific. Back in the late 1980s the Cambridge historian Peter Laslett proposed that rather than falling into three main stages—childhood, adulthood and old age—there are in fact four stages and that “later life can be divided into a ‘third age’ and a ‘fourth age’” (Gilleard and Higgs, “The Fourth Age” 368). Laslett’s distinction between a third age (active and characterised by personal fulfillment) and a fourth age (for Laslett an age of infirmity) has become increasingly significant in both age studies and in the provision and imagining of aged care. While the third age is increasingly depicted as something that, when managed “successfully”, can expand and fill with rich experiences and rewards (assuming one has the economic and social privilege and mobility to embrace these rich offerings—see Katz and McHugh cited in Zeilig, “Critical Use of Narrative”), the fourth age, on the other hand, is associated with frailty, increased dependence, vulnerability, precarity (see Lloyd; Gilleard and Higgs; and Morganroth Gullette on the fourth age). Of course, experiences of vulnerability, dependency and precarity run throughout the life course and cannot be reduced to chronological age. However, the distinction between a third and fourth age tends to assume that once one “leaves” the third age, it is a one-way path to “the three ‘Ds’: decrepitude, dependence, and death” (Laslett). The fourth age becomes associated with those aspects of ageing that are culturally rejected and pushed aside—in particular physical dependence which, as in much able-ist thinking, is rendered abject. As Morganroth Gullette has argued, a “savage contradiction” underlies and fuels this distinction, as “fantasies of the longevity bonanza proliferate alongside growing terrors of living too long” and becoming a “‘burden’” (21). In other words, those aspects of ageing—indeed those aspects of being human—that are seen as undesirable and/or abject are associated with the fourth age and imagined as somehow exclusive to it: they are placed elsewhere, contained in a fourth age “bubble”. The understanding of the fourth age as a kind of bubble is evident in and enabled by various kinds of cultural representations and institutional discourses around later life, including the kind of language used (particularly language connoting precarity and fragility and liminality) and recurrent media imagery in which people in their “fourth age” are depicted as mentally and physically out of reach (for instance isolated behind glass). Legislation around the movements of residents, visitors, and staff in aged care residence does not simply create “protective” bubbles around aged care residences but also constructs and imagines these residences and their inhabitants as “bubbled”, removed, and voiceless. Vulnerability, ephemerality, precarity and decline have become increasingly significant in representations of and discourses around ageing. Much of the media coverage of those in later life, particularly those living in aged care residences, has further fuelled what Sally Chivers has called the “nursing home specter” and delivered, in heightened and often spectacularised form, the “life-course narrative that dominant culture provides—an unliveable mind and unrecognizable body, mountainous expense” (Morganroth Gullette, 24). The discourse on ageing is characterised by the use of metaphor and metonymy, of which “the bubble” or “bubbling” is only one notable example. The culture of fear that surrounds the fourth age stems from the presumption that ageing inevitably leads to decay and decline in quality of life, and that the experience of ageing is characterised by various forms of physical and cognitive deterioration, such as dementia. Cultural gerontologist Hannah Zeilig has drawn attention to the pervasive use of metaphors—in both medical journals and mass media reports—to describe the experience of living with dementia. These metaphors attempt to capture and simplify the complexities of being, speaking, and knowing experienced by people with dementia. They are frequently used to communicate these experiences to people who do not live with dementia. The cultural metaphors of dementia are potent examples of ageism. They are not neutral in their connotations or implicit value judgements. These metaphors reveal wider social anxieties around ageing, despite the fact that people in their 40s and 50s can have dementia (Dementia Australia). As Zeilig has pointed out, many of these metaphors have presented a negative framing of dementia, describing the rising numbers of dementia diagnoses in apocalyptic, biblical terms such as “plague”, “crisis”, and “epidemic” (“Cultural Metaphor” 260). While this hyperbole may be grounded in statistics and the realities of an ageing population, it has nevertheless been alarming. This rhetoric has often been a necessary tactic for dementia organisations as part of their efforts to secure media coverage, raise public awareness of dementia, and lobby for increased government and private investment in funding research and support services. Despite these noble intentions, this rhetoric can risk excluding or marginalising the voices of people living with dementia. Some of the metaphors that have been used to describe dementia are particularly dehumanising and stigmatising, such as the perception of Alzheimer’s disease as a form of “living death”. This conception of Alzheimer’s, which Susan M. Behuniak has observed in both scholarly and popular discourse, elicits strong negative emotional responses of revulsion and fear. It constructs people with Alzheimer’s as abject zombie-like figures living a half-life or twilight existence. These trends in dementia discourse that Zeilig and Behuniak identified in the first half of the 2010s are also apparent in media imagery and discourse about older people in the COVID-19 pandemic. Much like the cultural narratives of dementia, these representations often reinforce the fourth age’s association with forms of vulnerability, decline and decay that are rendered abject. In contrast to this negative framing of both dementia and the fourth age, the trope of “living in a bubble” can also present a more ambivalent conception of both living with dementia and, by extension, the sociocultural experience of living in the fourth age during the time of COVID-19. “Bubbling” can serve a protective function for the person living with dementia by reducing sensory overload and cognitive confusion that may lead to anxiety and emotional distress. In dementia care, bubble wands and bubble wrap are two of the most commonly used tools in sensory therapy for reducing anxiety and agitation, and providing comfort (DailyCaring). These examples remind us of the materiality of the bubble, which functions as both cultural trope and material condition that affects people’s lives (to borrow from Helen Deutsch and Felicity Nussbaum, cited in Vivian Sobchack’s essay on metaphor and materiality). Within the diversity and range of caring practices encompassed by the trope of “bubbling”, there is clear potential for the bubble to be enabling, rather than disabling, if it is used to enhance quality of life and wellbeing for older people, rather than to separate, marginalise and isolate. Despite the multivalent possibilities of the bubble for enhancing quality of life for people with dementia, the bubble’s association with precarity has been heightened by its deployment to protect older people during the COVID-19 pandemic. This is a source of ambivalence around the COVID-19 bubble, a public health response that is acknowledged as having both protective and harmful effects. It involves “bubbling” older people, especially those living in residential care, by physically isolating them and limiting their contact with family and friends to conversations mediated by digital technology or a windowpane. By restricting physical and direct contact with the outside world in order to reduce and contain transmission of the virus, the COVID-19 bubble is intended to protect the physical health of older adults. But as Karra Harrington and Martin J. Sliwinski caution, this can also risk the cognitive health and mental wellbeing of older people by creating social isolation. These concerns about the negative health impacts of the COVID-19 bubble compound the existing popular understanding of late life as isolated and isolating, perpetuating the ageist assumptions that characterise the social imaginary around the fourth age. Creating Compassionate Bubbles The distress of separation caused by COVID-19 lockdowns and restrictions is felt by all generations, not just older people. Recognising the costs to our emotional and mental wellbeing of living in isolation to protect our bodies and our communities from viral