Journal articles on the topic 'West Africans Medical care Attitudes'

This article explores the homecoming experiences of international health care workers who responded to the 2014 to 2016 West African Ebola outbreak. Interviews with 11 frontline international medical staff were undertaken and data thematically analyzed. It was found that international health care workers faced an unforeseen risk of stigmatization upon their return home, related to others’ fears of their infectious status. Media representations of the disease appear to have played a significant role in heightening societal perceptions of the risks associated with the returning health care workers, resulting in public hostility toward them. For participants, these social risks overtook concerns about biological risks during the immediate postmission period. The participants developed different strategies to cope with courtesy stigma, by rationalizing stigmatizing attitudes, educating people, or simply through an avoidance of others.

Background: Rational drug use is of the utmost importance in a region such as West Africa, where the prevalence of drug resistance is increasing due to inappropriate use of medications. Objective: This study aimed to assess the pattern of prescription drug use at the General Outpatient Clinic of the University College Hospital, Ibadan. This study also assessed the knowledge and attitude toward rational drug use among prescribing physicians in the Clinic. Design: The study was a retrospective cross-sectional review of patients' records over three years. The medical records were selected by systematic random sampling and subjected to the WHO core drug use indicators. Prescribers at the study site had their knowledge, attitude, and practice (KAP) of rational drug use assessed with a self-administered questionnaire. Results: A total of 795 medical records were analyzed for drug use indicators. The mean number of drugs per encounter was 2.64 ±1.23. The percentage of encounters in which an antibiotic was prescribed was 20.4%, while 71.6% of all drugs prescribed were in the generic form. From the KAP survey, 64% of physicians routinely prescribed both generic and brand names, and 68% admitted they needed further education on rational drug use. Conclusion: Using the WHO core drug use indicators, this study identified some degree of polypharmacy and poor adherence to the generic prescription of drugs. Continuing Medical Education for health workers is encouraged to stem the irrational prescription of medications in the African sub-region. Keywords: Prescription Drugs Use, Rational Use of Medicines, Physician's knowledge, Nigeria

Background It is crucial to assess genomic literacy related to stroke among Africans in preparation for the ethical, legal and societal implications of the genetic revolution which has begun in Africa. Objective To assess the knowledge, attitudes and practices (KAP) of West Africans about stroke genetic studies. Methods A comparative cross-sectional study was conducted among stroke patients and stroke-free controls recruited across 15 sites in Ghana and Nigeria. Participants' knowledge of heritability of stroke, willingness to undergo genetic testing and perception of the potential benefits of stroke genetic research were assessed using interviewer-administered questionnaire. Descriptive, frequency distribution and multiple regression analyses were performed. Results Only 49% of 2029 stroke patients and 57% of 2603 stroke-free individuals knew that stroke was a heritable disorder. Among those who knew, 90% were willing to undergo genetic testing. Knowledge of stroke heritability was associated with having at least post-secondary education (OR 1.51, 1.25–1.81) and a family history of stroke (OR 1.20, 1.03–1.39) while Islamic religion (OR=0.82, CI: 0.72–0.94), being currently unmarried (OR = 0.81, CI: 0.70–0.92), and alcohol use (OR = 0.78, CI: 0.67–0.91) were associated with lower odds of awareness of stroke as a heritable disorder. Willingness to undergo genetic testing for stroke was associated with having a family history of stroke (OR 1.34, 1.03–1.74) but inversely associated with a medical history of high blood pressure (OR = 0.79, 0.65–0.96). Conclusion To further improve knowledge of stroke heritability and willingness to embrace genetic testing for stroke, individuals with less formal education, history of high blood pressure and no family history of stroke require targeted interventions.

Electronic Medical records document the treatment plan and patient care. This study intends to identify trained nurses' reception toward using EMR in the wards. A non-experimental cross-sectional survey covered the multi-discipline area. A stratified random sampling method in which the population in this research consisted of n= 138 trained nurses. Results found that the trained nurses tended to document the data at the nurse's station compared to the bedside entry. It's also shown that the demographics variable significantly correlated with attitude domains. Hence with the research results, it is envisaged to benefit the nurses and organization and hopefully can become the catalyst for the Ministry of Health in further improving and elevating the system throughout all hospitals in Malaysia. Keywords: Attitude, Electronic medical record, Nurses, Preferences eISSN: 2398-4287 © 2022. The Authors. Published for AMER ABRA cE-Bs by e-International Publishing House, Ltd., UK. This is an open access article under the CC BYNC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Peer–review under responsibility of AMER (Association of Malaysian Environment-Behaviour Researchers), ABRA (Association of Behavioural Researchers on Asians/Africans/Arabians) and cE-Bs (Centre for Environment-Behaviour Studies), Faculty of Architecture, Planning & Surveying, Universiti Teknologi MARA, Malaysia. DOI: https://doi.org/10.21834/ebpj.v7i21.3579

The present article seeks to fill a number of lacunae with regard to the study of the circulation and assimilation of different bodies of medical knowledge in an important cultural contact zone, that is the Upper Guinea Coast. Building upon ongoing research on trade and cultural brokerage in the area, it focuses upon shifting attitudes and practices with regard to health and healing as a result of cultural interaction and hybridisation against the background of growing intra-African and Afro-Atlantic interaction from the fifteenth to the late seventeenth century. Largely based upon travel accounts, missionary reports and documents produced by the Portuguese Inquisition, it shows how forms of medical knowledge shifted and circulated between littoral areas and their hinterland, as well as between the coast, the Atlantic and beyond. It shows that the changing patterns of trade, migration and settlement associated with Mandé influence and Afro-Atlantic exchange had a decisive impact on changing notions of illness and therapeutic trajectories. Over the centuries, cross-cultural, reciprocal borrowing contributed to the development of healing kits employed by Africans and non-African outsiders alike, which were used and brokered by local communities in different locations in the region.

Aims and methodTo assess attitudes of general practitioners (GPs) on who should be responsible for managing metabolic dysregulations associated with the use of antipsychotics prescribed by psychiatrists. A total of 121 GPs in West Galway catchment area were surveyed using a simple questionnaire.ResultsA total of 104 GPs responded (86% response rate). The vast majority of responders (82%) believed that medical management should be provided within primary care. However, 46% indicated that initial screening and simple non-pharmacological management should be provided by mental health services.Clinical implicationsThe vast majority of GPs appear willing to take over the medical management of metabolic dysregulations emerging from antipsychotic prescribing in secondary care. Clearly defined roles for mental health services and primary care in the management of metabolic complications are of paramount importance, and individual mental health services should implement protocols for screening, non-pharmacological management and referral to primary care.

Abstract Introduction Obstructive sleep apnea (OSA) syndrome is a common but underdiagnosed clinical problem with multiple health implications. The rising prevalence of OSA has been linked to increasing obesity. Because the obesity rate of West Virginia (WV) is almost 40%, successful identification and treatment of OSA is essential to improving the health of WV communities. Our previous work demonstrated that OSA is ineffectively managed in our rural communities. This study aimed to evaluate OSA knowledge and attitudes of primary care providers (PCPs) practicing at Federally Qualified Health Centers (FQHC) serving rural communities with significant health disparity in southern WV. Methods We assessed OSA knowledge and attitudes of 14 PCPs in southern WV (n=6 physicians and 8 mid-level providers; 53.2 + 12.2 years of age; 78% female) practicing at FQHC. The OSA Knowledge and Attitudes (OSAKA) questionnaire assesses providers’ knowledge via 18 true-false statements and importance and attitude via five Likert. OSA attitudes are assessed via two items for importance of OSA and three items for confidence in identifying and treating OSA. Results No respondents answered the 18-knowledge portion with 100% accuracy (mean = 14.3). Mann Whitney U tests were then used to compare Physicians’ and mid-level providers’ years in practice and OSAKA responses. Knowledge scores in physicians (Mdn = 16) significantly differed from mid-level providers scores (Mdn = 13.5) in our sample (U = 5.5, p < 0.05, r = -0.66). OSAKA Importance and Confidence questions revealed that PCPs felt OSA identification was important, but were not confident in their ability to manage OSA. Conclusion Our results demonstrate that rural PCPs have fairly good knowledge of OSA in general but lack knowledge in specific domains. Interestingly, providers feel OSA is an important disease and were fairly knowledgeable with the disease, but lacked confidence to manage OSA. Further explanatory studies are warranted to more robustly examine these findings. Our prior work demonstrates sleep apnea is ineffectively managed in the region. Thus, targeted training and further engagement with rural providers may well address disparity in OSA management for Appalachian communities. Support (If Any) (NIH/NIGMS 5U54GM104942-03).

Background: Underreporting of ADRs still remains a major obstacle in the complete success of pharmacovigilance programs. In order to improve ADR monitoring, it is thus imperative to assess the current knowledge, attitude, and practices of doctors. Therefore, the primary objective of this study was to evaluate the knowledge, attitude, and practices (KAP) of the healthcare professionals about pharmacovigilance in various tertiary care government teaching hospital vis-a-vis private clinics in West Bengal.Methods: A cross sectional, questionnaire based survey was conducted among healthcare practitioners in several tertiary care government set-ups and private set-ups in the state of West Bengal (India). The study instrument was a pre-validated structured questionnaire designed to obtain information on the knowledge of the ADRs reporting, the attitudes towards the reporting, and the factors that in practice could hinder the reporting among the doctors.Results: About 89.62% public practitioners correctly spotted the WHO definition for pharmacovigilance, while 77.5% of the private practitioners did the same. Only 19.81% of the public practitioners documented a suspected ADR in any surveillance form, while there were only 3.75% private practitioners who documented it. About 59.43% of the physicians in government hospitals published an ADR case report in any medical journal, while 81.25% private practitioners did no.Conclusions: Study revealed lack of time, incentive less extra work load being major factors responsible for ADR underreporting. In order to improve ADR reporting, continuous medical education, training and proper sensitization of healthcare professionals can help combating the existing scenario and promising an improved tomorrow. The PvPI should be widely publicized in the visual and print media to make health professionals, as well as the general population at large aware of its presence and scope. Pharmacovigilance should be integrated in undergraduate and postgraduate medical courses.

• Background Advance directives are important but often underused tools in critical care. Healthcare professionals’ understanding of how culture influences attitudes toward advance directives can improve knowledge and completion of these documents.• Objective To understand the attitudes of critically ill Filipino American patients and their families toward advance directives.• Methods A descriptive, correlational, cross-sectional study with a convenience sample of 22 Filipino American patients and 22 Filipino American family members at a West Coast medical center. All patients were admitted for cardiac surgery or cardiac interventions. Participants were interviewed with the Advance Directive Attitude Survey and A Short Acculturation Scale for Filipino Americans.• Results Family members’ scores were significantly more positive than patients’ scores on the attitude survey (P = .01). Family members were more American acculturated than were patients (P = .001). Family members with more education had more positive attitudes toward advance directives (P = .02). Only 2 patients (and no family members) had completed an advance directive before the study. Only 27.3% of family members had prior knowledge of advance directives.• Conclusion Overall attitudes toward advance directives were positive; however, the completion rate and knowledge of advance directives were low. Participants may have been saying what they thought the researcher wanted to hear in order to avoid disagreement. Such behavior could partly explain the positive attitudes of the Filipino Americans toward advance directives. Further research is warranted to understand how to increase completion rates for advance directives among Filipino Americans.

AimTo explore how the South-West Foundation Doctor Quality Improvement programme affected foundation year 1 (F1) doctors’ attitudes and ability to implement change in healthcare.MethodsTwenty-two qualitative interviews were carried out with two cohorts of doctors. The first F1 group before and after their participation in the QI programme; the second group comprised those who had completed the programme between 1 and 5 years earlier. Qualitative data were analysed using thematic analysis techniques.Results Prior to taking part in the QI programme, junior doctors’ attitudes towards QI were mixed. Although there was agreement on the importance of QI in terms of patient safety, not all shared enthusiasm for engaging in QI, while some were sceptical that they could bring about any change. Following participation in the programme, attitudes towards QI and the ability to effect change were significantly transformed. Whether their projects were considered a success or not, all juniors reported that they valued the skills learnt and the overall experience they gained through carrying out QI projects. Participants reported feeling more empowered in their role as junior doctors, with several describing how they felt ‘listened to’ and able to ‘have a voice’, that they were beginning to see things ‘at systems level’ and learning to ‘engage more critically’ in their working environment.Conclusions Junior doctors are ideally placed to engage in QI. Training in QI at the start of their medical careers may enable a new generation of doctors to acquire the skills necessary to improve patient safety and quality of care.

AbstractObjectiveThe 2014 Ebola virus disease (EVD) outbreak in West Africa remains the most deadly in history. Emergency departments (EDs) are more likely to come into contact with potential EVD patients. It is important for EDs to be prepared to care for suspected EVD patients. Our objective was to understand the perceived challenges experienced by Washington State ED medical directors in EVD preparedness.MethodsAn anonymous, electronic survey was sent to a convenience sample of ED medical directors across Washington State between November and February of 2014–2015. The perceived challenges of and attitudes toward EVD preparations were assessed and reported as stratified proportions.ResultsOf 85 medical directors contacted, 59 responses (69%) were received. This included EDs with annual patient volumes of <20,000 (20 hospitals, 34%), 20,000 to 40,000 (21 hospitals, 36%), 41,000 to 60,000 (4 hospitals, 6.8%), and >60,000 (12 hospitals, 20%). Among the perceived challenges in EVD preparations were spatial modifications (eg, building an anteroom for donning and doffing of personal protective equipment) and waste management planning. Ninety-five percent of respondents moderately or strongly agreed that it is important to have a predesignated hospital to care for EVD patients.ConclusionsWashington State ED medical directors have faced significant challenges in ensuring their EDs are prepared to safely care for suspected EVD patients. Attitudes toward EVD preparations are mixed. Varying levels of perceived importance may represent an additional barrier to statewide EVD preparedness. (Disaster Med Public Health Preparedness. 2016;10:662–668)

Background: COVID-19 disease is a highly contagious and totally unknown disease which is caused by SARS-CoV-2. This disease spread throughout the world irrespective of social, economical and political variation. Health care staff are the frontline COVID-19 worrier and their understanding of this disease is very important. Aims and Objective: The aim of this study was to assess the knowledge, attitudes and practices (KAP) towards COVID-19 disease among the healthcare staff of a tertiary care hospital of West Bengal. Materials and Methods: An analytic cross-sectional study was conducted at Murshidabad Medical College, Murshidabad from 25th April, 2020 to 2nd May, 2020. A total of 214 health care staff (83 nurses, 75 doctors, 20 para-medical staff, 24 administrative staff, and 12 sweepers) participated in this questionnaire based KAP study. The questionnaire was prepared according to the World Health Organization’ on Corona virus disease (COVID-19) “advice for the public”. The Systematic random sampling procedure was employed for data collection. The data was analysed using T-test, ANOVA, chi-square test and regression model. The informed consent was taken from each participant. Result: Female (62%) participants were more than male (38%) participants. Mean age of the participants was 27.03±7.63 years. About the half participants were unmarried (55%) and studied up to bachelor’s degree (49%). The overall knowledge score found to be “medium level” with 77% reporting correct answers. The knowledge score was statistically different among age group, education level, marital status and occupational group of health care staff in this hospital by univariate analysis. The good attitudes and good practices were not related with knowledge score. The majority of the respondents (78%) had confidence on their attitude that “India can win the battle against COVID-19”. Only 86% participants wore masks while going out in the lock-down period and 79% participants had not visited any crowded place. Only 18% participants used traditional home remedies for flu like symptoms. In multivariate analysis, doctors were found with better knowledge score and attitude towards COVID-19 than other healthcare staff in this hospital. Conclusion: The two preventive practice (social isolation and mask use) and optimistic attitude towards COVID-19 of health care staff were not totally depended on COVID-19 related knowledge score. However, knowledge score was depended on marital status, educational background, age, occupation and place of residence. Government should emphasize more on COVID-19 related health education and health promotion programme at community level.