invasion, Australian epidemiologist Mary-Louise McLaws has called for “a compassionate germ bubble”, modelled on New Zealand’s concept of an extended bubble that allows close contacts beyond one household. This alternative approach to “bubbling” is designed to strike a better balance between physical and mental health. Writing during Melbourne’s strict and prolonged lockdown following a second wave of cases in the winter of 2020, McLaws argued that “a compassionate germ bubble may foster resilience by reducing a sense of isolation for people living alone and friends, extended family and partners distressed by the separation”. There have been a number of creative and compassionate responses to the necessity of the COVID-19 bubble for protecting those most vulnerable to the virus. Aged care residences have developed innovative ways to safely maintain in-person visits and provide opportunities for face-to-face contact between residents and their families and friends. One example reported in the Australian media (Steger) is “The Window of Love” in Perth, which demonstrates the positive potential of the bubble—represented here as a pane of glass bordered by a painted frame—for facilitating social connection and supporting wellbeing despite restrictions on physical contact. The media reporting of these innovations tends to spectacularise the residents of these homes, reinforcing their fragility and vulnerability as they are framed behind plastic or glass. In December 2020, international media outlets The Guardian, RTE News, and Star Media posted a Reuters video story on their respective YouTube channels about a “hug bubble” created in an aged care home in Jeumont, France. This inflatable plastic tunnel allows physical touch between those living in the home and those outside it through hermetically sealed sleeves. Separating the resident from their visitors is a clear plastic sheet, which is disinfected by staff in between each visit. Recognising the importance of physical contact for wellbeing, nursing staff reported that the hug bubble has brought comfort to the residents, whose previous contact with family and friends since the outbreak of COVID-19 in March 2020 had been limited to video calls or talking through a window. Viewer comments reveal divergent responses to this media story across all three YouTube channels. Some viewers applaud the innovation while others disparage the hug bubble as “cruel” and “disgraceful”. Other comments register viewers’ ambivalence, recognising the good intentions behind the idea while despairing at the need for it. Several comments offer a snapshot of the cynical, often incoherent views about the pandemic commonly found on social media platforms like Facebook and Twitter, while also demonstrating the persistence of ageist attitudes that regard the elderly as a burden. These negative responses are striking in contrast with the positive framing of the original media report, which is presented as a “feel good” human interest story through brief interviews with family members and nursing home staff, reflecting on the residents’ experiences using the hug bubble. This positive framing is reinforced by the gentle music track accompanying the video posted on the RTE News channel. Beyond the institutional context of aged care residences, many families and communities have also engineered solutions to reduce the stress of separation. Craving physical contact after months of isolation, they have embraced the materiality and tactility inherent in the bubble trope. People have improvised using household objects, such as plastic sleeves attached to transparent shower curtains, to build “cuddle curtains”, and “hug machines” to enable safe—and playful—physical contact. These innovations and adaptations tap into the bubble’s playful qualities, while also “going viral” as families document their creativity, delight and joy through their own video stories shared on YouTube. As we move into the second year of the COVID-19 pandemic, with case numbers and the death toll continuing to climb globally, the concept of the COVID-19 bubble and its role in protecting the community will continue to be debated, refined and reconfigured in both public health responses and media discourse. Despite Australia’s relatively good fortune in terms of total number of COVID-related deaths compared to other Western nations such as the US and the UK, the disproportionately high number of deaths among Australians in aged care is a sobering reminder of the systemic failures in Australia’s aged care residences. As we move in and out of periods of social isolation, restrictions and lockdowns, it will become increasingly important to address the mental health impacts of “living in a bubble” and to consider creative, compassionate alternatives that challenge ageism and maintain quality of life for fourth age Australians. *** As COVID-19 and its management continue to reshape our world(s) and our relations to each other, its impacts continue to be unevenly felt, particularly for those in later life. For this reason, it becomes increasingly important to be alert to the ways in which “bubbling” the fourth age in response to COVID-19 risks reinforcing a homogenising view of older people as vulnerable and isolated, defenceless against viral invasion and voiceless in expressing agency and maintaining social connection. This essay responds to Hannah Zeilig’s earlier call to “radically rethink the ways in which age and ageing have been culturally configured” (“Critical Use of Narrative” 16). One of the purposes of this essay has been to critically assess some of the ways that the relatively new discourse of a fourth age—as somehow both qualitatively and quantifiably different to and separate from the third age—entails a homogenising view of older people. This view has enabled forms of ageism that have often been particularly brutal in their impact during the pandemic. In this essay we have argued that popular conceptions of and public health discourse and policy around the fourth age have often enabled—or, at the very least, supported—forms of ageism. This ageism has been further heightened through both the discourse and the imagery of the COVID-19 bubble. The fourth age, we argued, has often been understood as bubble-like: as a “stage” of life when one is somehow separated from the larger community and culture. The fourth age is configured as physically fragile and precarious, transient and temporary, ephemeral, and enclosed in—and as—its own world. Created in the name of protecting “our most vulnerable”, the bubble in the time of COVID-19 has heightened these pre-existing social anxieties around the fourth age. The challenge, as we move into the second year of the pandemic in Australia, is to find new ways of protecting the health and wellbeing of people in later life, while creating opportunities for connection, agency and play that are supported, rather than hindered, by the COVID-19 bubble. References Australian National Dictionary Centre. “2020 Word of the Year.” Canberra: School of Literature, Languages and Linguistics, ANU College of Arts and Social Sciences, Australian National University. 17 Nov. 2020. 12 Jan. 2021 <https://slll.cass.anu.edu.au/centres/andc/news/2020-word-year>. Behuniak, Susan M. “The Living Dead? The Construction of People with Alzheimer’s Disease as Zombies.” Ageing & Society 21 (2011): 70–92. 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Introduction: Bubbles and Sport The ephemeral materiality of bubbles – beautiful, spectacular, and distracting but ultimately fragile – when applied to protect or conserve in the interests of sport-media profit, creates conditions that exacerbate existing inequalities in sport and society. Bubbles are usually something to watch, admire, and chase after in their brief yet shiny lives. There is supposed to be, technically, nothing inside them other than one or more gasses, and yet we constantly refer to people and objects being inside bubbles. The metaphor of the bubble has been used to describe the life of celebrities, politicians in purpose-built capital cities like Canberra, and even leftist, environmentally activist urban dwellers. The metaphorical and material qualities of bubbles are aligned—they cannot be easily captured and are liable to change at any time. In this article we address the metaphorical sporting bubble, which is often evoked in describing life in professional sport. This is a vernacular term used to capture and condemn the conditions of life of elite sportspeople (usually men), most commonly after there has been a sport-related scandal, especially of a sexual nature (Rowe). It is frequently paired with connotatively loaded adjectives like pampered and indulged. The sporting bubble is rarely interrogated in academic literature, the concept largely being left to the media and moral entrepreneurs. It is represented as involving a highly privileged but also pressurised life for those who live inside it. A sporting bubble is a world constructed for its most prized inhabitants that enables them to be protected from insurgents and to set the terms of their encounters with others, especially sport fans and disciplinary agents of the state. The Covid-19 pandemic both reinforced and reconfigured the operational concept of the bubble, re-arranging tensions between safety (protecting athletes) and fragility (short careers, risks of injury, etc.) for those within, while safeguarding those without from bubble contagion. Privilege and Precarity Bubble-induced social isolation, critics argue, encourages a loss of perspective among those under its protection, an entitled disconnection from the usual rules and responsibilities of everyday life. For this reason, the denizens of the sporting bubble are seen as being at risk to themselves and, more troublingly, to those allowed temporarily to penetrate it, especially young women who are first exploited by and then ejected from it (Benedict). There are many well-documented cases of professional male athletes “behaving badly” and trying to rely on institutional status and various versions of the sporting bubble for shelter (Flood and Dyson; Reel and Crouch; Wade). In the age of mobile and social media, it is increasingly difficult to keep misbehaviour in-house, resulting in a slew of media stories about, for example, drunkenness and sexual misconduct, such as when then-Sydney Roosters co-captain Mitchell Pearce was suspended and fined in 2016 after being filmed trying to force an unwanted kiss on a woman and then simulating a lewd act with her dog while drunk. There is contestation between those who condemn such behaviour as aberrant and those who regard it as the conventional expression of youthful masculinity as part of the familiar “boys will be boys” dictum. The latter naturalise an inequitable gender order, frequently treating sportsmen as victims of predatory women, and ignoring asymmetries of power between men and women, especially in homosocial environments (Toffoletti). For those in the sporting bubble (predominantly elite sportsmen and highly paid executives, also mostly men, with an array of service staff of both sexes moving in and out of it), life is reflected for those being protected via an array of screens (small screens in homes and indoor places of entertainment, and even smaller screens on theirs and others’ phones, as well as huge screens at sport events). These male sport stars are paid handsomely to use their skill and strength to perform for the sporting codes, their every facial expression and bodily action watched by the media and relayed to audiences. This is often a precarious existence, the usually brief career of an athlete worker being dependent on health, luck, age, successful competition with rivals, networks, and club and coach preferences. There is a large, aspirational reserve army of athletes vying to play at the elite level, despite risks of injury and invasive, life-changing medical interventions. Responsibility for avoiding performance and image enhancing drugs (PIEDs) also weighs heavily on their shoulders (Connor). Professional sportspeople, in their more reflective moments, know that their time in the limelight will soon be up, meaning that getting a ticket to the sporting bubble, even for a short time, can make all the difference to their post-sport lives and those of their families. The most vulnerable of the small minority of participants in sport who make a good, short-term living from it are those for whom, in the absence of quality education and prior social status, it is their sole likely means of upward social mobility (Spaaij). Elite sport performers are surrounded by minders, doctors, fitness instructors, therapists, coaches, advisors and other service personnel, all supporting athletes to stay focussed on and maximise performance quality to satisfy co-present crowds, broadcasters, sponsors, sports bodies and mass media audiences. The shield offered by the sporting bubble supports the teleological win-at-all-costs mentality of professional sport. The stakes are high, with athlete and executive salaries, sponsorships and broadcasting deals entangled in a complex web of investments in keeping the “talent” pivotal to the “attention economy” (Davenport and Beck)—the players that provide the content for sale—in top form. Yet, the bubble cannot be entirely secured and poor behaviour or performance can have devastating effects, including permanent injury or disability, mental illness and loss of reputation (Rowe, “Scandals and Sport”). Given this fragile materiality of the sporting bubble, it is striking that, in response to the sudden shutdown following the economic and health crisis caused by the 2020 global pandemic, the leaders of professional sport decided to create more of them and seek to seal the metaphorical and material space with unprecedented efficiency. The outcome was a multi-sided tale of mobility, confinement, capital, labour, and the gendering of sport and society. The Covid-19 Gilded Cage Sociologists such as Zygmunt Bauman and John Urry have analysed the socio-politics of mobilities, whereby some people in the world, such as tourists, can traverse the globe at their leisure, while others remain fixed in geographical space because they lack the means to be mobile or, in contrast, are involuntarily displaced by war, so-called “ethnic cleansing”, famine, poverty or environmental degradation. The Covid-19 global pandemic re-framed these matters of mobilities (Rowe, “Subjecting Pandemic Sport”), with conventional moving around—between houses, businesses, cities, regions and countries—suddenly subjected to the imperative to be static and, in perniciously unreflective technocratic discourse, “socially distanced” (when what was actually meant was to be “physically distanced”). The late-twentieth century analysis of the “risk society” by Ulrich Beck, in which the mysterious consequences of humans’ predation on their environment are visited upon them with terrifying force, was dramatically realised with the coming of Covid-19. In another iteration of the metaphor, it burst the bubble of twenty-first century global sport. What we today call sport was formed through the process of sportisation (Maguire), whereby hyper-local, folk physical play was reconfigured as multi-spatial industrialised sport in modernity, becoming increasingly reliant on individual athletes and teams travelling across the landscape and well over the horizon. Co-present crowds were, in turn, overshadowed in the sport economy when sport events were taken to much larger, dispersed audiences via the media, especially in broadcast mode (Nicholson, Kerr, and Sherwood). This lucrative mediation of professional sport, though, came with an unforgiving obligation to generate an uninterrupted supply of spectacular live sport content. The pandemic closed down most sports events and those that did take place lacked the crucial participation of the co-present crowd to provide the requisite event atmosphere demanded by those viewers accustomed to a sense of occasion. Instead, they received a strange spectacle of sport performers operating in empty “cathedrals”, often with a “faked” crowd presence. The mediated sport spectacle under the pandemic involved cardboard cut-out and sex doll spectators, Zoom images of fans on large screens, and sampled sounds of the crowd recycled from sport video games. Confected co-presence produced simulacra of the “real” as Baudrillardian visions came to life. The sporting bubble had become even more remote. For elite sportspeople routinely isolated from the “common people”, the live sport encounter offered some sensory experience of the social – the sounds, sights and even smells of the crowd. Now the sporting bubble closed in on an already insulated and insular existence. It exposed the irony of the bubble as a sign of both privileged mobility and incarcerated athlete work, both refuge and prison. Its logic of contagion also turned a structure intended to protect those inside from those outside into, as already observed, a mechanism to manage the threat of insiders to outsiders. In Australia, as in many other countries, the populace was enjoined by governments and health authorities to help prevent the spread of Covid-19 through isolation and immobility. There were various exceptions, principally those classified as essential workers, a heterogeneous cohort ranging from supermarket shelf stackers to pharmacists. People in the cultural, leisure and sports industries, including