Background: Hepatitis B and Hepatitis C are among the major public health problems in the world and students in the medical schools as a group is highly vulnerable to these infections. The current study aimed to assess the perspectives (knowledge, attitude and practices) of these students about both Hepatitis B and Hepatitis C.Methods: The present cross-sectional study was conducted in a medical school in northwest India using a self administered questionnaire. This study was carried out in the month of July 2017 using a convenience sample of Pre-final MBBS students.Results: The knowledge of the respondents was found to be good on most of the parameters except for living with Hepatitis B/C patient being a risk factor for disease and Hepatitis B being curable. On the same pattern, attitudes were also found to be positive on most of the parameters except willingness to undergo screening for the diseases. Practices of the respondents were also adequate except for use of gloves while examining a patient/collecting blood sample. An important positive practice observed was that 92.8% of the respondents were protected against Hepatitis B.Conclusions: The study has concluded that perspective of medical students towards Hepatitis B and Hepatitis C are reasonably good and areas of concern need to be taken care of. Both these diseases remain a challenge for health community in general and medical students in particular due to their being an occupational hazard, so the need for infection control training before they start clinical education is strongly recommended.

Background: Evidence supporting physical activity (PA) as an effective modality in the prevention and management of non-communicable diseases is robust. Medical doctors are ideally placed to translate this into practice; however, realising this has proved challenging. To ensure doctors are well prepared, the training of medical students to be proficient in PA counselling seems essential. This study aimed to explore the PA counselling practice of junior doctors, to gain insight into how undergraduate training might influence their future practice. Methods: Interviews were conducted with 11 junior doctors recruited by purposive sampling from across seven different medical schools. All junior doctors were currently undertaking their post-graduate training in North-West England. Interviews were digitally recorded, transcribed verbatim and analysed using thematic analysis. Results: Themes developed from the data were PA attitudes and practices, and barriers and facilitators to PA counselling in clinical practice. Conclusion: The PA counselling practice of junior doctors was found to be inadequate, and attitudes towards PA promotion were particularly discouraging while in the hospital setting. Lack of training in PA counselling at both the undergraduate and postgraduate level and lack of support from consultants were major hindrances. However, unexplored opportunities exist for junior doctors to incorporate PA counselling into primary and secondary care and thus transform the practice of the next generation of doctors.

Objectives The study aims to investigate GPs’ experiences of how UK COVID-19 policies have affected the management and safety of complex elderly patients, who suffer from multimorbidity, at the primary care level in North West London (NWL). Design This is a service evaluation adopting a qualitative approach. Setting Individual semi-structured interviews were conducted between 6 and 22 May 2020, 2 months after the introduction of the UK COVID-19 Action Plan, allowing GPs to adapt to the new changes and reflect on their impact. Participants Fourteen GPs working in NWL were interviewed, until data saturation was reached. Outcome measures The impact of COVID-19 policies on the management and safety of complex elderly patients in primary care from the GPs’ perspective. Results Participants’ average experience was fourteen years working in primary care for the NHS. They stated that COVID-19 policies have affected primary care at three levels, patients’ behaviour, work conditions, and clinical practice. GPs reflected on the impact through five major themes; four of which have been adapted from the Safety Attitudes Questionnaire (SAQ) framework, changes in primary care (at the three levels mentioned above), involvement of GPs in policy making, communication and coordination (with patients and in between medical teams), stressors and worries; in addition to a fifth theme to conclude the GPs’ suggestions for improvement (either proposed mitigation strategies, or existing actions that showed relative success). A participant used an expression of “infodemic” to describe the GPs’ everyday pressure of receiving new policy updates with their subsequent changes in practice. Conclusion The COVID-19 pandemic has affected all levels of the health system in the UK, particularly primary care. Based on the GPs’ perspective in NWL, changes to practice have offered opportunities to maintain safe healthcare as well as possible drawbacks that should be of concern.

West Virginia (WV) has the highest rates of obesity and cardiopulmonary disease in the United States (U.S.). Recent work has identified a significant care gap in WV for obstructive sleep apnea (OSA). This OSA care gap likely has significant health implications for the region given the high rates of obesity and cardiopulmonary disease. The purpose of this mix methods study was to identify barriers that contribute to the rural OSA care disparity previously identified in WV. Methods: This study used mixed methods to evaluate the barriers and facilitators to management of OSA at Federally Qualified Health Centers serving communities in southern WV. Focus groups were conducted at federally qualified health centers with providers serving Appalachian communities. Participants also completed the validated Obstructive Sleep Apnea Knowledge and Attitudes (OSAKA) questionnaire to gain insight into provider knowledge and beliefs regarding OSA. EMR analysis using diagnostic codes was completed at the sites to assess OSA prevalence rates. The same individual served as the interviewer in all focus group sessions to minimize interviewer variability/bias. Our team checked to ensure that the professional transcriptions were correct and matched the audio via spot checks. Results: Themes identified from the focus groups fell into three broad categories: (1) barriers to OSA care delivery, (2) facilitators to OSA care delivery, and (3) community-based care needs to optimize management of OSA in the targeted rural areas. Questionnaire data demonstrated rural providers feel OSA is an important condition to identify but lack confidence to identify and treat OSA. Evaluation of the electronic medical record demonstrates an even larger OSA care gap in these rural communities than previously described. Conclusion: This study found a lack of provider confidence in the ability to diagnose and treat OSA effectively and identified specific themes that limit OSA care in the communities studied. Training directed toward the identified knowledge gaps and on new technologies would likely give rural primary care providers the confidence to take a more active role in OSA diagnosis and management. An integrated model of care that incorporates primary care providers, specialists and effective use of modern technologies will be essential to address the identified OSA care disparities in rural WV and similar communities across the U.S. Community engaged research such as the current study will be essential to the creation of feasible, practical, relevant and culturally competent care pathways for providers serving rural communities with OSA and other respiratory disease to achieve health equity.

Objectives: Children with type 1 diabetes (T1D) need a supportive, non-stigmatizing school environment for self-care activities such as checking blood glucose (BG) and taking pre-meal insulin. Data about T1D self-care in schools in developing countries are scarce. We looked at diabetes self-care activities at school, and attitudes of school staff toward diabetes care. Material and Methods: We interviewed, over an 8-week period, consecutive patient-parent dyads attending T1D clinics in North (Delhi, Gurgaon, and Kanpur), West (Aurangabad), and South (Hyderabad) India. Results: We received responses from 397 patients, 51% of boys. Mean age was 11.7 years (SD: 3.7), mean age at diagnosis 7.2 years (SD: 3.7), and mean diabetes duration 4.5 years (SD: 3.5). A majority (69.8%) were attending private (fee paying) schools (PS) and the rest were studying at government (subsidized/free) schools (GS). More than half of the parents had high educational status: graduate or more (mothers: 52.1%, fathers: 56.9%). Parents visited school daily in 17.1%, significantly more if they had high educational status and if the child was <6 years. Less than half (47.4%) were administering a pre-meal insulin bolus at school (self-injection: 33%, by parent: 12.9%, and by staff: 1.5%); only 24.4% were checking BG regularly (< once per week) at school. The odds of performing diabetes self-care activities at school were significantly higher in children attending PS compared to GS (OR: 3.17, 95% CI: 1.99–5.03 for taking insulin, OR: 3.24, 95% CI: 1.75–5.98 for regular BG checking). The odds of taking insulin at school were also higher with higher parental education (OR: 2.81, 95% CI: 1.87–4.24 for mother’s education, OR: 3.02, 95% CI: 1.99–4.57 for father’s). Testing and injecting we done in classroom (26.2%); medical room (16.1%), staffroom (7.8%), or toilet (2.5%). School insisted on secrecy in 12.6%, excluded children with T1D from sports/excursions in 17.9%, refused permission for injecting in 4.3%, for testing 15.9%, and for pre-activity snack 7.6%. This non-supportive behavior was equal in PS and GS. PS had slightly better care infrastructure such as availability of glucometer (29.6% vs. 3.3%), sick room (21.7% vs. 0.3%), and dedicated nurse (9.7% vs. none). Conclusion: Half of our children were able to manage T1D self-care in school, as schools were often supportive, whether private or government. Parental educational status was positively associated with better care. Although self-care was better in PS and they had better infrastructure, there is much scope for improvement.

Background Acceptance of the COVID-19 vaccine by health professionals highly influences the communities’ decision to receive the vaccine, because health professionals are perceived to be a reliable source of health information. Hence, this study aimed at assessing COVID-19 vaccine acceptance and associated factors among health professionals in two tertiary hospitals in southwest Ethiopia. Methods A cross-sectional study was conducted among 319 health professionals working in Jimma University Medical Center and Mizan-Tepi university teaching hospital, southwest Ethiopia, from June 30, 2021 to July 30, 2021. Data were collected by a structured self-administered questionnaire and analyzed by SPSS version 23. A multivariate logistic regression model was used to identify independent factors associated with health professionals’ covid-19 vaccine acceptance. Variables with P-value < .25 on univariate analysis were candidates for multivariate logistic regression. Then, variables with P-value < .05 at 95% CI in multivariate logistics regression were considered statistically significant. Results Of the total participants, 232 (72.73%) received COVID-19 vaccines. Among non-vaccinated health care professionals, 82 (94.3%) of them stated, worries about the safety and side effects of the vaccines, as the reason for non-acceptance. Factors such as, friends or families diagnosed with COVID-19 (AOR = .086; CI: 95%, .041–.18; P = .001), and attitudes and beliefs about COVID-19 and its vaccine (AOR = .129; CI: 95%, .037–.449; P = .001), were significantly associated with the acceptance of COVID-19 vaccine. Conclusion More than one-fourth of health professionals who did not accept COVID-19 vaccines require immediate intervention through awareness creation on the safety and adverse effects of the vaccine by the government and other stakeholders. Otherwise, the community may in large reject the vaccine as they trust health professionals.

We explored the attitudes and responses of older people to telecare technologies. Questionnaires were given to subjects in three locations: two day hospitals in Tayside (a region of north-east Scotland); five units of sheltered housing run by West Lothian local authority (in central Scotland); and five schemes of a private housing association across Tayside. There were 199 returned questionnaires (a 42% response rate). The sample was divided into two groups according to whether the subjects did agree or did not agree with the statement 'I would welcome technology that helps me to stay in my home even if it means losing some of the freedom and control I currently have'. 'Tele-receptive' individuals ( n = 127) were found to be significantly more likely both to feel excited about new technology and to feel that their age was not a barrier to further learning. The present study suggests that individuals receptive to telecare will tend to be younger (under 80 years) and will be satisfied clients of current health services. They are likely to express a wish to stay at home for as long as possible, even when they would need a lot of help or have to pay for care. They are also keen to use an interactive mode of communication for both social interaction and medical consultation.

Abstract Background Travel-related arboviral infections are important preventable, emerging infectious diseases, with an estimated annual global toll of US$950 million. We investigated the burden of arboviral infections in the military health system (MHS). Methods KAPOS (Deployment and Travel Health: Knowledge, Attitudes, Practices, and Outcomes Study) is a multi-cohort study evaluating the burden of travel-associated diseases in the MHS. The MHS Data Repository was searched for International Classification of Diseases (ICD)-9/10 codes for arboviral infection in military beneficiaries receiving care in military treatment facilities (direct care) or civilian centers (purchased care) for fiscal years 2011-2019. Diagnostic codes were classified as Dengue, Chikungunya, Zika, or other arboviral infection. 755 outpatient charts in the direct-care system were randomly selected for diagnostic validation using Armed Forces Health Surveillance Center case definitions, and review of travel history, medical comorbidities, and pre-travel counseling. Results 11,066 unique-patient ICD codes for arboviral infections were identified; 6356 (57.4%) were direct care; 4710 (42.6%) were purchased care; 889 (8.0%) were inpatient. Median age was 31 years; 5110 (46.2%) were active duty. The most frequent ICD codes for arboviral infection were Japanese encephalitis virus (JEV) (n=4483), dengue (DENV) (n=1786), yellow fever (YF) (n=230), Zika virus (ZIKV) (n=217), West Nile virus (WNV) (n=171), and chikungunya virus (CHIKV) (n=91). DENV codes were confirmed in 166/249 (66.7%) charts; CHIKV in 23/41 (56.1%), and ZIKV in 15/129 (11.6%). No cases of JEV were confirmed in 171 encounters; all codes referred to JEV vaccine administration. 173/204 (84.8%) of confirmed arboviral cases did not undergo pre-travel counseling. Conclusion Arboviral infections constitute a substantial burden of preventable infections within the MHS. Dengue contributed the largest burden of arboviral infection when corrected for accuracy. Coding for ZIKV and JEV likely overestimated the burden of these diseases in the MHS. Low rates of pre-travel counseling among patients with confirmed, non-endemic arboviral infections represent an opportunity for increased emphasis on travel counseling and insect-avoidance precautions. Disclosures All Authors: No reported disclosures

Background Generalized restriction of movement due to the COVID-19 pandemic, together with unprecedented pressure on the health system, has disrupted routine care for non–COVID-19 patients. Telemedicine should be vigorously promoted to reduce the risk of infections and to offer medical assistance to restricted patients. Objective The purpose of this study was to understand physicians’ attitudes toward and perspectives of telemedicine during and after the COVID-19 pandemic, in order to provide support for better implementation of telemedicine. Methods We surveyed all physicians (N=148), from October 17 to 25, 2020, who attended the clinical informatics PhD program at West China Medical School, Sichuan University, China. The physicians came from 57 hospitals in 16 provinces (ie, municipalities) across China, 54 of which are 3A-level hospitals, two are 3B-level hospitals, and one is a 2A-level hospital. Results Among 148 physicians, a survey response rate of 87.2% (129/148) was attained. The average age of the respondents was 35.6 (SD 3.9) years (range 23-48 years) and 67 out of 129 respondents (51.9%) were female. The respondents come from 37 clinical specialties in 55 hospitals located in 14 provinces (ie, municipalities) across Eastern, Central, and Western China. A total of 94.6% (122/129) of respondents’ hospitals had adopted a telemedicine system; however, 34.1% (44/129) of the physicians had never used a telemedicine system and only 9.3% (12/129) used one frequently (≥1 time/week). A total of 91.5% (118/129) and 88.4% (114/129) of physicians were willing to use telemedicine during and after the COVID-19 pandemic, respectively. Physicians considered the inability to examine patients in person to be the biggest concern (101/129, 78.3%) and the biggest barrier (76/129, 58.9%) to implementing telemedicine. Conclusions Telemedicine is not yet universally available for all health care needs and has not been used frequently by physicians in this study. However, the willingness of physicians to use telemedicine was high. Telemedicine still has many problems to overcome.