musicians, actors, and athletes, were not counted among this crucial labour force. Indeed, the performing arts (including dance, theatre and music) were put on ice with quite devastating effects on the livelihoods and wellbeing of those involved. So, with all major sports shut down (the exception being horse racing, which received the benefit both of government subsidies and expanding online gambling revenue), sport organisations began to represent themselves as essential services that could help sustain collective mental and even spiritual wellbeing. This case was made most aggressively by Australian Rugby League Commission Chairman, Peter V’landys, in contending that “an Australia without rugby league is not Australia”. In similar vein, prominent sport and media figure Phil Gould insisted, when describing rugby league fans in Western Sydney’s Penrith, “they’re lost, because the football’s not on … . It holds their families together. People don’t understand that … . Their life begins in the second week of March, and it ends in October”. Despite misgivings about public safety and equality before the pandemic regime, sporting bubbles were allowed to form, re-form and circulate. The indefinite shutdown of the National Rugby League (NRL) on 23 March 2020 was followed after negotiation between multiple entities by its reopening on 28 May 2020. The competition included a team from another nation-state (the Warriors from Aotearoa/New Zealand) in creating an international sporting bubble on the Central Coast of New South Wales, separating them from their families and friends across the Tasman Sea. Appeals to the mental health of fans and the importance of the NRL to myths of “Australianness” notwithstanding, the league had not prudently maintained a financial reserve and so could not afford to shut down for long. Significant gambling revenue for leagues like the NRL and Australian Football League (AFL) also influenced the push to return to sport business as usual. Sport contests were needed in order to exploit the gambling opportunities – especially online and mobile – stimulated by home “confinement”. During the coronavirus lockdowns, Australians’ weekly spending on gambling went up by 142 per cent, and the NRL earned significantly more than usual from gambling revenue—potentially $10 million above forecasts for 2020. Despite the clear financial imperative at play, including heavy reliance on gambling, sporting bubble-making involved special licence. The state of Queensland, which had pursued a hard-line approach by closing its borders for most of those wishing to cross them for biographical landmark events like family funerals and even for medical treatment in border communities, became “the nation's sporting hub”. Queensland became the home of most teams of the men’s AFL (notably the women’s AFLW season having been cancelled) following a large Covid-19 second wave in Melbourne. The women’s National Netball League was based exclusively in Queensland. This state, which for the first time hosted the AFL Grand Final, deployed sport as a tool in both national sports tourism marketing and internal pre-election politics, sponsoring a documentary, The Sporting Bubble 2020, via its Tourism and Events arm. While Queensland became the larger bubble incorporating many other sporting bubbles, both the AFL and the NRL had versions of the “fly in, fly out” labour rhythms conventionally associated with the mining industry in remote and regional areas. In this instance, though, the bubble experience did not involve long stays in miners’ camps or even the one-night hotel stopovers familiar to the popular music and sport industries. Here, the bubble moved, usually by plane, to fulfil the requirements of a live sport “gig”, whereupon it was immediately returned to its more solid bubble hub or to domestic self-isolation. In the space created between disciplined expectation and deplored non-compliance, the sporting bubble inevitably became the scrutinised object and subject of scandal. Sporting Bubble Scandals While people with a very low risk of spreading Covid-19 (coming from areas with no active cases) were denied entry to Queensland for even the most serious of reasons (for example, the death of a child), images of AFL players and their families socialising and enjoying swimming at the Royal Pines Resort sporting bubble crossed our screens. Yet, despite their (players’, officials’ and families’) relative privilege and freedom of movement under the AFL Covid-Safe Plan, some players and others inside the bubble were involved in “scandals”. Most notable was the case of a drunken brawl outside a Gold Coast strip club which led to two Richmond players being “banished”, suspended for 10 matches, and the club fined $100,000. But it was not only players who breached Covid-19 bubble protocols: Collingwood coaches Nathan Buckley and Brenton Sanderson paid the $50,000 fine imposed on the club for playing tennis in Perth outside their bubble, while Richmond was fined $45,000 after Brooke Cotchin, wife of team captain Trent, posted an image to Instagram of a Gold Coast day spa that she had visited outside the “hub” (the institutionally preferred term for bubble). She was subsequently distressed after being trolled. Also of concern was the lack of physical distancing, and the range of people allowed into the sporting bubble, including babysitters, grandparents, and swimming coaches (for children). There were other cases of players being caught leaving the bubble to attend parties and sharing videos of their “antics” on social media. Biosecurity breaches of bubbles by players occurred relatively frequently, with stern words from both the AFL and NRL leaders (and their clubs) and fines accumulating in the thousands of dollars. Some people were also caught sneaking into bubbles, with Lekahni Pearce, the girlfriend of Swans player Elijah Taylor, stating that it was easy in Perth, “no security, I didn’t see a security guard” (in Barron, Stevens, and Zaczek) (a month later, outside the bubble, they had broken up and he pled guilty to unlawfully assaulting her; Ramsey). Flouting the rules, despite stern threats from government, did not lead to any bubble being popped. The sport-media machine powering sporting bubbles continued to run, the attendant emotional or health risks accepted in the name of national cultural therapy, while sponsorship, advertising and gambling revenue continued to accumulate mostly for the benefit of men. Gendering Sporting Bubbles Designed as biosecurity structures to maintain the supply of media-sport content, keep players and other vital cogs of the machine running smoothly, and to exclude Covid-19, sporting bubbles were, in their most advanced form, exclusive luxury camps that illuminated the elevated socio-cultural status of sportsmen. The ongoing inequalities between men’s and women’s sport in Australia and around the world were clearly in evidence, as well as the politics of gender whereby women are obliged to “care” and men are enabled to be “careless” – or at least to manage carefully their “duty of care”. In Australia, the only sport for women that continued during the height of the Covid-19 lockdown was netball, which operated in a bubble that was one of sacrifice rather than privilege. With minimum salaries of only $30,000 – significantly less than the lowest-paid “rookies” in the AFL – and some being mothers of small children and/or with professional jobs juggled alongside their netball careers, these elite sportswomen wanted to continue to play despite the personal inconvenience or cost (Pavlidis). Not one breach of the netballers out of the bubble was reported, indicating that they took their responsibilities with appropriate seriousness and, perhaps, were subjected to less scrutiny than the sportsmen accustomed to attracting front-page headlines. National Netball League (also known after its Queensland-based naming rights sponsor as Suncorp Super Netball) players could be regarded as fortunate to have the opportunity to be in a bubble and to participate in their competition. The NRL Women’s (NRLW) Premiership season was also completed, but only involved four teams subject to fly in, fly out and bubble arrangements, and being played in so-called curtain-raiser games for the NRL. As noted earlier, the AFLW season was truncated, despite all the prior training and sacrifice required of its players. Similarly, because of their resource advantages, the UK men’s and boy’s top six tiers of association football were allowed to continue during lockdown, compared to only two for women and girls. In the United States, inequalities between men’s and women’s sports were clearly demonstrated by the conditions afforded to those elite sportswomen inside the Women’s