Objectives: Understanding vaccine intentions and attitudes of health professionals is critical as the Pfizer-BioNTech and the Moderna COVID19 vaccines are being administered throughout the United States. This study estimates the level of vaccine hesitancy at a health sciences center in West Texas prior to the distribution of the vaccines. Methods: An analytical cross-sectional study was performed via anonymous Qualtrics survey administered to approximately 4500 faculty, staff, postdoctoral research associates/medical residents, and employees at a multi-campus health sciences university in the United States. Respondents were asked demographic questions and intention to receive the vaccine. Factors associated with the intention to receive a vaccine were determined using logistic regression analysis. Results: A total sample of 2258 subjects were evaluated (50.0% response rate). Among all respondents, 64.6% reported that they would probably or definitely receive the COVID-19 vaccine. Men had higher levels of intention to receive the vaccine (OR = 2.11, 95% CI 1.64-2.71); respondents who indicated yearly influenza vaccines are necessary were also more likely to receive the vaccine (OR = 6.04, 95% CI 4.70-7.75). Eighty-three percent of faculty and 56% of the staff reported intention to receive the vaccine. Respondents who had previously tested positive for COVID-19 reported more interest in receiving the vaccine (58.5% yes vs 41.5% no). Conclusion: In this study, the intention to receive the COVID-19 vaccination at a United States health sciences center falls below the necessary herd immunity estimates. Public health initiatives must be developed to decrease vaccine hesitancy, especially among health professionals.

The need to replace foreign-language medical terms with indigenous terms has prompted researchers to search for indigenous equivalents of the foreign medical terms. This study which focused on the dearth of standard anatomical terminologies in Yorùbá language was an attempt to examine the adoptability of butchers’ terminologies as descriptive anatomical terms for human abdomino-thoracic organs. Practising butchers in the South West Nigeria were interviewed on their terminologies for cow’s abdomino-thoracic organs and the basis for each terminology. The butchers’ terminologies, in Yorùbá language were critically appraised for adoptability as anatomical terms for human abdomino-thoracic organs. The study observed that cow’s abdomino-thoracic organs were grossly similar to those of humans. Majority (65%) of the cow’s abdomino-thoracic organs are named by the butchers’ in traditional Yorùbá terminologies. The butchers’ terminologies were etymologically derived based on pre-existing concepts similar to the modern terminologies derived from the ancient Greek and Latin words. About 25% of the butchers’ terminologies were the same with some human anatomical terminologies which were in use by the health care professionals. The terminologies concur with the cultural attitudes of the Yorùbá with reference to the private parts of the human body and majority (80%) of the butchers’ terminologies is simple and familiar to the people. Given these characteristic features, we concluded that the butchers’ terminologies are strongly adoptable as descriptive anatomical terms for human abdomino-thoracic organs and may resolve the dearth of standard anatomical terminologies in Yorùbá language. The findings may form a baseline for future studies on the translation of anatomical terminologies to Yorùbá language. Key words: Anatomical terms; Butchers terms; Abdomino-thoracic organs; Yorùbá language.

Purpose – The purpose of this paper is to address and understand recruitment difficulties into psychiatry; however, to date there is no published research with respect to forensic psychiatry. Forensic psychiatry has always been considered to be a popular specialty amongst junior doctors and therefore the recent trend in local unfilled core training (CT) (junior doctor) posts and national reduced competition ratios for higher specialist training has triggered concern. The impact vacant CT posts within the Forensic Service may have on the future workforce must be considered. Further understanding of this trend is required. Design/methodology/approach – A short statement-style survey addressing attitudes and opinions with respect to the field of forensic psychiatry was devised and distributed to all West Midlands core psychiatry trainees who attended post-graduate teaching (November 2014). Findings – Response rate was 64 per cent. In total, 52 per cent of participants expressed an interest in the specialty, but only 13 per cent wished to pursue a career in forensic psychiatry. In total, 68 per cent of responses deemed forensic psychiatry to be a demanding speciality, with over 50 per cent perceiving forensic patients as difficult to work with. There were high rates of uncertain responses with respect to specialty work life. In total, 78 per cent of responses considered experience of the specialty to be useful. Research limitations/implications – The method chosen to distribute the survey maximised response rate, but may have introduced a Hawthorne effect, as well as response bias, with the visual presence of the researcher. Participants were limited to those who attended teaching on the specified day. This could potentially skew results with an absence of opinions of non-attenders. It may be that characteristics and therefore attitudes and opinions of these two groups are different. A further limitation of the study is that opinions explored are limited to statements included within the survey. Practical implications – The current views may represent stigma, negative media portrayal and misinformed opinions. Action must be taken to increase understanding, interest and experience. Increased exposure to the specialty needs to occur. This could occur as early as high school, using case-study exercises and career sessions. Teaching sessions, summer school placements and elective opportunities should be made available for medical students. At post-graduate level, taster days as well as earlier access to rotations may be a way forward. Originality/value – Although entry into Forensic Higher Training remains comparatively competitive, the potential impact of vacant junior doctor (CT) posts within the speciality is concerning. This is likely to negatively influence recruitment into higher training, which may ultimately lead to decreased numbers of qualified forensic psychiatrists. Specialised care for such a risky and challenging patient group could thus be significantly compromised in the near future. Hence, it is vital to understand the current trend in order to act pre-emptively and address the underlying problems. To date no such research has been conducted.

The article illuminates the situation for single mothers in the ex-communist countries - Poland, Russia (the European part), ex. DDR and in Sweden and West Germany. The purpose is to discuss the mothers' situation with reference to their relation to three spheres - tlie family and social networks, public social policies and the working life. One basic question that is if the situation of single women with children is more exposed tlian that of the married women, and what possible consequences this might have for themselves and their children. How do single mothers differ from married mothers in the respective countries as far as education, incomes, work and views on the future are concerned? Despite comprising economic and social dissimilarities between these countries, comparisons are interesting since we focus the comparisons on married and single mothers with children. Hereby we get a measure of the structures and processes within these countries, and it can be discussed whether these are generally applied or not. An important aspect is to what extent the social policies or other factors lead to different attitudes in the countries. The results show that the transformation in the former communist nations afflict particularly women, and only in a negative manner. Large groups of women are rejected from the labour märket, and end up in a situation of poverty and dependence. The investigations in all the countries show that single mothers are more exposed than married mothers. They run a greater risk of losing their jobs than the married mothers do, and they thus run a greater risk of ending up in miserable poverty - particularly the mothers in Poland and Russia. The situation of single mothers in Sweden is better from a material point of view. In spite of this, many lone mothers feel worried about their economy - a worry that can be expected to increase along with increasing fees for social services, child care, health- and medical care, increased residential costs etc. The results indicate that the largest disability that women have on the labour märket is not the motherhood in itself, nor is it the gender, but the absence of marriage, in combination with being female. Comprising international research shows that poverty and exposition in one-parent families tend to be reproduced to the next generation. There is no automatic relationship in the relation between divorce, one-parenthood and social problems. It is rather the stigmatisation in different forms that is concerned, in combination with shortages in the possibilities of support that can lead to an assimilation of prolems. Via stigmatising treatment, both the mothers and the children lose their dignity and their self-assured identity.

Background Even before the US upswing of the current COVID pandemic, the number of sickle cell disease (SCD) patients coming to hospitals and EDs appeared to fall drastically. This happened despite SCD patients having often been heavy utilizers of the ED and hospital for their iconic vaso-occlusive crises (VOC). Though ambulatory SCD clinics quick converted largely to telehealth in order to comply with stay-at-home orders designed to suppress person-to-person transmission, some SCD patients appeared to avoid care, delay care, or refuse doctors' invitations for care. Presumably patients did so out of COVID fears, but this has not been confirmed in the literature. Further, whether these patients had COVID symptoms but stayed at home has not been studied. As part of quality improvement (QI) to conduct COVID surveillance in an adult sickle cell program, we sought to explain and predict SCD health care utilization patterns we were observing, as well as to determine urgent physical and mental health needs of patients who appeared to be avoiding care. Methods Fifteen staff in the Adult Sickle Cell Medical Home at Virginia Commonwealth University, a large urban academic medical center, conducted a telephone survey ("wellness check"was used when we talked to patients) of all known adults with SCD over 19 days in 2020. A staff member confirmed the patient had SCD, asked permission to proceed, then asked about symptoms consistent with COVID-19. At the end of the telephone survey, respondents wer invited to complete an email survey of sickle cell and COVID-19 utilization attitudes (19-33 items, depending on the response pattern, either drawn from the National Health Interview Survey, from the Adult Sickle Cell Quality of Life Measurement quality of care survey, or drafted by the authors), the Sickle Cell Stress Survey-Adult (SCSS-A, a 10-item previously validated survey), and anxiety and depression (PHQ9 of the PRIME-MD). Results Of 622 adults approached by phone call, 353 responded to the following yes/no screening questions regarding the prior 14 days: fever over 100 F 0/353 (0.00%); cough 3/353(0.01%); difficulty breathing 0/353(0.00%); unexplained shortness of breath 2/353(0.01%); sore throat 2/353 (0.01%); unexplained muscle soreness 2/353(0.01%);contact with anyone who tested positive for COVID-19 2/353(0.01%); testing for COVID 19 6/353(0.02%). For QI purposes, we set a threshold of three or more COVID-associated symptoms or the presence of fever as criteria requiring intense telephone or in-person staff monitoring for the following week. Only three patients met criteria. A total of 219/353 had email surveys sent. Of 63 patients (28.8%) who returned email surveys by June 10, 2020, 35.9% had already managed a "pain attack" at home 4 or more times in the prior 12 months, and 45.5% of these said their bad ER experiences were very or somewhat important in that decision. In the prior 14 days, although 30/64 reported a crisis for at least one day, only 4/64 had visited the Emergency Department for pain. On a 0-10 scale, 21/61 patients endorsed "0" for worry that they would be COVID-infected by going for medical care (weighted mean 3.9), but 18/59 endorsed "10" for worry they were more at risk of COVID because of SCD (weighted mean 6.31), and 22/60 endorsed "10" for worry they would fare worse than others if COVID infected (weighted mean 6.97). Many patients forwent "needed" care (16/62) or delayed "needed" care by at least a day (36/61). Eleven patients met criteria for moderately severe to severe depression on the PHQ-9, and 28/63 somewhat or strongly agreed with the statement "death is always on the back of my mind" on the SCSS-A. Conclusions In adolescents and adults with SCD, many were already reticent to come to the ED for pain, but a significant portion reported delays or avoidance of needed care during the early stages of the US COVID pandemic, and few reported using the ED despite over half reporting at least one crisis day in 14. Patients nonetheless reported very few COVID-associated symptoms. Fears of COVID infection/susceptibility may limit visits for needed sickle cell care among adults. Acknowledgements: Mica Ferlis RN, FNP, Caitlin McManus, RN, FNP, Emily Sushko, RN, FNP, Justin West, RN, Kate Osborne, RN, Stefani Vaughan-Sams, Marla Brannon, BS, Nakeiya Williams, BS Disclosures Smith: GlycoMimetics, Inc.: Consultancy; Emmaeus Pharmaceuticals, Inc.: Consultancy; Novartis, Inc.: Consultancy, Other: Investigator, Research Funding; Global Blood Therapeutics, Inc.: Consultancy, Research Funding; Shire, Inc.: Other: Investigator, Research Funding; NHLBI: Research Funding; Patient-Centered Outcomes Research Institute: Other: Investigator, Research Funding; Health Resources and Services Administration: Other: Investigator, Research Funding; Incyte: Other: Investigator; Pfizer: Consultancy; Ironwood: Consultancy; Novo Nordisk: Consultancy; Imara: Research Funding; Shire: Research Funding.

Background:Rheumatoid arthritis (RA) is a widespread chronic disease affecting about 1% of the population in the West. It is characterised by pain, fatigue and inflammation that can flare-up without warning. This makes the condition difficult to predict and manage. Bury (1982) introduced the concept of chronic illness as a disruptive experience to one’s self-identity. This is often an invisible part of managing the illness and taken for granted by others, such as family members, friends and health care professionals. Thus, there is a need to raise awareness of the patients’ lived experiences of self-managing this long-term chronic illness.Objectives:We aimed to collaborate with people with RA to (i) record and reflect the community’s strengths and concerns; (ii) raise awareness of the lived experience of self-managing RA (iii) spark a dialogue among key stakeholders around the self-management of RA.Methods:A purposeful sample of people with RA (n=12) was recruited. An innovative qualitative methodology, Photovoice, was used (Wang & Burris, 1997). A series of small group workshops took place. Participants were provided with cameras and appropriate training. They were asked to take photographs of the“challenges and solutions to living with RA” over approximately two weeks. Semi-structured interviews were conducted incorporating photo elicitation. As a group, the participants, a visual artist and researcher co-created a photo exhibition for the public.Results:Participants selected 32 photographs for the exhibition. They carried out a thematic analysis of the photos identifying four themes:•I’m Here but I’m Not– this theme reflected feelings of alienation and social isolation.•Medicine in all its forms –this theme captured attitudes towards medication and devices, as well as the creative ways people coped with RA.•Visible illness– this concerned the recognition of RA. It captures the experience of RA as a “contested illness” and the challenge of gaining medical and cultural legitimacy.•Mind yourself –this theme highlighted the value of self-care, often closely connected with the natural world and engagement with social activities.Exhibitions were held at a community arts centre and a large central hospital in Dublin city. A plain language report was also collaboratively produced.Conclusion:This study shows how participatory methods can be used to explore the hidden experience of living with an invisible illness. This research design enabled participants to use photographs to reflect on their experiences and the meaning they intended to convey, thereby increasing trustworthiness of the findings through individual and group member checking. This approach extends beyond traditional written and verbal responses to share the worldview of participants. It demonstrates how to work with patients to create opportunities to improve awareness and spark dialogue among those who play a role in supporting the self-management of chronic illness. The integration of creative arts and participatory methods can have a positive impact for those involved in research and can enhance public engagement with research.References:[1]Bury, Michael (1982) Chronic Illness as Biographical Disruption. Sociology of Health & Illness. 4. 167-82.[2]Wang, C., & Burris, M. A. (1997). Photovoice: Concept, Methodology, and Use for Participatory Needs Assessment.Health Education & Behavior,24(3), 369–387.Acknowledgments:Funding is awarded from the UCD Wellcome Trust Institutional Strategic Support Fund as part of a Medical Humanities and Social Science Collaboration Scheme (ref 204844/Z/16/Z).As part of a Patient and Public Involvement (PPI) strand, a Research Advisory Group composed of people living with RA was supported the design and execution of this project.Disclosure of Interests:None declared

BackgroundThe search for causal links between human resource management (HRM) and organisational performance has dominated academic and practitioner debates for many years. However, much of this work comes from contexts outside health care and/or the UK.ObjectivesThis study tested the later stages of a well-established HRM model, testing whether or not there was evidence of causal links between staff experience and intermediate (staff) and final (patient and organisational) outcomes, and whether or not these differed in parts of the NHS. We used large-scale longitudinal secondary data sets in order to answer these questions in a thorough way.Data sourcesSearches were conducted using Health Management Information Consortium, MEDLINE, PsycINFO, Social Sciences Citation Index and EBSCOhost(from inception to May 2012).MethodsStaff experience data came from the national NHS staff surveys of 2009, 2010 and 2011, with trust-level measures of staff absenteeism, turnover, patient satisfaction, mortality and infection rates gathered from the same NHS years. Several analytical methods were used, including multilevel analysis, mediated regression, latent growth curve modelling and cross-lagged correlation analysis.ResultsIn general, the pattern was that better staff experiences are associated with better outcomes for employees and patients. Multilevel analysis found that the positive effects of staff perceiving equal opportunities on employee outcomes were especially strong, as were the negative effects of aggression and discrimination. Organisational-level analysis showed that better staff experiences (particularly those associated with better well-being and better job design, and more positive attitudes about the organisation generally) were linked to lower levels of absenteeism and greater patient satisfaction. There was some evidence that the relationship with absenteeism is causal, although the causal link with patient satisfaction was less clear-cut. Some relationships between staff experience and turnover, and some between staff experience and patient mortality, were also found (and a few with infection rates), with longitudinal analysis comparatively unclear about the direction of causality. Although many staff experiences were associated with absenteeism and patient satisfaction, these effects were not mediated and the reason staff experiences are linked to patient satisfaction appears to be separate from the link with absenteeism. In general, there is no single group of staff (or geographical region) for which staff experiences are the most important. However, nurses’ experiences generally had the strongest effects on absenteeism, followed by medical/dental staff. Few clear or explainable patterns for other staff group effects were found. Absenteeism was most readily predicted by staff experience in the West Midlands. Two Action Learning Sets of managers, and patient and public involvement representatives broadly supported the emerging findings of the factors that seemed to be important indicators of staff satisfaction and organisational outcomes.LimitationsThe relatively blunt nature of the data used meant that conclusions about the direction of causality were less clear. More specific limitations included that we had to limit outcome variables to those that were available already, that many variables were available for acute trusts, and that we could not break down data further within trusts or years.ConclusionsOverall, the research confirmed many expected links between staff experiences and outcomes, providing support for that part of the overall HRM model in the NHS. However, conclusions about the direction of causality were less clear (except for absenteeism). This is probably due in part to the relatively blunt nature of the data used. Future research may involve the careful evaluation of interventions designed to improve staff experience on more specific groups of staff, and the continued use of secondary data sources, such as those used in this report, to answer more specific, theoretically driven questions.FundingThe National Institute for Health Research Health Services and Delivery Research programme.