National Basketball Association (WNBA) sport bubble in the IMG Academy in Florida. Players shared photos of rodent traps in their rooms, insect traps under their mattresses, inedible food and blocked plumbing in their bubble accommodation. These conditions were a far cry from the luxury usually afforded elite sportsmen, including in Florida’s Walt Disney World for the men’s NBA, and is just one of the many instances of how gendered inequality was both reproduced and exacerbated by Covid-19. Bursting the Bubble As we have seen, governments and corporate leaders in sport were able to create material and metaphorical bubbles during the Covid-19 lockdown in order to transmit stadium sport contests into home spaces. The rationale was the importance of sport to national identity, belonging and the routines and rhythms of life. But for whom? Many women, who still carry the major responsibilities of “care”, found that Covid-19 intensified the affective relations and gendered inequities of “home” as a leisure site (Fullagar and Pavlidis). Rates of domestic violence surged, and many women experienced significant anxiety and depression related to the stress of home confinement and home schooling. During the pandemic, women were also more likely to experience the stress and trauma of being first responders, witnessing virus-related sickness and death as the majority of nurses and care workers. They also bore the brunt of much of the economic and employment loss during this time. Also, as noted above, livelihoods in the arts and cultural sector did not receive the benefits of the “bubble”, despite having a comparable claim to sport in contributing significantly to societal wellbeing. This sector’s workforce is substantially female, although men dominate its senior roles. Despite these inequalities, after the late March to May hiatus, many elite male sportsmen – and some sportswomen - operated in a bubble. Moving in and out of them was not easy. Life inside could be mentally stressful (especially in long stays of up to 150 days in sports like cricket), and tabloid and social media troll punishment awaited those who were caught going “over the fence”. But, life in the sporting bubble was generally preferable to the daily realities of those afflicted by the trauma arising from forced home confinement, and for whom watching moving sports images was scant compensation for compulsory immobility. The ethical foundation of the sparkly, ephemeral fantasy of the sporting bubble is questionable when it is placed in the service of a voracious “media sports cultural complex” (Rowe, Global Media Sport) that consumes sport labour power and rolls back progress in gender relations as a default response to a global pandemic. Covid-19 dramatically highlighted social inequalities in many areas of life, including medical care, work, and sport. For the small minority of people involved in sport who are elite professionals, the only thing worse than being in a sporting bubble during the pandemic was not being in one, as being outside precluded their participation. Being inside the bubble was a privilege, albeit a dubious one. But, as in wider society, not all sporting bubbles are created equal. Some are more opulent than others, and the experiences of the supporting and the supported can be very different. The surface of the sporting bubble may be impermanent, but when its interior is opened up to scrutiny, it reveals some very durable structures of inequality. Bubbles are made to burst. They are, by nature, temporary, translucent structures created as spectacles. As a form of luminosity, bubbles “allow a thing or object to exist only as a flash, sparkle or shimmer” (Deleuze, 52). In echoing Deleuze, Angela McRobbie (54) argues that luminosity “softens and disguises the regulative dynamics of neoliberal society”. The sporting bubble was designed to discharge that function for those millions rendered immobile by home confinement legislation in Australia and around the world, who were having to deal with the associated trauma, risk and disadvantage. 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This article is about refugees’ and migrants’ dreams of home and family and stems from an Australian Research Council Linkage Grant, “A Hand Up: Disrupting the Communication of Intergenerational Welfare Dependency” (LP140100935), with Partner Organisation St Vincent de Paul Society (WA) Inc. (Vinnies). A Vinnies-supported refugee and migrant support centre was chosen as one of the hubs for interviewee recruitment, given that many refugee families experience persistent and chronic economic disadvantage. The de-identified name for the drop-in language-teaching and learning social facility is the Migrant and Refugee Homebase (MARH). At the time of the research, in 2018, refugee and forced migrant families from Syria, Iraq, and Afghanistan constituted MARH’s primary membership base. MARH provided English language classes alongside other educational and financial support. It could also organise provision of emergency food and was a conduit for furniture donated by Australian families. Crucially, MARH operated as a space in which members could come together to build shared community.As part of her role, the researcher was introduced to Sara (de-identified), a mother-tongue Arabic speaker and the centre’s coordinator. Sara had personal experience of being a refugee, as well as being MARH’s manager, and she became both a point of contact for the researcher team, an interpreter/translator, and an empathetic listener as refugees shared their stories. Dreams of home and family emerged throughout the interviews as a vital part of participants’ everyday lives. These dreams and hopes were developed in the face of what was, for some, a nightmare of adversity. Underpinning participants’ sense of agency, subjectivity and resilience, Badiou argues (93, as noted in Jackson, 241) that hope can appear as a basic form of patience or perseverance rather than a dream for justice. Instead of imagining an improvement in personal circumstances, the dream is one of simply moving forward rather than backward. While dreams of being reunited with family are rooted in the past and project a vision of a family which no longer exists, these dreams help fashion a future which once again contains a range of possibilities.Although Sara volunteered her time on the research project as part of her commitment to Vinnies, she was well-known to interviewees as a MARH staff member and, in many cases, a friend and confidante. While Sara’s manager role implies an imbalance of power, with Sara powerful and participants comparatively less so, the majority of the information explored in the interviews pertained to refugees’ experiences of life outside the sphere in which MARH is engaged, so there was limited risk of the data being sanitised to reflect positively upon MARH. The specialist information and understandings that the interviewees shared positions them as experts, and as co-creators of knowledge.Recruitment and Methodological ApproachThe project researcher (Jaunzems) met potential contributors at MARH when its members gathered for a coffee morning. With Sara’s assistance, the researcher invited MARH members to take part in the research project, giving those present the opportunity to ask and have answered any questions they deemed important. Coffee morning attendees were under no obligation to take part, and about half chose not to do so, while the remainder volunteered to participate. Sara scheduled the interviews at times to suit the families participating. A parent and child from each volunteer family was interviewed, separately. In all cases it was the mother who volunteered to take part, and all interviewees chose to be interviewed in their homes. Each set of interviews was digitally recorded and lasted no longer than 90 minutes. This article includes extracts from interviews with three mothers from refugee families who escaped war-torn homelands for a new life in Australia, sometimes via interim refugee camps.The project researcher conducted the in-depth interviews with Sara’s crucial interpreting/translating assistance. The interviews followed a traditional approach, except that the researcher deferred to Sara as being more important in the interview exchange than she was. This reflects the premise that meaning is socially constructed, and that what people do and say makes visible the meanings that underpin their actions and statements within a wider social context (Burr). Conceptualising knowledge as socially constructed privileges the role of the decoder in receiving, understanding and communicating such knowledge (Crotty). Respecting the role of the interpreter/translator signified to the participants that their