Despite the well-documented health benefits of breastfeeding and recommendations by the Department of Health for women to exclusively breastfeed for approximately the first six months of life and continuation beyond one year, a large percentage of South African women do not breastfeed their infants, or only do so for a short period of time. No national South African statistics are available but figures emerging from the attendance of mothers at a baby clinic on the West Rand in Gauteng indicated the following: 64% of the mothers breastfeed up to six weeks, after which the figure rapidly declines to less than 20% at three months (Truter 2007). Several studies have assessed the attitudes of health care personnel towards breastfeeding, but little is known of the type of information given to breastfeeding mothers by private medical practitioners who are the frontline of contact with clients and who may convey information that either promotes or discourages breastfeeding. The following question was thus formulated: With regard to breastfeeding, what are the constraints to breastfeeding in private practice?Therefore, in order to understand the constraints to breastfeeding, the purpose of this study was to assess the breastfeeding information given to pregnant women by health professionals in private practice. The specific objectives of the study were to determine the breastfeeding recommendations made by private health professionals during pregnancy, to describe the management of breastfeeding in the consulting rooms of private medical practitioners, and to describe women’s experiences of breastfeeding in private hospitals. In Phase 1 of the study the population comprised all mothers who attended a support group for new mothers at a private post-natal clinic In Phase 2 the population comprised all mothers who attended a community baby clinic or support group. The sample consisted of all primigravidae who breastfed or attempted to breastfeed in the first six weeks.Purposive convenient sampling, as described by Babbie and Mouton (2002:166), was used in both phases of the study. All participants chose a gynaecologist as the primary care giver and delivered in various private hospitals in Johannesburg. Data were collected by means of an anonymous questionnaire, compiled from national and international literature, as well as personal interviews. Data from the questionnaires were analysed by hand. Descriptive statistics were applied. The interviews were analysed according to the descriptive analysis suggested by Tesch (in Creswell, 1994:155). Themes that emerged were clustered and coded. A co-coder, experienced in the field of qualitative research, assisted with the analysis of the transcripts of the interviews. A literature control was conducted to validate the findings. Ethical considerations were based on the DENOSA Ethical Standards for Nurse Researchers (1998:2.3.2–2.3.4). Themes and sub-themes were identified.OpsommingTen spyte van die goed gedokumenteerde gesondheidsvoordele van borsvoeding en die aanbevelings van die Departement van Gesondheid dat vroue vir ongeveer die eerste ses weke tot een jaar uitsluitlik moet borsvoed, word gevind dat 'n groot aantal Suid-Afrikaanse vroue hul babas nie borsvoed nie, of slegs vir 'n kort tydperk borsvoed. Geen nasionale Suid-Afrikaanse statistiek is beskikbaar nie, maar 64% van moeders wat 'n babakliniek besoek het op die Wes Rand in Gauteng borsvoed steeds op ses weke, waarna die aantal borsvoedende moeders verminder tot minder as 20% op drie maande (Truter 2007). Verskeie studies het die houding van gesondheidspersoneel ten opsigte van borsvoeding bepaal, maar min is bekend oor die tipe inligting wat deur die mediese praktisyn aangebied word. Hierdie praktisyn het eerstehandse kontak met die kliente en mag inligting aanbied wat borsvoeding kan bevorder of belemmer. Die volgende vraag is dus geformuleer: Met betrekking tot borsvoeding, wat is die beperkinge in privaat praktyk?Die doel van hierdie studie was om vas te stel watter borsvoedinginligting deur gesondheidspersoneel in privaatpraktyk aan swanger vroue oorgedra word. Die doelwitte van die studie was om die aanbevelings om te borsvoed te bepaal, om die behandeling en sorg in die spreekkamer van die geneesheer te beraam, en om die vroue se belewenisse van borsvoeding in privaat hospitale te ondersoek. In Fase 1 van die studie het die populasie bestaan uit alle moeders wat 'n ondersteuningsgroep by 'n privaat nageboortekliniek bygewoon het. In Fase 2 was die populasie alle moeders wat 'n ondersteuningsgroep bygewoon het en 'n babakliniek besoek het. Die steekproef het bestaan uit alle primigravidae wat borsvoed of probeer het om te borsvoed gedurende die eerste ses weke.Doelgerigte gerieflikheidssteekproefneming, soos beskryf deur Babbie and Mouton (2002:166), is in albei fases van die studie gebruik. Alle deelnemers het 'n ginekoloog as primêre sorggewer gebruik en het in verskillende Johannesburgse hospitale gekraam. Data is deur middel van anonieme vraelyste, saamgestel uit nasionale en internasionale literatuur, ingesamel sowel as deur middel van persoonlike onderhoude. Data vanaf die vraelyste is deur die navorser ontleed en beskrywende statistiek is toegepas. Die onderhoude is ontleed volgens die beskrywende analise voorgestel deur Tesch (in Creswell, 1994:155). Temas is saamgevoeg en gekodeer.'n Mede-kodeerder was behulpsaam met die ontleding van die transkripsies van die onderhoude. Literatuur is aangewend as kontrole om die bevindinge te valideer. Etiese oorwegings is gebaseer op die DENOSA Etiese Standaarde vir Verpleegnavorsers (1998:2.3.2–2.3.4). Temas en subtemas is geïdentifiseer.

Background: There is an increase in the suicide rate by 43% in the last three decades (from 1975 to 2005). All the five States viz. Tamil Nadu, West Bengal, Andhra Pradesh, Maharashtra and Karnataka have registered consistently higher number of suicidal deaths during the last few years. Attitude plays a key role in preventing suicide and also providing quality care. Aim: To assess the attitude towards suicide among medical and paramedical personnel. Methodology: This study was carried out at Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation (Dr. PSIMS & RF). Medical professionals and paramedical personnel of our hospital were taken as study group and individuals from general population were taken as the control group. Suicidal attitude questionnaire was employed to measure attitude. Results: Positive attitude towards suicide was observed more among the medical professionals when compared to paramedical and control groups. Conclusion: Levels of attitude towards suicide is not similar for each individual and also differs in between the groups .Low levels of positive attitude among paramedical and control group indicates the need to increase awareness of suicide among the general population and paramedical group for prevention of suicides and to provide better care.

The management of obstetric health is a delicate issue in Cameroon where the use of obstetric care takes into consideration several parameters such as socio-cultural, economic, and medical ethical constraints. As a result, populations are divided between the biomedical obstetric care system and the traditional one. This implies a diversification of therapeutic routes. As a result of advances in biomedicine and obstetrics, the biomedical system has taken over the monopoly of expertise in this field. However, through traditional methods, means, and elements of nature, people in developing countries are investing in the quest for health. The field of obstetrics is no exception to this approach whereby Africans, especially the Bamoun, seek solutions to their health problems. However, this approach is, according to the biomedical obstetric system, its prerogative, because it is the only one to hold the secrets and cogs of a sensitive and complex practice. Faced with two «incompatible» medical cultures that still covet the same object that is obstetric health, can we not think of a possible complementarity between these two systems of care? Through a study on the use of modern and/or traditional oxytocics during the gestational period in Bamoun women from West Cameroon, this work aims to analyse the reasons for the «supposed» incompatibility between these two care systems and highlight the failures or limitations and benefits of oxytocics on a case-by-case basis in these care systems. This article is also interested in exploring the possibility of complementarity between these two care systems in terms of gestational period management from modern and traditional oxytocics. For this reason, individual interviews have been used to collect data in certain rural and urban areas of the Bamoun region to enable the objectives to be achieved.

Abstract Background Interprofessional simulation based education (IPSBE) programs positively impact participants' attitudes towards interprofessional collaboration and learning. However, the extent to which students in different health professions benefit and the underlying reasons for this are subject of ongoing debate. Methods We developed a 14-h IPSBE course with scenarios of critical incidents or emergency cases. Participants were final year medical students (FYMS) and final year anesthesia technician trainees (FYATT). To assess attitudes towards interprofessionalism, the University of the West of England Interprofessional Questionnaire was administrated before and after the course. Using focus group illustration maps, qualitative data were obtained from a subcohort of the participants (n = 15). Results After the course, self-assessment of communication and teamwork skills, attitudes towards interprofessional interactions and relationships showed comparative improvement in both professions. Attitudes towards interprofessional learning improved only in FYMS. Qualitative data revealed teamwork, communication, hierarchy and the perception of one’s own and other health profession as main topics that might underlie the changes in participants’ attitudes. An important factor was that participants got to know each other during the course and understood each other's tasks. Conclusions Since adequate communication and teamwork skills and positive attitudes towards interprofessionality account to effective interprofessional collaboration, our data support intensifying IPSBE in undergraduate health care education.

Abstract Background Good attitude on collaborative care between nurses and midwives with physicians is crucial for better team working. This further enables those vital health care professionals to provide quality and improved care for their clients. Objective To assess the attitude of nurses and midwives towards collaborative care with physicians in Jimma University medical center, Jimma, South West Ethiopia. Methodology The institution-based cross-sectional study was conducted from March 20 to April 8, 2019, using a semi-structured and standardized questionnaire. Study units were selected by simple random sampling using the lottery method. A total of 410 participants were included in the study. Data were entered into Epi data version 4.2 and exported to statistical packages for social sciences version 23 for cleaning and further analysis. Descriptive statistics were presented with tables, figures, and narratives. The level of significance was set at a p value of less than 0.05 in multivariable logistic regression. Results and conclusion More than five out of ten, 234 (57.2%) of participants had a good (good attitude is defined in the operational definition section of methodology) attitude towards collaborative care with physicians, and the rest 175 (42.8%) poor attitude toward it. Participants had the highest median score in the shared education and teamwork (26.0) subscale and midwives were found to have higher mean rank scores compared to nurses. It was only in the nurse's/midwife's autonomy subscale that a statistically significant difference was found (Z = − 2.92, p value = 0.003). More generally, more than have of the participants had a good attitude on providing care collaboratively with physicians, though a significant proportion of nurses and midwives also rate collaborative care provision with physicians as poor. Recommendations The findings of this study suggested that interventions are needed to be taken to improve nurse's and midwife’s attitudes on the provision of collaborative care with physicians. Enhancement of shared education, cooperation rather than dominance and caring attitude are all vital. These all could in turn enhance the quality of care provided for clients.

Abstract Introduction Transition from adolescence to adult care is very challenging for most patients. Without appropriate appointments and education, adolescents can get lost to follow up within one-year of transitioning to adult care (Mistry et al. Diabet Med 32(7):881–885, 2015). Loss to follow-up can increase risks of adverse short and long term diabetes-related complications, with healthcare contacts mainly limited to crisis-based management (Iversen et al. Scand J Caring Sci 33(3):723–730, 2019). Aims The purpose of this study was to evaluate the patient’s perspective of the process of transition from paediatric to adult-based diabetes services in the Mid-West Region of Ireland. Methods We implemented a new transition clinic at University Hospital Limerick with the collaboration of paediatric and adult endocrinology teams. Eighteen patients opted to attend the clinic, but only 17 patients consented to participate in a qualitative assessment study and completed questionnaires before and after the transition clinic. Results and conclusion In terms of medical management, patients had a good understanding of hypoglycaemia and insulin dose adjustment principles, but were least comfortable with carbohydrate counting. Patients self-ranked their knowledge on driving and sexual health with a diagnosis of diabetes as poor, in comparison to understanding effects of alcohol and smoking on diabetes. Overall, a majority of the respondents felt more confident in moving to adult-care after attending the transition clinic.

ObjectivesEnvironmental sustainability is an important concern within the National Health Service. Compared with other specialties, there has been little research within palliative care. This study aims to calculate the carbon footprint of a specialist palliative care unit.MethodsResources grouped into medical, non-medical, travel, energy and waste were collected for the year 2021 in a hospice in the South West of England. Following a top-down approach, the activity used for each resource was multiplied by an emissions factor to calculate the carbon footprint. Staff attitudes were also surveyed.ResultsThe hospice carbon footprint was calculated as 420 tonnes kgCO2e. Travel (35%) was the highest contributor to emissions followed by gas (33%) and non-medical supplies (17%). There were 95 responses to the staff survey (59% response rate) with strong enthusiasm towards sustainable practices.ConclusionThis is the first study to estimate the carbon footprint of a specialist palliative care unit. Compared with other specialties, palliative care has relatively low greenhouse gas emissions. Identifying sources of carbon equivalent production can be a first step into developing interventions to reduce this use. Our carbon footprint study will be used by the Hospice Sustainability Group to reduce our unit’s carbon footprint.

Abstract Men who have sex with men (MSM) in Senegal face a challenging socio-legal context, marked by homophobia and the illegality of homosexuality. In addition, human immunodeficiency virus (HIV) prevalence among MSM is 27.6%, 46 times greater than the one in the general population (0.5%). Nevertheless, access to healthcare by MSM may be hampered by stigmatizing attitudes from health facility staff (medical and non-medical). This article describes the health facility staff/MSM relationship and analyses its effects on access to healthcare by MSM. The data used were collected through a field survey based on observations and qualitative interviews conducted in 2019 and 2020 with 16 MSM, 1 non-governmental organization (NGO) staff and 9 healthcare providers in Dakar (the capital city) and Mbour (secondary city on the West Coast) hospitals. The data were subject to a thematic analysis assisted by the ATLAS software. The relationship between MSM and healthcare providers is ambiguous. On the one hand, healthcare providers are torn between their professional duty to treat MSM and the cost of being stigmatized by other colleagues. Therefore, they often limit their empathy with MSM within the hospital context. On the other hand, MSM, trusting in the confidentiality of healthcare providers, feel safe in the care pathway. However, we identify the following stigmatizing factors limiting access to care include (1) fear of meeting a relative, (2) difficult relationships with non-medical support staff (mainly security guards), (3) HIV status disclosure and (4) potential conflicts with other MSM. This study is unique as it includes non-medical staff in its respondents. It shows that hospitals are divided into several areas, based on the stigma perceived by MSM. It is important to map out MSM’s care trajectories and spaces and to identify all types of staff working within them, including non-medical staff, and enrol them in stigma reduction interventions.

In Africa, the emergence of a “modern” mental health regime centered on psychiatry is often portrayed as a unidirectional intervention by “the West.” Analyses ranging from medical histories of colonial psychiatry to more recent studies of Global Mental Health focus mostly on the role of external actors and the ways their actions impact(ed) on local populations. Uncritical studies simply reduce the complexity of African therapeutic landscapes to a “treatment gap” and see the introduction of “science-based” mental health approaches as necessary “civilizing” missions. Critical studies emphasize the harms of psychiatric interventions and celebrate local healing practices instead. Both approaches are problematic: they ignore the many interconnections between highly dynamic treatment regimes that cannot be neatly designated as African or western, portray local populations as largely passive, and neglect the multiple ways in which psychiatry has been embraced, adapted, and disrupted by Africans themselves. This article challenges simplistic depictions of “western” psychiatry in Africa by providing a portrait of Rwashana Selina, the first Ugandan psychiatric nurse who—after being sent to the UK in the 1950s for training—became a central figure in Ugandan psychiatry. Based on interview material, I recount her life story and discuss her formative role in the development of psychiatric care in the colonial and postcolonial era. Rwashana's tale of Ugandan psychiatry emphasizes co-operation, mutual acknowledgments and pluralistic leadership and thus breaks with typical images of and dichotomies between white doctors and supposedly inferior African medical staff.

Abstract Background During the first wave of the pandemic when clinical placements were suspended, a UK medical student volunteering programme was developed to support local GP practices. This study aimed to explore the impact that volunteering in primary care had on students’ learning and professional development to inform the design of future service-learning curricula innovations. Methods Seventy medical students across all years volunteered across forty-five GP practices in north-west London. Ten volunteer students and six GPs who had hosted students volunteered to participate in remotely conducted, semi-structured interviews with a researcher. Transcriptions were independently coded by two researchers and analysed by thematic analysis using service learning and communities of practice as sensitising concepts. Results Analysis showed a strong alignment between the views of students and GPs in terms of perceived learning. Our analysis of both sets of interviews resulted in five themes describing student outcomes from the volunteering scheme: developing as a doctor, understanding the complexity of medicine, responsibility driven learning, a meaningful role in a community of practice, and seeing behind the scenes in primary care. Discussion and conclusion Results from this study highlighted how a meaningful service-led role and responsibility in primary care can empower and motivate students to learn beyond the traditional medical curriculum and assessments. Adopting these new ‘pro-active’ roles within general practices led volunteers, particularly those in the early years of study, to develop a better understanding of primary care and medical complexity. It also enhanced their professional skills, attitudes and behaviours, while having a beneficial impact on patient care during the pandemic.

Abstract Background The aims of Evidence-Based medicine (EBM) are to promote critical thinking and produces better patients’ outcome (Profetto-McGrath J, J Prof Nurs Off J Am Assoc Coll Nurs 21:364-371, 2005). Accreditation Council for Graduate Medical Education (ACGME) competencies require trainees to locate, appraise and apply clinical evidence to patients’ care. Despite the emphasis that ACGME place on EBM, few organizations provide adequate training in EBM. This is even more critical in regions where medical trainees matriculate from diverse backgrounds of undergraduate medical education, where EBM may not be emphasized nor taught at all. EBM practice has a history of research in the West, however, EBM has not been widely studied in the Middle East. Methods Clinicians and trainees at Hamad Medical Corporation (HMC) matriculate from many countries in the Middle East and North Africa (MENA) and Asia. Because trainees in Graduate Medical Education (GME) come to HMC from a variety of geographic backgrounds, it is assumed that they also have a variety of experiences and aptitudes in EBM. To assess trainees EBM attitudes and knowledge in the internal medicine department at HMC in Doha, Qatar, the authors surveyed residents and fellows using a two-part survey. The first part was adapted from the evidence-based practice inventory by Kaper to assess trainees’ attitudes and perceptions of EBM. Trainees were also asked to complete the Assessing Competency in Evidence Based Medicine (ACE) tool to evaluate their aptitude in different elements of EBM. The results from the two parts were analyzed. Results The average score on the ACE tool among the participants was 8.9 (±1.6). Most participants rated themselves as beginners or intermediate in their EBM capabilities. Higher ACE scores were observed from participants with educational background from South Asia, and among those with more favorable attitudes towards EBM. There was no clear pattern that early incorporation of EBM into practice will result in better ACE score. Participants also reported reasonable abilities in EBM tasks and a favorable work atmosphere for EBM implementation. Lack of knowledge, resources, and time were the most reported barriers to utilizing EBM. Conclusions While it is clear that participants are enthusiastic about EBM and see it as a useful method for clinical decision making, their aptitude in EBM is not optimal and there are gaps and barriers for them to practice.

Abstract Background In the absence of a well-rounded syllabus that emphasises both interpersonal and medical dimensions in clinical communication, medical students in the early stages of their career may find it challenging to effectively communicate with patients, especially when dealing with perceived priorities and challenges across different disciplines. Methods To explore the priorities, challenges, and scope of clinical communication teaching as perceived by clinicians from different clinical disciplines, we recruited nine medical educators, all experienced frontline clinicians, from eight disciplines across seven hospitals and two medical schools in Hong Kong. They were interviewed on their clinical communication teaching in the Hong Kong context, specifically its priorities, challenges, and scope. We then performed interpretative phenomenological analysis of the interview data. Results The interview data revealed five themes related to the priorities, challenges, and scope of clinical communication teaching across a wide range of disciplines in the Hong Kong context, namely (1) empathising with patients; (2) using technology to teach both the medical and interpersonal dimensions of clinical communication; (3) shared decision-making with patients and their families: the influence of Chinese collectivism and cultural attitudes towards death; (4) interdisciplinary communication between medical departments; and (5) the role of language in clinician–patient communication. Conclusions Coming from different clinical disciplines, the clinicians in this study approached the complex nature of clinical communication teaching in the Hong Kong context differently. The findings illustrate the need to teach clinical communication both specifically for a discipline as well as generically. This is particularly important in the intensive care unit, where clinicians from different departments frequently cooperate. This study also highlights how communication strategies, non-verbal social cues, and the understanding of clinical communication in the Hong Kong Chinese context operate differently from those in the West, because of differences in sociocultural factors such as family dynamics and hierarchical social structures. We recommend a dynamic teaching approach that uses role-playing tasks, scenario-based exercises, and similar activities to help medical students establish well-rounded clinical communication skills in preparation for their future clinical practice.

Abstract Background/Aims The COVID-19 pandemic led to the widespread adoption of remote consultations. Whilst remote consultations offer many potential advantages to patients and healthcare services, they are unlikely to be suitable for all. Guidance encourages clinicians to consider patient preferences when choosing face-to-face vs remote consultations. However, little is known about acceptability of, and preferences for remote consultations, particularly amongst patients with musculoskeletal conditions. This study aimed to explore the acceptability of, and preferences for, remote consultations among patients with osteoporosis and rheumatoid arthritis. Methods Data for this study derived from three UK qualitative studies: iFraP (improving fracture prevention study), Blast Off (BO; Bisphosphonate aLternAtive regimenS for the prevenTion of Osteoporotic Fragility Fractures), and ERA (Exploring people with Rheumatoid Arthritis’ experience of the pandemic). Each study explored patient experiences of accessing and receiving healthcare during the pandemic year. Transcripts from each data set relating to remote consulting were extracted. A minimum of two study team members worked independently, following a consistent approach, to conduct a rapid deductive analysis using the Theoretical Framework of Acceptability (TFA). The TFA consists of 7 constructs to understand acceptability of, in this context, remote consultations, including: affective attitudes; intervention coherence; perceived effectiveness; burden; self-efficacy; opportunity-costs; and ethicality. Following coding, the findings of all three studies were pooled. Analysis was facilitated by group meetings to discuss interpretations. Results Findings from 1 focus group and 64 interviews with 35 people, who had mostly experienced telephone consultations, were included the analysis. Participants’ emotional attitudes to remote consultations, views on fairness (ethicality) and sense making (intervention coherence) varied according to their specific needs for the consultation and values, relative to the pandemic context; participants perceived remote consultations as making more sense and being ‘fairer’ earlier in the pandemic. Some participants valued the reduced burden associated with remote consultations, while others highly valued, and did not want to give up, non-verbal communication or physical examination associated with face-to-face consults (opportunity costs); although perceived need for physical examination in participants with RA was associated with strong preference for face-to-face consultations, asymptomatic participants with RA and osteoporosis also expressed similar strong preferences. Some participants described low confidence (self-efficacy) in being able to communicate in remote consultations and others perceived remote consultations as ineffective, in part due to suboptimal communication. Conclusion Acceptability of, and preferences for remote consultation appear to be influenced by a range of societal, healthcare provider and personal factors and in this study, were not fixed, or condition-dependent. Remote care by default has the potential to exacerbate health inequalities and needs nuanced implementation. The findings have supported the development of patient-centred recommendations for practice that should be considered alongside clinician-focused recommendations when deciding whether remote consultations are appropriate. Disclosure Z. Paskins: Grants/research support; NIHR, Clinician Scientist Award (CS-2018-18-ST2-010)/NIHR Academy. L. Bullock: None. F. Manning: Grants/research support; part funded NIHR Clinical Research Network Scholar Programme. S. Bishop: None. P. Campbell: None. E. Cottrell: None. C. Jinks: Grants/research support; part funded by the NIHR Applied Research Collaboration (ARC) West Midlands. M. Narayanasamy: None. I. Scott: Grants/research support; funded by an NIHR Advanced Research Fellowship Award (NIHR300826). O. Sahota: None. S. Ryan: None.

This study aims to identify factors on the community, the human health and the animal health provider level that determine access to Post Exposure Prophylaxis (PEP) and animal rabies diagnosis in the light of a future integrated bite case management (IBCM) approach for rabies control in Chad. The study was embedded in an overall project conducted from 2016 to 2018, to determine rabies burden and vaccine demand in West and Central Africa. Data collection took place during the projects closing workshops with stakeholders organized between August and September 2018 in the three study zones in Chad covering Logone Occidental and Ouaddaï province and parts of Hadjer Lamis and Chari Baguirmi province. A qualitative approach based on focus group discussion and in-depth interviews was used to get insights on access to care and animal investigation after suspected rabies exposure. A total of 96 participants, including 39 from the community (bite victims, dog owners) and 57 human and animal health providers (health center managers, chief veterinary officers, chief district medical officers, chiefs of livestock sectors) contributed to the study. Based on an existing conceptual framework of access to health care, several points of dissatisfaction were identified, in particular the unaffordability of human rabies vaccine for PEP (affordability) and the distance to travel to a health facility in case of a bite (accessibility). In addition, there are unfavorable attitudes observed highlighted by the importance given to traditional or local rabies care practices to the detriment of PEP (acceptability) and a low level of knowledge among Chadian communities regarding bite prevention, coupled with a very inadequate information and awareness system regarding the disease (adequacy). As for human and veterinary health services, both sectors suffer from insufficient resources for PEP on the human health and rabies diagnosis on the veterinary side impacting negatively on availability and accessibility of both these services. Action to improving provision of rabies health services and increasing knowledge about risk and prevention of the disease among the population need to be undertaken to implement IBCM, improve access to PEP and achieve the goal of eliminating dog mediated human rabies by 2030 in Chad.

Abstract Background Paracetamol, also known as acetaminophen, is one of the most common antipyretic and analgesic over-the-counter (OTC) medicines administered to children due to its efficacy, safety, and availability in many pharmaceutical forms, including suppositories, syrup, and drops. Parents frequently administer the wrong dose of paracetamol by mistake for their children, as reported by many previous studies. We aimed in this study to assess parents’ knowledge, attitudes, and practice regarding paracetamol dosing and toxicity, as well as their awareness regarding paracetamol-containing products. Methods This was a cross-sectional study that targeted parents of children seeking healthcare services at primary health care centers in the Nablus area in the West Bank, Palestine. We used questionnaire-based interviews with parents for data collection. Results A total of 300 parents were included in the study. Most of the caregivers surveyed were (87%) females (mothers). About half the parents (50.9%) reported previously using paracetamol as an antipyretic in children under the age of six. A quarter (25.4%) preferred the syrup forms, while 33.8% preferred the suppository dosage form. Medical personnel was the primary source of information for half the caregivers (51.2%). The mean knowledge score about paracetamol was 2.1 (SD = 1.4) out of 6, and the median was 2.0 with an interquartile range of 1.0–3.0. Two hundred seventy-four (95.5%) of the participants scored less than 80% and were considered to have insufficient knowledge. Only 50.9% of parents recognized that paracetamol overdose could result in serious harm. Conclusions We found a serious lack of knowledge regarding paracetamol dosing, administration, and potential toxicity among Palestinian parents. We recommend raising awareness regarding this problem among healthcare providers and authorities and working on plans that aim to provide caregivers with accurate and adequate information on dosing, formulation, side effects, and other aspects of paracetamol use, as well as developing effective educational plans targeting healthcare providers, as well as the public.