views, opinions and their overall cultural context were valued.Once complete, the interviews were sent for translation and transcription by a trusted bi-lingual transcriber, where both the English and Arabic exchanges were transcribed. This was deemed essential by the researchers, to ensure both the authenticity of the data collected and to demonstrate “trust, understanding, respect, and a caring connection” (Valibhoy, Kaplan, and Szwarc, 23) with the participants. Upon completion of the interviews with volunteer members of the MARH community, and at the beginning of the analysis phase, researchers recognised the need for the adoption of an interpretive framework. The interpretive approach seeks to understand an individual’s view of the world through the contexts of time, place and culture. The knowledge produced is contextualised and differs from one person to another as a result of individual subjectivities such as age, race and ethnicity, even within a shared social context (Guba and Lincoln). Accordingly, a mother-tongue Arabic speaker, who identifies as a refugee (Al-Hameed), was added to the project. All authors were involved in writing up the article while authors two, three and four took responsibility for transcript coding and analysis. In the transcripts that follow, words originally spoken in Arabic are in intalics, with non-italcised words originally spoken in English.Discrimination and BelongingAya initially fled from her home in Syria into neighbouring Jordan. She didn’t feel welcomed or supported there.[00:55:06] Aya: …in Jordan, refugees didn’t have rights, and the Jordanian schools refused to teach them [the children…] We were put aside.[00:55:49] Interpreter, Sara (to Researcher): And then she said they push us aside like you’re a zero on the left, yeah this is unfortunately the reality of our countries, I want to cry now.[00:56:10] Aya: You’re not allowed to cry because we’ll all cry.Some refugees and migrant communities suffer discrimination based on their ethnicity and perceived legitimacy as members of the host society. Although Australian refugees may have had searing experiences prior to their acceptance by Australia, migrant community members in Australia can also feel themselves “constructed in the public and political spheres as less legitimately Australian than others” (Green and Aly). Jackson argues that both refugees and migrants experiencethe impossibility of ever bridging the gap between one’s natal ties to the place one left because life was insupportable there, and the demands of the nation to which one has travelled, legally or illegally, in search of a better life. And this tension between belonging and not belonging, between a place where one has rights and a place where one does not, implies an unresolved relationship between one’s natural identity as a human being and one’s social identity as ‘undocumented migrant,’ a ‘resident alien,’ an ‘ethnic minority,’ or ‘the wretched of the earth,’ whose plight remains a stigma of radical alterity even though it inspires our compassion and moves us to political action. (223)The tension Jackson refers to, where the migrant is haunted by belonging and not belonging, is an area of much research focus. Moreover, the label of “asylum seeker” can contribute to systemic “exclusion of a marginalised and abject group of people, precisely by employing a term that emphasises the suspended recognition of a community” (Nyers). Unsurprisingly, many refugees in Australia long for the connectedness of the lives they left behind relocated in the safe spaces where they live now.Eades focuses on an emic approach to understanding refugee/migrant distress, or trauma, which seeks to incorporate the worldview of the people in distress: essentially replicating the interpretive perspective taken in the research. This emic framing is adopted in place of the etic approach that seeks to understand the distress through a Western biomedical lens that is positioned outside the social/cultural system in which the distress is taking place. Eades argues: “developing an emic approach is to engage in intercultural dialogue, raise dilemmas, test assumptions, document hopes and beliefs and explore their implications”. Furthermore, Eades sees the challenge for service providers working with refugee/migrants in distress as being able to move beyond “harm minimisation” models of care “to recognition of a facilitative, productive community of people who are in a transitional phase between homelands”. This opens the door for studies concerning the notions of attachment to place and its links to resilience and a refugee’s ability to “settle in” (for example, Myers’s ground-breaking place-making work in Plymouth).Resilient PrecariousnessChaima: We feel […] good here, we’re safe, but when we sit together, we remember what we went through how my kids screamed when the bombs came, and we went out in the car. My son was 12 and I was pregnant, every time I remember it, I go back.Alongside the dreams that migrants have possible futures are the nightmares that threaten to destabilise their daily lives. As per the work of Xavier and Rosaldo, post-migration social life is recreated in two ways: the first through participation and presence in localised events; the second by developing relationships with absent others (family and friends) across the globe through media. These relationships, both distanced and at a distance, are dispersed through time and space. In light of this, Campays and Said suggest that places of past experiences and rituals for meaning are commonly recreated or reproduced as new places of attachment abroad; similarly, other recollections and experience can trigger a sense of fragility when “we remember what we went through”. Gupta and Ferguson suggest that resilience is defined by the migrant/refugee capacity to “reimagine and re-materialise” their lost heritage in their new home. This involves a sense of connection to the good things in the past, while leaving the bad things behind.Resilience has also been linked to the migrant’s/refugee’s capacity “to manage their responses to adverse circumstances in an interpersonal community through the networks of relationships” (Eades). Resilience in this case is seen through an intersubjective lens. Joseph reminds us that there is danger in romanticising community. Local communities may not only be hostile toward different national and ethnic groups, they may actively display a level of hostility toward them (Boswell). However, Gill maintains that “the reciprocal relations found in communities are crucially important to their [migrant/refugee] well-being”. This is because inclusion in a given community allows migrants/refugees to shrug off the outsider label, and the feeling of being at risk, and provides the opportunity for them to become known as families and friends. One of MAHR’s central aims was to help bridge the cultural divide between MARH users and the broader Australian community.Hope[01:06: 10] Sara (to interviewee, Aya): What’s the key to your success here in Australia?[01:06:12] Aya: The people, and how they treat us.[01:06:15] Sara (to Researcher): People and how they deal with us.[01:06:21] Aya: It’s the best thing when you look around, and see people who don’t understand your language but they help you.[01:06:28] Sara (to Researcher): She said – this is nice. I want to cry also. She said the best thing when I see people, they don’t understand your language, and I don’t understand theirs but they still smile in your face.[01:06:43] Aya: It’s the best.[01:06:45] Sara (to Aya): yes, yes, people here are angels. This is the best thing about Australia.Here, Sara is possibly shown to be taking liberties with the translation offered to the researcher, talking about how Australians “smile in your face”, when (according to the translator) Aya talked about how Australians “help”. Even so, the capacity for social connection and other aspects of sociality have been linked to a person’s ability to turn a negative experience into a positive cultural resource (Wilson). Resilience is understood in these cases as a strength-based practice where families, communities and individuals are viewed in terms of their capabilities and possibilities, instead of their deficiencies or disorders (Graybeal and Saleeby in Eades). According to Fozdar and Torezani, there is an “apparent paradox between high-levels of discrimination experienced by humanitarian migrants to Australia in the labour market and everyday life” (30) on the one hand, and their reporting of positive well-being on the other. That disparity includes accounts such as the one offered by Aya.As Wilson and Arvanitakis suggest,the interaction between negative experiences of discrimination and reports of wellbeing suggested a counter-intuitive propensity among refugees to adapt to and make sense of their migration experiences in unique, resourceful and life-affirming ways. Such response patterns among refugees and trauma survivors indicate a similar resilience-related capacity to positively interpret and derive meaning from negative migration experiences and associated emotions. … However, resilience is not expressed or employed uniformly among individuals or communities. Some respond in a resilient manner, while others collapse. On this point, an argument could be made that collapse and breakdown is a built-in aspect of resilience, and necessary for renewal and ongoing growth.Using this approach, Wilson and Arvanitakis have linked resilience to hope, as a “present- and future-oriented mode of situated defence against adversity”. They argue that the term “hope” is often utilised in a tokenistic way “as a strategic instrument in increasingly empty domestic and international political vocabularies”. Nonetheless, Wilson and Arvanitakis believe hope to be of vital academic interest due to the prevalence of war and suffering throughout the world. In the research reported here, the authors found that participants’ hopes were interwoven with dreams of being reunited with their families in a place of safety. This is a common longing. As Jackson states,so it is that migrants travel abroad in pursuit of utopia, but having found that place, which is also no-place (ou-topos), they are haunted by the thought that utopia actually lies in the past. It is the family they left behind. That is where they properly belong. Though the family broke up long ago and is now scattered to the four winds, they imagine a reunion in which they are together again. (223)There is a sense here that with their hopes and dreams lying in the past, refugees/migrants are living forward while looking backwards (a Kierkegaardian concept). If hope is thought to be key to resilience (Wilson and Arvanitakis), and key to an individual’s ability to live with a sense of well-being, then perhaps a refugee’s past relations (familial) impact both their present relations (social/community), and their ability to transform negative experiences into positive experiences. And yet, there is no readily accessible way in which migrants and refugees can recreate the connections that sustained them in the past. As Jackson suggests,the irreversibility of time is intimately connected with the irreversibility of one’s place of origin, and this entwined movement through time and across space proves perplexing to many migrants, who, in imagining themselves one day returning to the place from where they started out, forget that there is no transport which will convey them back into the past. … Often it is only by going home that is becomes starkly and disconcertingly clear that one’s natal village is no longer the same and that one has also changed. (221)The dream of home and family, therefore and the hope that this might somehow be recreated in the safety of the here and now, becomes a paradoxical loss and longing even as it is a constant companion for many on their refugee journey.Esma’s DreamAccording to author three, personal dreams are not generally discussed in Arab culture, even though dreams themselves may form part of the rich tradition of Arabic folklore and storytelling. Alongside issues of mental wellbeing, dreams are constructed as something private, and it generally breaks social taboos to describe them publicly. However, in personal discussions with other refugee women and men, and echoing Jackson’s finding, a recurring dream is “to meet my family in a safe place and not be worried about my safety or theirs”. As a refugee, the third author shares this dream. This is also the perspective articulated by Esma, who had recently had a fifth child and was very much missing her extended family who had died, been scattered as refugees, or were still living in a conflict zone. The researcher asked Sara to ask Esma about the best aspect of her current life:[01:17:03] Esma: The thing that comforts me here is nature, it’s beautiful.[01:17:15] Sara (to the Researcher): The nature.[01:17:16] Esma: And feeling safe.[01:17:19] Sara (to the Researcher): The safety. ...[01:17:45] Esma: Life’s beautiful here.[01:17:47] Sara (to the Researcher): Life is beautiful here.[01:17:49] Esma: But I want to know people, speak the language, have friends, life is beautiful here even if I don’t have my family here.[01:17:56] Sara (to the Researcher): Life is so pretty you only need to improve the language and have friends, she said I love my life here even though I don’t have any family or community here. (To Esma:) I am your family.[01:18:12] Esma: Bring me my siblings here.[01:18:14] Sara (to Esma): I just want my brothers here and my sisters.[01:18:17] Esma: It’s a dream.[01:18:18] Sara (to Esma): it’s a dream, one day it will become true.Here Esma uses the term dream metaphorically, to describe an imagined utopia: a dream world. In supporting Esma, who is mourning the absence of her family, Sara finds herself reacting and emoting around their shared experience of leaving siblings behind. In doing so, she affirms the younger woman, but also offers a hope for the future. Esma had previously made a suggestion, absorbed into her larger dream, but more achievable in the short term, “to know people, speak the language, have friends”. The implication here is that Esma is keen to find a way to connect with Australians. She sees this as a means of compensating for the loss of family, a realistic hope rather than an impossible dream.ConclusionInterviews with refugee families in a Perth-based migrant support centre reveals both the nightmare pasts and the dreamed-of futures of people whose lives have experienced a radical disruption due to war, conflict and other life-threatening events. Jackson’s work with migrants provides a context for understanding the power of the dream in helping to resolve issues around the irreversibility of time and circumstance, while Wilson and Arvanitakis point to the importance of hope and resilience in supporting the building of a positive future. 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“Live free or die!” (New Hampshire State motto) Should individuals be free to make lifestyle decisions (such as what, when and how much to eat and how much physical activity to take), without undue interference from the state, even when their decisions may lead to negative consequences (obesity, heart disease, diabetes)? The UN Declaration of Human Rights enshrines the belief that “All human beings are born free and equal in dignity and rights”. The philosophy of Libertarianism (Locke) proposes that rights can be negative (e.g. the freedom to be free from outside interference) as well as positive (e.g. the right to certain benefits supplied by others). Robert Nozick, a proponent of Libertarianism, has argued that we have the right to make informed decisions about our lives without unnecessary interference. This entitlement requires that we exercise our rights only as far as they do not infringe the rights of others. The popular notion of the “Nanny State” (often used derogatively) is discussed, and the metaphor is extended to draw on the Super Nanny phenomenon, a reality television series that has been shown in numerous countries including the UK, the US, and Australia. It is argued in this paper that social marketing, when done well, can help create a “Super Nanny State” (implying positive connotations). In the “Nanny State” people are told what to do; in the “Super Nanny State” people are empowered to make healthier decisions. Social marketing applies commercial marketing principles to “sell” ideas (rather than goods or services) with the aim of improving the welfare of individuals and/or society. Where the common good may not be easily discerned, Donovan and Henley recommended using the UN Declaration of Human Rights as the baseline reference point. Social marketing is frequently used to persuade individuals to make healthier lifestyle decisions such as “eat less [saturated] fat”, “eat two fruits and five veg a day”, “find thirty minutes of physical activity a day”. Recent medical gains in immunisation, sanitation and treating infectious diseases mean that the health of a population can now be more improved by influencing lifestyle decisions than by treating illness (Rothschild). Social marketing activities worldwide are directed at influencing lifestyle decisions to prevent or minimise lifestyle diseases. “Globesity” is the new epidemic (Kline). Approximately one billion people globally are overweight or obese (compared to 850 million who are underweight); most worryingly, about 10% of children worldwide are now overweight