I hate being misunderstood. I guess we all do, but it goes with the territory. I use the word coloured, and he seems offended: 'We Brits don't say 'coloured'. It's regarded as patronising. We say black, if we say anything. And if we do it's for reasons of simple practicality. It doesn't matter. ' Of course, what he seems to be missing, is that the word coloured in South Africa now refers less to skin colour, and more to a distinct cultural group, with it's own language (a dialect of Afrikaans), food (of Malay origin), and music. To say black in this context would be inaccurate, and cause confusion. Danya and Kyla attend the Yeoville Community School, situated in a vibrant and culturally diverse suburb of Johannesburg. On returning from school one day Danya announces: 'We have to do something at school about our culture. What is our culture Daddy?'To which her father replies, 'Go and ask your mother.' 'Well…we're sort of New Age, sort of holistic…', Toni fumbles. A few days later… 'So what did you do in the end?' Soli asks. 'Oh, us and all the other coloured kids sang, Daar Kom die Alabama'1 says Kyla. It would seem that children want to know where they come from. 'I want you to divide yourself up into your different race groups', the facilitator says. We are in a Managing Diversity workshop, and he means the old South African race classification system, but of course he wants to see what we do with it. We end up with a group of Blacks (including three 'Asians'); an African group (including two 'Whites'); a White group (two); and the Human Race (two).'Why didn't you join the white group?' Thloki asks the Human Race.'I don't define myself by my race', I reply.'Ha! Wait till there's a war over resources' he laughs, 'then you'll quickly pick a side!' The postmodernist argument ensues: 'There is no such thing as race…all these arbitrary classifications…it's nothing but a social construct!''Well you never lived as a black person under apartheid. It was very real to me!'The facilitator aims to mediate/translate for the rest of us: 'Well yes, it is just a social construct. But one which had very real consequences for people.' 'Nobody goes into town anymore' a woman says. To which Har Bhajan replies, 'When I was last in town, there were lots of people there.' Of course, what she means is, hardly any white people go into town anymore. (And she's right about that.) But what is that, the way certain people become invisible, depending on who's looking? My friend Karima and I attend an Al Jarreau concert. Fairly expensive tickets, and almost the entire audience is black. I'm not sure why I'm quite so surprised. But this is Sandton, the richest formerly white suburb of Johannesburg. Perhaps working in the NGO sector I've missed how much things are actually changing… I wonder how many people in the audience have been into town lately. With the shift in power, and the -- albeit slow -- levelling of the playing field, now it is possible for white South Africans to be at the receiving end of racial discrimination too… I am visiting my cousin. He is 60, and a musician. But times are tough for him now. His brother was shot dead in his driveway while someone stole his car. And it's hard for him to find work. 'I am too white, now', he says. He is not bitter, just saddened. In his day he had probably the most famous jazz club in Johannesburg. Rumours it was called. 'The best little bootlegger in Bellevue' he called himself. He was known for breaking the law then. His club was racially integrated long before it was allowed. Controversial South African artist, Beezy Bailey, has an alter ego: 'The creation of Joyce was born of the frustration of 'increasingly prevalent affirmative action'. Bailey submitted two artworks for a triennial exhibition. One was with the traditional 'Beezy Bailey' signature (rejected) the other signed 'Joyce Ntobe'! The latter now enjoys an honoured place in the SA National Gallery as part of its permanent collection. When the curator of the SA National Gallery wanted to work on a paper about three black women artists, Joyce Ntobe being one, Bailey let the cat out the bag which caused a huge media 'scandale'.' (Carmel Art) I spent three months in London, and I realised how easy it is to be white there. Or rather, how easy it is to not be white. Of course, it 'doesn't matter' there, because it doesn't matter. It's easy to donate a monthly cheque to Worldvision, and read about the latest chaos in Zimbabwe in the free rag on the tube, and never have to look overwhelming poverty and disease in the face. But when you live on the African continent, you are very aware of being white. At the diversity workshop, I realise how white South Africans seem to get to take the rap here for the actions of white people on the planet. It's not just the effects of apartheid that black South Africans are angry about it seems, it's also the effects of the global economy, that cause the rich to become richer, and the poor to become poorer. Oh sure, that's not just an issue of race, but the poorest on our planet remain 'people of colour', and wealth remains concentrated in the West/North. I realise also that the Black and African groups at the workshop have one thing that they agree on quite strongly - the importance of making the African continent one's focus. Though the two of us in the Human Race group have both read Naomi Klein's No Logo -- and care about the effects on the poor of economic globalisation -- our sense of 'internationalism' is not viewed in a positive light, but seen rather as 'elitist'. * * * 'The thing about the Dutch' says Gary, 'is that they're pragmatic. They're not politically correct -- call the prostitutes prostitutes, not sex workers, but tax them, and give them health care. They have a strong human rights culture.' The Afrikaners are descendents of these transparent, curtainless Dutch. Sometimes I can see it. 'It is not words that make for bigotry, but attitudes', says columnist Ira Pilgrim. 'Some of the most bigoted people I have known always used the 'correct' words.'2 I am not politically correct. There are certain words I'd never use, and couldn't bring myself to, not out of political correctness, but because they're invested with hate. But words like 'whitey', darkie' and 'honky', where I sit, are terms of endearment. I'd never use them on strangers, but amongst friends, they're terms of affection and irony, because we're laughing at ourselves, and each other. 'It's hard to explain to anyone' Gary continues, 'what it's like living in a place where -- from the time you wake up in the morning, till you close your eyes at night -- every breath that you take is politicised.' Gary left the country because he didn't want to be conscripted to fight a war he didn't believe in. He's done well for himself in Europe. But he had to give up his homeland. I catch a 'Zola', the mini-bus taxi named after South Africa's barefoot runner Zola Budd, probably most famous for inadvertently tripping Mary Decker at the 1984 Olympics (Finnegan). Zola was little and fast, like the taxi's that 'zip, zip, zip' -- often to the infuriation of other motorists -- hence the affectionate nickname. They're the peril of the road, but the saviour of the immobile masses, with their unique language and hand signals. I overhear bits of Zulu conversation, including 'Brooke…Ridge…Thorne.' Our soaps, too, are politicised. It would seem that even black South Africans watch The Bold and the Beautiful for light relief. Usually I am the only whitey here, but accepted as just another carless commuter moving from A to B. Despite the safety risks of bad driving, I enjoy it. I did a Zulu course a few years ago. I didn't learn much Zulu -- discovered I don't have the tongue or an ear for African languages -- but I learnt a lot from the course nevertheless. 'Tell us about an experience that you've had, that was a result of cultural misunderstandings' says the facilitator. 'I spent much of my first year at University hungry' says Nhlanhla. 'My white friends would offer me food when I was visiting, but I would refuse, because in our culture, if you ask you don't really want to give. We just hand you a plate.' Nombulelo tells of the time she went on a yoga retreat. She was confused when she started to undress openly in the dormitory, and got disapproving looks from the other women. 'Why?' she wondered, 'we are all women together?' But these were Hindu women, whose sense of modesty was different from the openness of African women. For the whiteys, the major confusion seems to come from the issue of timekeeping. 'African time' is often referred to. Though in London, I did hear talk of 'Caribbean time'. Perhaps the concept of being on time is a particularly Western one (Makhale-Mahlangu). We are visiting friends of friends. There's an unlikely combination at the dinner table. She is tall and dark. I am short and fair. 'So where do you two know each other from?' Cairo asks. 'I'm Andie's sister', Kim replies. She reads the dumbfoundedness in Cairo's face. 'What can I say…my line got a bit deviated!' she laughs. She has my father's sense of humour. So have I. I ask my father, when he first became aware of racial prejudice. 'I was about six years old', he says. 'I threw my ball out of the school grounds, and called to the black man outside: 'Boy, please would you throw my ball back to me?' And the man replied: 'I am not a boy. I am old enough to be your grandfather.'' I am thinking about the time in our lives before we become aware of race… A friend tells me a story about how her six-year-old daughter came home from school and asked, 'Mommy, what's a [racist-term-not-to-be-repeated]?' She'd been called that. The late Lenny Bruce, controversial American comedian and social critic in the sixties, argued that it is 'the word that gives it the power of violence'3, and if we used 'the words' colloquially often enough, and began to invest them with new meanings, they would lose their power to hurt us. I am about to board a bus…'Woza (come) Mama', says the driver. 'Uyaphi?' (Where are you going?) '…green green, I'm going away to where the grass is greener still', come the Reggae sounds from his radio. We are discussing whether we should be focusing on our sameness or our differences. 'Of course we all want the same things…a home, a job, an education for our children', says Karima, but it's our differences that make us interesting.' I agree. Notes 1 Daar Kom die Alabama (Here Comes the Alabama) is a traditional 'Cape Coloured' song, originally sung in tribute to the Alabama, a confederate ship that docked in Cape Town in 1863. On board were Al Jolson-esque (Burlesque) performers, whom the slaves admired, and they imitated their style of performance. This tradition continues still today with the 'Coon Carnival' held on New Years Day and 'Tweede Nuwe Jaar' (Second New Year). It is said that the custom of Tweede Nuwe Jaar originated as a holiday for the slaves, who were too busy attending to their masters' needs on the first. For more information on the Coon Carnival, see http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html. 2 While the author makes some important general points about the drawbacks of political correctness, his reference to South Africa (including the correction) are in fact incorrect. The apartheid government had four major 'population groups' in it's classification system: African (black), Coloured, Asian and White. (The term black was used then only informally.) These were then sub-divided into other categories. See http://www.csvr.org.za/race.htm for further details. 3 The relevant extract from Julian Barry's 1971 play Lenny, can be found at http://www.abc.net.au/rn/talks/8.30/relrpt/stories/s271585.htm. References Barry, Julian. Lenny. Random House, 1971. http://www.freenetpages.co.uk/hp/lennybruce/ Downloaded 14 April 2002. Carmel Art Galleries. Beezy Bailey Curriculum Vitae, at http://www.carmelart.co.za/site/cvbb.htm Downloaded 14 April 2002. Finnegan, Mark. 'The 10 worst mishaps in the history of sport.' Observer Sport Monthly 5 November (2000). http://www.observer.co.uk/osm/story/0,69... Downloaded 14 April 2002. Klein, Naomi. No Logo: Taking Aim at the Brand Bullies. USA: Picador, 2000. http://www.nologo.org/ Downloaded 14 April 2002. Makhale-Mahlangu, Palesa. 'Reflections on Trauma Counselling Methods.' Seminar presented at the Centre for the Study of Violence and Reconciliation, Johannesburg, 31 July 1996. http://www.csvr.org.za/articles/artpales.htm Downloaded 14 April 2002. Martin, Denis-Constant. 'The Famous Invincible Darkies Cape Town's Coon Carnival: Aesthetic Transformation, Collective Representations and Social Meanings', 1998. http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html Downloaded 14 April 2002. Pilgrim, Ira. 'Kikes, Niggers, Queers, Scotchmen and Chinamen', Mendocino County Observer, 22 March (1990). http://www.mcn.org/c/irapilgrim/race02.html Downloaded 14 April 2002. Transfer of African Language Knowledge (TALK). http://www.icon.co.za/~sadiverse/about.htm Downloaded 14 April 2002. Andie Miller was born, and spent the first 23 years of her life at the Southern-most tip of the African continent, in Cape Town. She currently works as webmaster for the Centre for the Study of Violence and Reconciliation, and the National Development Agency in Johannesburg, South Africa. Links http://www.observer.co.uk/osm/story/0 http://www.iias.nl/host/ccrss/cp/cp3/cp3-__171___.html http://www.carmelart.co.za/site/cvbb.htm http://www.csvr.org.za/ http://www.abc.net.au/rn/talks/8.30/relrpt/stories/s271585.htm http://www.csvr.org.za/articles/artpales.htm http://www.nologo.org/ http://www.mcn.org/c/irapilgrim/race02.html http://www.freenetpages.co.uk/hp/lennybruce/ http://www.icon.co.za/~sadiverse/about.htm http://www.csvr.org.za/race.htm http://www.nda.org.za/ Citation reference for this article MLA Style Miller, Andie. "Multiculturalism and Shades of Meaning in the New South Africa" M/C: A Journal of Media and Culture 5.3 (2002). [your date of access] < http://www.media-culture.org.au/0207/shadesofmeaning.php>. Chicago Style Miller, Andie, "Multiculturalism and Shades of Meaning in the New South Africa" M/C: A Journal of Media and Culture 5, no. 3 (2002), < http://www.media-culture.org.au/0207/shadesofmeaning.php> ([your date of access]). APA Style Miller, Andie. (2002) Multiculturalism and Shades of Meaning in the New South Africa. M/C: A Journal of Media and Culture 5(3). < http://www.media-culture.org.au/0207/shadesofmeaning.php> ([your date of access]).