or obese with rising incidence of type 2 diabetes in this population (Yach, Stuckler, and Brownwell). “Nanny state” is a term people often use derogatively to refer to government intervention (see Henley and Jackson). Knag (405) made a distinction between old-style, authoritarian “paternalism”, which chastised the individual using laws and sanctions, and a newer “maternalism” or “nanny state” which smothers the individual with “education and therapy (or rather, propaganda and regulation)”. Knag’s use of the term “Nanny State” still has pejorative connotations. In the “Nanny State”, governments are seen as using the tool of social marketing to tell people what they should and shouldn’t do, as if they were children being supervised by a nanny. At the extreme, people may be afraid that social marketing could be used by the State as a way to control the thoughts of the vulnerable, a view expressed some years ago by participants in a survey of attitudes towards social marketing (Laczniak, Lusch, and Murphy). More recently, the debate is more likely to focus on why social marketing often appears to be ineffective, rather than frighteningly effective (Hastings, Stead, and Macintosh). Another concern is the high level of fear being generated by much of the social marketing effort (Hastings and MacFadyen; Henley). It is as if nanny thinks she must scream at her children all the time to warn them that they will die if they don’t listen to her. However, by extension, I am suggesting that the “Super Nanny State” metaphor could have positive associations, with an authoritative (rather than authoritarian) parenting figure, one who explains appropriate sanctions (laws and regulations) but who is also capable of informing, inspiring and empowering. Still, the Libertarian ethical viewpoint would question whether governments, through social marketers, have the right to try to influence people’s lifestyle decisions such as what and how much to eat, how much to exercise, etc. In the rise of the “Nanny State”, Holt argued that governments are extending the range of their regulatory powers, restricting free markets and intruding into areas of personal responsibility, all under the guise of acting for the public’s good. A number of arguments, discussed below, can be proposed to justify interference by the State in the lifestyle decisions of individuals. The Economic Argument One argument that is often quoted to justify interference by the State is that the economic costs of allowing unsafe/unhealthy behaviours have to be borne by the community. It has been estimated in the US that medical costs relating to diabetes (which is associated directly with obesity) increased from $44 billion to $92 billion in five years (Yach, et al). The economic argument can be useful for persuading governments to invest in prevention but is not sufficient as a fundamental justification for interference. If we say that we want people to eat more healthily because their health costs will be burdensome to the community, we imply that we would not ask them to do so if their health costs were not burdensome, even if they were dying prematurely as a result. The studies relating to the economic costs of obesity have not been as extensive as those relating to the economic costs of tobacco (Yach, et al), where some have argued that prematurely dying of smoking-related diseases is less costly to the State than the costs incurred in living to old age (Barendregt, et al). This conclusion has been disputed (Rasmussen et al), but even if true, would not provide sufficient justification to cease tobacco control efforts. Similarly, I think people would expect social marketing efforts relating to nutrition and physical activity to continue even if an economic analysis showed that people dying prematurely from obesity-related illnesses were costing the State less overall in health care costs than people living an additional twenty years. The Consumer Protection Argument Some degree of interference by the State is desirable and often necessary because people are not entirely self-reliant in every circumstance (Mead). The social determinants of health (Marmot and Wilkinson) are sufficiently well-understood to justify government regulation to reduce inequalities in housing, education, access to health services, etc. Implicit in the criticism that the “Nanny State” treats people like children is the assumption that children are treated without dignity and respect. The positive parent or “Super Nanny” treats children with respect but recognises their vulnerability in unfamiliar or dangerous contexts. A survey of opinion in the UK in 2004 by the King’s Fund, an independent think tank, found that the public generally supported government initiatives to encourage healthier school meals; ensure cheaper fruit and vegetables; pass laws to limit salt, fat and sugar in foods; stop advertising junk foods for children and regulate for nutrition labels on food (UK public wants a “Nanny State”). The UK’s recently established National Social Marketing Centre has made recommendations for social marketing strategies to improve public health and Prime Minister Tony Blair has responded by making public health, especially the growing obesity problem, a central issue for government initiatives, offering a “helping hand” approach (Triggle). The Better Alternative Argument Wikler considered the case for more punitive government intervention in the obesity debate by weighing the pros and cons of an interesting strategy: the introduction of a “fat tax” that would require citizens to be weighed and, if found to be overweight, require them to pay a surcharge. He concluded that this level of state interference would not be justified because there are other ways to appeal to the risk-taker’s autonomy, through education and therapeutic efforts. Governments can use social marketing as one of these better alternatives to punitive sanctions. The Level Playing Field Argument Social marketers argue that many lifestyle behaviours are not entirely voluntary (O’Connell and Price). For example, it is argued that an individual’s choices about eating fast food, consuming sweetened soft drinks, and living sedentary lives have already been partially determined by commercial efforts. Thus, they argue that social marketing efforts are intended to level the playing field – educate, inform, and restore true personal autonomy to people, enabling them to make rational choices (Smith). For example, Kline’s media education program in Canada, with a component of “media risk reduction”, successfully educated young consumers (elementary school children) with strategies for “tuning out” by asking them to come up with a plan for what they would do if they “turned off TV, video games and PCs for a whole week?” (p. 249). The “tune out challenge” resulted in a reduction of media exposure (80%) displaced into active leisure pursuits. A critical aspect of this intervention was the contract drawn up in advance, with the children setting their own goals and strategies (Kline). In this view, the state is justified in trying to level the playing field, by using social marketing to offer information as well as alternative, healthier choices that can be freely accepted or rejected (Rothschild). Conclusion A real concern is that when people are treated like children, they become like children, retaining their desires and appetites but abdicating responsibility for their individual choices to the state (Knag). Some smokers, for example, declare that they will continue to smoke until the government bans smoking (Brown). Governments and social marketers have a responsibility to fund/design campaigns so that the audience views the message as informative rather than proscriptive. Joffe and Mindell (967) advocated the notion of a “canny state” with “less reliance on telling people what to do and more emphasis on making healthy choices easier”. Finally, one of the central tenets of marketing is the concept of “exchange” – the marketer must identify the benefits to be gained from buying a product. In social marketing terms, interference in an individual’s right to act freely can be effective and justified when the benefits are clearly identifiable and credible. Rothschild described marketing’s role as providing a middle point between libertarianism and paternalism, offering free choice and incentives to behave in ways that benefit the common good. Rather than shaking a finger at the individual (along the lines of earlier “Don’t Do Drugs” campaigns), the “Super Nanny” state, via social marketing, can inform and engage individuals in ways that make healthier choices more appealing and the individual feel more empowered to choose them. 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