Introduction The scientific validity of climate change claims, how to intervene (if at all) in environmental, economic, political and social consequences of climate change, and the adaptation and mitigation needed with any given climate change scenario, are contested areas of public, policy and academic discourses. For marginalised populations, the climate discourses around adaptation, mitigation, vulnerability and resilience are of particular importance. This paper considers the silence around disabled people in these discourses. Marci Roth of the Spinal Cord Injury Association testified before Congress in regards to the Katrina disaster: [On August 29] Susan Daniels called me to enlist my help because her sister in-law, a quadriplegic woman in New Orleans, had been unsuccessfully trying to evacuate to the Superdome for two days. […] It was clear that this woman, Benilda Caixetta, was not being evacuated. I stayed on the phone with Benilda, for the most part of the day. […] She kept telling me she’d been calling for a ride to the Superdome since Saturday; but, despite promises, no one came. The very same paratransit system that people can’t rely on in good weather is what was being relied on in the evacuation. […] I was on the phone with Benilda when she told me, with panic in her voice “the water is rushing in.” And then her phone went dead. We learned five days later that she had been found in her apartment dead, floating next to her wheelchair. […] Benilda did not have to drown. (National Council on Disability, emphasis added) According to the Intergovernmental Panel on Climate Change (IPCC), adaptation is the “Adjustment in natural or human systems in response to actual or expected climatic stimuli or their effects, which moderates harm or exploits beneficial opportunities” (IPCC, Climate Change 2007). Adaptations can be anticipatory or reactive, and depending on their degree of spontaneity they can be autonomous or planned (IPCC, Fourth Assessment Report). Adaptations can be private or public (IPCC, Fourth Assessment Report), technological, behavioural, managerial and structural (National Research Council of Canada). Adaptation, in the context of human dimensions of global change, usually refers to a process, action or outcome in a system (household, community, group, sector, region, country) in order for that system to better cope with, manage or adjust to some changing condition, stress, hazard, risk or opportunity (Smit and Wandel). Adaptation can encompass national or regional strategies as well as practical steps taken at the community level or by individuals. According to Smit et al, a framework for systematically defining adaptations is based on three questions: (i) adaptation to what; (ii) who or what adapts; and (iii) how does adaptation occur? These are essential questions that have to be looked at from many angles including cultural and anthropological lenses as well as lenses of marginalised and highly vulnerable populations. Mitigation (to reduce or prevent changes in the climate system), vulnerability (the degree to which a system is susceptible to, and unable to cope with, the adverse effects of climate change), and resilience (the amount of change a system can undergo without changing state), are other important concepts within the climate change discourse. Non-climate stresses can increase vulnerability to climate change by reducing resilience and can also reduce adaptive capacity because of resource deployment to competing needs. Extending this to the context of disabled people, ableism (sentiment to expect certain abilities within humans) (Wolbring, “Is there an end to out-able?”) and disablism (the unwillingness to accommodate different needs) (Miller, Parker and Gillinson) are two concepts that will thus play themselves out in climate discourses. The “Summary for Policymakers” of the IPCC 2007 report, Climate Change 2007: Impacts, Adaptation and Vulnerability, states: “Poor communities can be especially vulnerable, in particular those concentrated in high-risk areas. They tend to have more limited adaptive capacities, and are more dependent on climate-sensitive resources such as local water and food supplies.” From this quote one can conclude that disabled people are particularly impacted, as the majority of disabled people live in poverty (Elwan). For instance, CARE International, a humanitarian organisation fighting global poverty, the UN Office for the Coordination of Humanitarian Affairs, and Maplecroft, a company that specialises in the calculation, analysis and visualisation of global risks, conclude: “The degree of vulnerability is determined by underlying natural, human, social, physical and financial factors and is a major reason why poor people—especially those in marginalised social groups like women, children, the elderly and people with disabilities—are most affected by disasters” (CARE International). The purpose of this paper is to expose the reader to (a) how disabled people are situated in the culture of the climate, adaptation, mitigation and resilience discourse; (b) how one would answer the three questions, (i) adaptation to what, (ii) who or what adapts, and (iii) how does adaptation occur (Smit et al), using a disabled people lens; and (c) what that reality of the involvement of disabled people within the climate change discourse might herald for other groups in the future. The paper contends that there is a pressing need for the climate discourse to be more inclusive and to develop a new social contract to modify existing dynamics of ableism and disablism so as to avoid the uneven distribution of evident burdens already linked to climate change. A Culture of Neglect: The Situation of Disabled People As climates changes, environmental events that are classified as natural disasters are expected to be more frequent. In the face of recent disaster responses, how effective have these efforts been as they relate to the needs and challenges faced by disabled people? Almost immediately after Hurricane Katrina devastated the Gulf Coast, the National Council on Disability (NCD) in the United States estimated that 155,000 people with disabilities lived in the three cities hardest hit by the hurricane (about 25 per cent of the cities’ populations). The NCD urged emergency managers and government officials to recognise that the need for basic necessities by hurricane survivors with disabilities was “compounded by chronic health conditions and functional impairments … [which include] people who are blind, people who are deaf, people who use wheelchairs, canes, walkers, crutches, people with service animals, and people with mental health needs.” The NCD estimated that a disproportionate number of fatalities were people with disabilities. They cited one statistic from the American Association of Retired Persons (AARP): “73 per cent of Hurricane Katrina-related deaths in New Orleans area were among persons age 60 and over, although they comprised only 15 per cent of the population in New Orleans.” As the NCD stated, “most of those individuals had medical conditions and functional or sensory disabilities that made them more vulnerable. Many more people with disabilities under the age of 60 died or were otherwise impacted by the hurricanes.” As these numbers are very likely linked to the impaired status of the elderly, it seems reasonable to assume similar numbers for non-elderly disabled people. Hurricane Katrina is but one example of how disabled people are neglected in a disaster (Hemingway and Priestley; Fjord and Manderson). Disabled people were also disproportionately impacted in other disasters, such as the 1995 Great Hanshin Earthquake in Japan (Nakamura) or the 2003 heatwave in France, where 63 per cent of heat-related deaths occurred in institutions, with a quarter of these in nursing homes (Holstein et al.). A review of 18 US heatwave response plans revealed that although people with mental or chronic illnesses and the homeless constitute a significant proportion of the victims in recent heatwaves, only one plan emphasised outreach to disabled persons, and only two addressed the shelter and water needs of the homeless (Ebi and Meehl; Bernhard and McGeehin). Presence of Disabled People in Climate Discourse Although climate change will disproportionately impact disabled people, despite the less than stellar record of disaster adaptation and mitigation efforts towards disabled people, and despite the fact that other social groups (such as women, children, ‘the poor’, indigenous people, farmers and displaced people) are mentioned in climate-related reports such as the IPCC reports and the Human Development Report 2007/2008, the same reports do not mention disabled people. Even worse, the majority of the material generated by, and physically set up for, discourses on climate, is inaccessible for many disabled people (Australian Human Rights Commission). For instance, the IPCC report, Climate Change 2007: Impacts, Adaptation and Vulnerability, contains Box 8.2: Gender and natural disasters, makes the following points: (a) “men and women are affected differently in all phases of a disaster, from exposure to risk and risk perception; to preparedness behaviour, warning communication and response; physical, psychological, social and economic impacts; emergency response; and ultimately to recovery and reconstruction”; (b) “natural disasters have been shown to result in increased domestic violence against, and post-traumatic stress disorders in, women”; and (c) “women make an important contribution to disaster reduction, often informally through participating in disaster management and acting as agents of social change. Their resilience and their networks are critical in household and community recovery.” The content of Box 8.2 acknowledges the existence of different perspectives and contributions to the climate discourse, and that it is beneficial to explore these differences. It seems reasonable to assume that differences in perspectives, contributions and impact may well also exist between people with and without disabilities, and that it may be likewise beneficial to explore these differences. Disabled people are differently affected in all phases of a disaster, from exposure to risk and risk perception; to preparedness behaviour, warning communication and response; physical, psychological, social and economic impacts; emergency response; and ultimately to recovery and reconstruction. Disabled people could also make an important contribution to disaster reduction, often informally through participating in disaster management and acting as agents of social change. Their resilience and their networks are critical in household and community recovery, important as distributors of relief efforts and in reconstruction design. The Bonn Declaration from the 2007 international conference, Disasters are always Inclusive: Persons with Disabilities in Humanitarian Emergency Situations, highlighted many problems disabled people are facing and gives recommendations for inclusive disaster preparedness planning, for inclusive response in acute emergency situations and immediate rehabilitation measures, and for inclusive post-disaster reconstruction and development measures. Many workshops were initiated by disabled people groups, such as Rehabilitation International. However, the disabled people disaster adaptation and mitigation discourse is not mainstreamed. Advocacy by people with disability for accessible transport and universal or “life-cycle” housing (among other things) shows how they can contribute significantly to more effective social systems and public facilities. These benefit everyone and help to shift public expectations towards accessible and flexible amenities and services—for example, emergency response and evacuation procedures are much easier for all if such facilities are universally accessible. Most suggestions by disabled people for a more integrative, accessible physical environment and societal attitude benefit everyone, and gain special importance with the ever-increasing proportion of elderly people in society. The IPCC Fourth Assessment Report is intended to be a balanced assessment of current knowledge on climate change mitigation. However, none of the 2007 IPCC reports mention disabled people. Does that mean that disabled people are not impacted by, or impact, climate change? Does no knowledge of adaptation, mitigation and adaptation capacity from a disabled people lens exist, or does the knowledge not reach the IPCC, or does the IPCC judge this knowledge as irrelevant? This culture of neglect and unbalanced assessment of knowledge evident in the IPCC reports was recognised before for rise of a ‘global’ climate discourse. For instance, a 2001 Canadian government document asked that research agendas be developed with the involvement of, among others, disabled people (Health Canada). The 2009 Nairobi Declaration on Africa’s response to climate change (paragraph 36) also asks for the involvement of disabled people (African Ministerial Conference on the Environment). However, so far nothing has trickled up to the international bodies, like the IPCC, or leading conferences such as the United Nations Climate Change Conference Copenhagen 2009. Where Will It End? In his essay, “We do not need climate change apartheid in adaptation”, in the Human Development Report 2007/2008, Archbishop Desmond Tutu suggests that we are drifting into a situation of global adaptation apartheid—that adaptation becomes a euphemism for social injustice on a global scale (United Nations Development Programme). He uses the term “adaptation apartheid” to highlight the inequality of support for adaptation capacity between high and low income countries: “Inequality in capacity to adapt to climate change is emerging as a potential driver of wider disparities in wealth, security and opportunities for human development”. I submit that “adaptation apartheid” also exists in regard to disabled people, with the invisibility of disabled people in the climate discourse being just one facet. The unwillingness to accommodate, to help the “other,” is nothing new for disabled people. The ableism that favours species-typical bodily functioning (Wolbring, “Is there an end to out-able?”; Wolbring, “Why NBIC?”) and disablism (Miller, Parker, and Gillinson)—the lack of accommodation enthusiasm for the needs of people with ‘below’ species-typical body abilities and the unwillingness to adapt to the needs of “others”—is a form of “adaptation apartheid,” of accommodation apartheid, of adaptation disablism that has been battled by disabled people for a long time. In a 2009 online survey of 2000 British people, 38 per cent believed that most people in British society see disabled people as a “drain on resources” (Scope). A majority of human geneticist concluded in a survey in 1999 that disabled people will never be given the support they need (Nippert and Wolff). Adaptation disablism is visible in the literature and studies around other disasters. The 1988 British Medical Association discussion document, Selection of casualties for treatment after nuclear attack, stated “casualties whose injuries were likely to lead to a permanent disability would receive lower priority than those expected to fully recover” (Sunday Morning Herald). Famine is seen to lead to increased infanticide, increased competitiveness and decreased collaboration (Participants of the Nuclear Winter: The Anthropology of Human Survival Session). Ableism and disablism notions experienced by disabled people can now be extended to include those challenges expected to arise from the need to adapt to climate change. It is reasonable to expect that ableism will prevail, expecting people to cope with certain forms of climate change, and that disablism will be extended, with the ones less affected being unwilling to accommodate the ones more affected beyond a certain point. This ableism/disablism will not only play itself out between high and low income countries, as Desmond Tutu described, but also within high income countries, as not every need will be accommodated. The disaster experience of disabled people is just one example. And there might be climate change consequences that one can only mitigate through high tech bodily adaptations that will not be available to many of the ones who are so far accommodated in high income countries. Desmond Tutu submits that adaptation apartheid might work for the fortunate ones in the short term, but will be destructive for them in the long term (United Nations Development Programme). Disability studies scholar Erik Leipoldt proposed that the disability perspective of interdependence is a practical guide from the margins for making new choices that may lead to a just and sustainable world—a concept that reduces the distance between each other and our environment (Leipoldt). This perspective rejects ableism and disablism as it plays itself out today, including adaptation apartheid. Planned adaptation involves four basic steps: information development and awareness-raising; planning and design; implementation; and monitoring and evaluation (Smit et al). Disabled people have important knowledge to contribute to these four basic steps that goes far beyond their community. Their understanding and acceptance of, for example, the concept of interdependence, is just one major contribution. Including the concept of interdependence within the set of tools that inform the four basic steps of adaptation and other facets of climate discourse has the potential to lead to a decrease of adaptation apartheid, and to increase the utility of the climate discourse for the global community as a whole. References African Ministerial Conference on the Environment. Nairobi Declaration on the African Process for Combating Climate Change. 2009. 26 Aug. 2009 ‹ http://www.unep.org/roa/Amcen/Amcen_Events/3rd_ss/Docs/nairobi-Decration-2009.pdf ›. American Association of Retired Persons. We Can Do Better: Lessons Learned for Protecting Older Persons in Disasters. 2009. 26 Aug. 2009 ‹ http://assets.aarp.org/rgcenter/il/better.pdf ›. Australian Human Rights Commission. “Climate Change Secretariat Excludes People with Disabilities.” 2008. 26 Aug. 2009 ‹ http://www.hreoc.gov.au/about/media/media_releases/2008/95_08.html ›. Bernhard, S., and M. McGeehin. “Municipal Heatwave Response Plans.” American Journal of Public Health 94 (2004): 1520-21. CARE International, the UN Office for the Coordination of Humanitarian Affairs, and Maplecroft. Humanitarian Implications of Climate Change: Mapping Emerging Trends and Risk Hotspots for Humanitarian Actors. CARE International, 2008. 26 Aug. 2009 ‹ http://www.careclimatechange.org/files/reports/Human_Implications_PolicyBrief.pdf ›, ‹ http://www.careclimatechange.org/files/reports/CARE_Human_Implications.pdf ›. "Disasters Are Always Inclusive: Persons with Disabilities in Humanitarian Emergency Situations." Bonn Declaration from the International Conference: Disasters Are Always Inclusive: Persons with Disabilities in Humanitarian Emergency Situations. 2007. 26 Aug. 2009 ‹ http://www.disabilityfunders.org/webfm_send/6, http://www.disabilityfunders.org/emergency_preparedness ›, ‹ http://bezev.de/bezev/aktuelles/index.htm ›. Ebi, K., and G. Meehl. Heatwaves and Global Climate Change: The Heat Is On: Climate Change and Heatwaves in the Midwest. 2007. 26 Aug. 2009 ‹ www.pewclimate.org/docUploads/Regional-Impacts-Midwest.pdf ›. Elwan, A. Poverty and Disability: A Survey of the Literature. Worldbank, Social Protection Discussion Paper Series (1999): 9932. 26 Aug. 2009 ‹ http://siteresources.worldbank.org/DISABILITY/Resources/Poverty/Poverty_and_Disability_A_Survey_of_the_Literature.pdf ›. Fjord, L., and L. Manderson. “Anthropological Perspectives on Disasters and Disability: An Introduction.” Human Organisation 68.1 (2009): 64-72. Health Canada. First Annual National Health and Climate Change Science and Policy Research Consensus Conference: How Will Climate Change Affect Priorities for Your Health Science and Policy Research? Health Canada, 2001. 26 Aug. 2009 ‹ http://www.hc-sc.gc.ca/ewh-semt/pubs/climat/research-agenda-recherche/population-eng.php ›. Hemingway, L., and M. Priestley. “Natural Hazards, Human Vulnerability and Disabling Societies: A Disaster for Disabled People?” The Review of Disability Studies (2006). 26 Aug. 2009 ‹ http://www.rds.hawaii.edu/counter/count.php?id=13 ›. Holstein, J., et al. “Were Less Disabled Patients the Most Affected by the 2003 Heatwave in Nursing Homes in Paris, France?” Journal of Public Health Advance 27.4 (2005): 359-65. Intergovernmental Panel on Climate Change. Climate Change 2007: Impacts, Adaptation and Vulnerability. 2007. 26 Aug. 2009 ‹ http://www.ipcc.ch/publications_and_data/publications_ipcc_fourth_assessment_report_wg2_report_impacts_adaptation_and_vulnerability.htm ›. Intergovernmental Panel on Climate Change. “Summary for Policymakers.” Eds. O. F. Canziani, J. P. Palutikof, P. J. van der Linden, C. E. Hanson, and M.L.Parry. Cambridge, UK: Cambridge University Press, 2007. 7-22. 26 Aug. 2009 ‹ http://www.ipcc.ch/pdf/assessment-report/ar4/wg2/ar4-wg2-spm.pdf ›. Intergovernmental Panel on Climate Change. IPCC Fourth Assessment Report Working Group III Report: Mitigation of Climate Change Glossary. 2007. 26 Aug. 2009 ‹ http://www.ipcc.ch/ipccreports/ar4-wg3.htm, http://www.ipcc.ch/pdf/assessment-report/ar4/wg3/ar4-wg3-annex1.pdf ›. Leipoldt, E. “Disability Experience: A Contribution from the Margins. Towards a Sustainable Future.” Journal of Futures Studies 10 (2006): 3-15. Miller, P., S. Parker and S. Gillinson. “Disablism: How to Tackle the Last Prejudice.” Demos, 2004. 26 Aug. 2009 ‹ http://www.demos.co.uk/files/disablism.pdf ›. Nakamura, K. “Disability, Destitution, and Disaster: Surviving the 1995 Great Hanshin Earthquake in Japan.” Human Organisation 68.1 (2009): 82-88. National Council on Disability, National Council on Independent Living, National Organization on Disability, and National Spinal Cord Injury Association and the Paralyzed Veterans of America. Emergency Management and People with Disabilities: before, during and after Congressional Briefing, 10 November 2005. 26 Aug. 2009 ‹ http://www.ncd.gov/newsroom/publications/2005/transcript_emergencymgt.htm ›. National Council on Disability. National Council on Disability on Hurricane Katrina Affected Areas. 2005. 26 Aug. 2009 ‹ http://www.ncd.gov/newsroom/publications/2005/katrina2.htm ›. National Research Council of Canada. From Impacts to Adaptation: Canada in a Changing Climate 2007. 26 Aug. 2009 ‹ http://adaptation.nrcan.gc.ca/assess/2007/pdf/full-complet_e.pdf ›. Nippert, I. and G. Wolff. “Ethik und Genetik: Ergebnisse der Umfrage zu Problemaspekten angewandter Humangenetik 1994-1996, 37 Länder.” Medgen 11 (1999): 53-61. Participants of the Nuclear Winter: The Anthropology of Human Survival Session. Proceedings of the 84th American Anthropological Association's Annual Meeting. Washington, D.C., 6 Dec. 1985. 26 Aug. 2009 ‹ http://www.fas.org/sgp/othergov/doe/lanl/lib-www/la-pubs/00173165.pdf ›. Scope. “Most Britons Think Others View Disabled People ‘As Inferior’.” 2009. 26 Aug. 2009 ‹ http://www.scope.org.uk/cgi-bin/np/viewnews.cgi?id=1244379033, http://www.comres.co.uk/resources/7/Social%20Polls/Scope%20PublicPoll%20Results%20May09.pdf ›. Smit, B., et al. “The Science of Adaptation: A Framework for Assessment.” Mitigation and Adaptation Strategies for Global Change 4 (1999): 199-213. Smit, B., and J. Wandel. “Adaptation, Adaptive Capacity and Vulnerability.” Global Environmental Change 16 (2006): 282-92. Sunday Morning Herald. “Who Lives and Dies in Britain after the Bomb.” Sunday Morning Herald 1988. 26 Aug. 2009 ‹ http://news.google.com/newspapers?nid=1301&dat=19880511&id=wFYVAAAAIBAJ&sjid=kOQDAAAAIBAJ&pg=3909,113100 ›. United Nations Development Programme. Human Development Report 2007/2008: Fighting Climate Change – Human Solidarity in a Divided World. 2008. 26 Aug. 2009 ‹ http://hdr.undp.org/en/media/HDR_20072008_EN_Complete.pdf ›. Wolbring, Gregor. “Is There an End to Out-Able? Is There an End to the Rat Race for Abilities?” M/C Journal 11.3 (2008). 26 Aug. 2009 ‹ http://journal.media-culture.org.au/index.php/mcjournal/article/viewArticle/57 ›. Wolbring, Gregor. “Why NBIC? Why Human Performance Enhancement?” Innovation: The European Journal of Social Science Research 21.1 (2008): 25-40.

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. Chivers, Sally. “‘Blind People Don’t Run’: Escaping the ‘Nursing Home Specter’ in Children of Nature and Cloudburst.” Journal of Aging Studies 34 (2015): 134–41. “COVID-19 Deaths by Age Group and Sex.” Australian Government Department of Health: Coronovirus (COVID-19) Current Situation and Case Numbers. 1 Jan. 2021 <https://www.health.gov.au/news/health-alerts/novel-coronavirus-2019-ncov-health-alert/coronavirus-covid-19-current-situation-and-case-numbers#cases-and-deaths-by-age-and-sex>. DailyCaring. “6 Alzheimer’s Sensory Activities Reduce Anxiety without Medication.” 12 Jan. 2021 <https://dailycaring.com/6-alzheimers-sensory-activities-reduce-anxiety-without-medication/>. Dementia Australia. “What Is Dementia?” 12 Jan. 2021 <https://www.dementia.org.au/about-dementia/what-is-dementia>. Fuchs, Anne, Desmond O'Neill, Mary Cosgrove, and Julia Langbein. “Report on COVID-19 – Reframing Ageing Webinar 12 June 2020.” Preprint. Aug. 2020. DOI: 10.13140/RG.2.2.34508.44161. Gilleard, Chris, and Paul Higgs. “Aging without Agency: Theorizing the Fourth Age.” Aging and Mental Health 14.2 (2010): 121–28. Gilleard, Chris, and Paul Higgs. “Ageing Abjection and Embodiment in the Fourth Age.” Journal of Aging Studies 25.2 (2011): 135–42. Gilleard, Chris, and Paul Higgs. “The Fourth Age and the Concept of a ‘Social Imaginary’: A Theoretical Excursus.” Journal of Aging Studies 27 (2013): 368–76. Gulland, Jackie. “Households, Bubbles, and Hugging Grandparents: Caring and Lockdown Rules during COVID-19.” Feminist Legal Studies 28 (2020): 329–39. Harrington, Karra, and Martin J. Sliwinski. “The Loneliness of Social Isolation Can Affect Your Brain and Raise Dementia Risk in Older Adults.” The Conversation 4 Aug. 2020. 12 Jan. 2021 <https://theconversation.com/the-loneliness-of-social-isolation-can-affect-your-brain-and-raise-dementia-risk-in-older-adults-141752>. Laslett, Peter. A Fresh Map of Life: The Emergence of the Third Age. London: Weidenfeld and Nicolson, 1989. Lloyd, Liz. “The Fourth Age.” Routledge Handbook of Cultural Gerontology. Eds. Julia Twigg and Wendy Martin. London: Routledge, 2015. 20 Dec. 2020 <https://www.routledgehandbooks.com/doi/10.4324/9780203097090.ch33>. McLaws, Mary-Louise. “What Is the COVID ‘Bubble’ Concept, and Could It Work in Australia?” The Conversation 1 Sep. 2020. 12 Jan. 2021 <https://theconversation.com/what-is-the-covid-bubble-concept-and-could-it-work-in-australia-144938>. Morganroth Gullette, Margaret. “Aged by Culture.” Routledge Handbook of Cultural Gerontology. Eds. Julia Twigg and Wendy Martin. London: Routledge, 2015. 28 Dec. 2020 <https://www.routledgehandbooks.com/doi/10.4324/9780203097090.ch3>. Royal Commission into Aged Care Quality and Safety. Neglect. Interim Report Volume 1. Canberra: Commonwealth Government of Australia, 31 Oct. 2019. 12 Jan. 2021 <https://agedcare.royalcommission.gov.au/publications/interim-report>. Sobchack, Vivian. “A Leg to Stand On: Prosthetics, Metaphor, and Materiality.” In The Prosthetic Impulse: From a Posthuman Present to a Biocultural Future. Cambridge: MIT Press, 2006. 17–41. Steger, Sarah. “Coronavirus Crisis: Oryx Communities Aged Care Home Creates ‘Window of Love’ to Help Residents Stay Connected to Families.” The West Australian 5 Apr. 2020. 12 Jan. 2021 <https://thewest.com.au/news/coronavirus/coronavirus-crisis-oryx-communities-aged-care-home-creates-window-of-love-to-help-residents-stay-connected-to-families-ng-b881510245z>. Zeilig, Hannah. “The Critical Use of Narrative and Literature in Gerontology.” International Journal of Ageing and Later Life 6.2 (2011): 7-37. ———. “Dementia as a Cultural Metaphor.” The Gerontologist 54.2 (2013): 258–67. ———. “What Do We Mean When We Talk about Dementia? Exploring Cultural Representations of ‘Dementia’.” Working with Older People 19.1 (2015): 12–20.

Apart from its negative literary connotations, the notion of adaptation generally carries an optimistic connotation in the sense that it is most often associated with an improved outcome in the face of challenging circumstances. However, this is not an inevitable response to an adaptive imperative: there are often indicators of significant failure to adapt. In short, there is often evidence of maladaption. Examples include the spiralling rates of heart disease, obesity and adult-onset diabetes that have characterised richer western populations over the past half-century. Arguably, the West as a whole has failed to adapt to the health opportunities provided by plentiful food supplies. Instead, a growing dietary emphasis upon refined carbohydrates (including simple sugars) and animal-sourced protein (including dairy foods) is harming these populations. This paper applies the metaphors of adaptation and maladaptation to the development of a new sense of self following a diagnosis of heart disease. There is a range of evidence to suggest that newly-diagnosed heart patients resist accepting the implications of lifestyle-related heart disease. Such a lack of acceptance can impact upon short-term health, exercise and diet priorities, as well as upon long-term life expectancy. While this paper does not describe a medical, but a cultural approach to the well-adapted self as heart patient, it is also important to stress that there is a significant range of heart conditions that are not lifestyle related. Counterproductively, the links increasingly made between lifestyle choices and heart disease mean that many heart patients feel “punished” by people with healthy hearts who seem to assume that the patient is to “blame”. Nonetheless, there are few heart patients who cannot positively impact their health and recovery prospects by improving lifestyle choices. Ladwig and his research team argue that the challenge lies in getting heart patients to take their illness seriously without precipitating a traumatically negative view of the experience of illness. Such a negative view may, in itself, facilitate poor outcomes. These perspectives indicate that issues of communication and identity—that is, cultural imperatives—are important determinants of a healthy recovery. This paper records and analyses recent research relating to heart patients who are members of an online support community, HeartNET. HeartNET is an experimental Website funded by two Australian Research Council Linkage Grants (2004-10), with the National Heart Foundation (WA Division) as the industry partner. The authors/researchers speculate that engagement in the HeartNET online community enables the positive adaptation of an individual’s sense of self (rather than the fostering of a maladaptive identity, including a denial of the implications of heart disease that can lead to behaviours which promote morbidity). Early indications are that supportive online interactions can foster the development of a positive persona of a “heart patient“. At the optimistic end of the response-spectrum, a positive heart patient is a person who is keenly motivated to maximise their health and—if possible—halt or reverse (see, for example, Esselstyn) the progress of their disease. Such a response can be constituted and enhanced via supportive online interactions. Insofar as medical commentators theorise about reactions to a life-changing health diagnosis, this tends to be in terms of self-image (see, for example, Petrie et al.) and sometimes includes Kubler-Ross’s stages of grief: Denial, Anger, Bargaining, Depression and Acceptance. The results reported here look instead at issues of adapting to a new identity as “heart patient” that potentially involves positive commitment to improved health, partly as a result of giving and receiving social support. The rationale behind this perspective is influenced by significant evidence that compliance with the therapeutic regimes recommended and prescribed by physicians is lacking. It is speculated that patients are enacting a denial of the importance of the health challenges confronting them. For example, Hugtenburg et al. found that “of 232 first-time chronic medicine prescriptions [repeats], 132 were not collected at all (46.1%) or too late (11%).” Noting that 46% of the 232 prescriptions studied were for cardiovascular drugs (353), Hugtenburg et al. conclude that “This kind of non-compliance may result in an increased health risk as well as constituting a waste of a large amount of money” (352). Clearly, more emphasis needs to be placed on communicating constructively with patients and supporting the evolution and reconstitution of an identity that includes positive constructions of self-as-heart-patient and that works to facilitate recovery. The Website that enables the HeartNET community was developed by the National Heart Foundation (WA Branch: NHFWA) and Edith Cowan University (ECU) as part of an ARC-Linkage grant, 2004-6 “Evaluating the effectiveness of online support in building community, promoting healthy behaviours and supporting philanthropy”. The first three months of the Website’s operation (when the tiny number of postings trickled away and then dried up completely) are reported in Bonniface et al. (“Affect”) and graphed below (see Figure 1). They followed on from a careful process of recruitment via databases of existing heart patients that were held by the NHFWA and supportive cardiologists. Participants were approached to gain ethical consent, and would-be Website participants were matched with people who had equivalent heart illness, but who weren’t invited to join the HeartNET community, thus acting as comparisons. Baseline data was collected to compare “before” the HeartNET intervention with the yet-to-be collected “after” data. The idea was to see if there were differences between the online and offline groups that could be attributed to Website activity. Instead, the first version of the supposed-community remained stillborn, and it wasn’t until the Website was thrown open to all comers that it began to thrive. This was a preliminary indication that an invitation to participate in a therapeutic community was not effective, by itself, in encouraging communication with people who shared important health-related experiences. While Website engagement might have fitted comparatively well into a (Kubler-Ross) Bargaining approach to heart patients’ illnesses (“I’ll help others, and they’ll help me”) the default position appeared to be non-engagement, possibly an indication of the patients having become “stuck“ in the first stage of grief, Denial. Even though the initial HeartNET participants were well established as heart patients, and had all been diagnosed some time earlier, it is possible that they preferred to ignore the implications of this for their health. Figure 1 records the patterns of postings made by the 68 people who agreed to join the HeartNET Web community and who signed and returned the ethical consent forms. Of the 68 people recruited, only 53 logged on (despite phone calls to every individual) and of the 53 who logged into the site, only 22 posted (Bonniface et al. “Affect”). The heaviest week’s traffic was 40 postings in Week 4. By Week 12, activity had ceased entirely. The decision to relaunch had been taken a fortnight earlier and the first iteration of the Website was closed down. Figure 1, reprinted from Bonniface et al (“Affect”) The relaunch of the Website made it available for anyone interested in participating, and membership and traffic both grew exponentially. Amongst other innovations were “newbie” icons (to indicate new members to be welcomed and nurtured), guest status (to “try before you buy”), and symbols to indicate whether the member was a heart patient, a family member or supporter, or an administrator. In due course a “ratings system“ was added to indicate the total number of member-postings to date, so that people could gauge an individual’s commitment and contribution to the community. People contributing up to 150 posts to discussion boards were allotted from one to five stars, while Superstar status indicated 1000-plus posts. One of the major differences between the group of heart patients invited to participate in the site’s first iteration, and the group that ultimately launched the Website as a viable and vibrant community, is that the second-stage members were generally recently diagnosed. The research team speculate that they were actively reconstituting their identities as heart patients, and they and their families consequently had many matters and issues they wanted to discuss. In effect, the people who joined the relaunched site were “learning“ to be heart patients. Weis et al., investigating a pharmaceutically-sponsored Website for MS sufferers, argued that “users are diverse” and “communication needs change over time [as the disease progresses]” (146). They found that, of the 943 users who responded to their online survey, indications were that participants used “the website the most during early stages of the disease” (135). However, one area the HeartNET research is investigating is whether a community-member whose persona includes “care and support for my Web community“ will continue to participate even after the first information-seeking phase of their illness is over. Support offered for new heart patients by cardiologists, hospital staff, other specialists and general practitioners is an important part of the enculturation of the self-as-heart-patient, but it leaves unexplored the more personal work of reconstituting the individual’s identity as a person with heart disease (or as a supporter of such a person). It also leaves unaddressed the sense of “aloneness“ that HeartNET members say they feel until they are able to talk regularly with people who understand exactly what they are going through, as a result of having already “been there“ themselves. Although health professionals, family and friends are supportive, that support is only occasionally able to cut through the isolation. Extracts from two (separate) interviews are typical of the kinds of comments made: Murphy: I mean the support from Sandra and the family was all great but—to actually talk to other people who know what you’re feeling and … Yes, nothing against family and friends but they’re [other patients are] going through the same thing, they know what you’re feeling and … you know. Margo: I found friends were pains. It was like “well, okay, but you’re better now, they fixed you.” Well I looked at her and I said, ‘“You’re never fixed, but [it’s] something you live with for the rest of your life that doesn’t go away. …’ The implication is that heart patients have a differential need to communicate with others about their experience of heart disease, and that the communicative imperative is greatest in the first stages of being a heart patient, soon after diagnosis. For the well-established patients invited to contribute to the original HeartNET Website, their status as people-with-heart-disease was no longer problematic. Consequently, they had little to say and very few incentives to revisit the adaptive processes of personal identity construction. People who are used to their status as a heart patient may be theorised as having very different information needs and behaviours compared with the newly diagnosed. There is evidence that at least some of these well established patients were prompted to engage when new patients who needed support joined the site in the second iteration. However, those who are never given the opportunity to interact and learn from others may take longer to reach a level of adaptation. Even worse, they may adopt maladaptive behaviours encompassing issues of denial or self-sabotage—such as rejecting medications or increasing behaviours which progress morbidity, such as smoking and excessive alcohol consumption. Patients’ denial of the implications of heart disease is recognised as a major medical problem. Cooper et al. (234) cite evidence from Petrie et al. that “only a third of eligible patients under 65 years old attended cardiac rehabilitation” while noting that “Ades et al. showed uptake as low as 21% in eligible patients over 62 years”. In another study of patients who did/did not adhere to their pharmacological treatment regime, Horwitz et al. found that “Compared with patients with good adherence, patients with poor adherence were twice as likely to have died within a year of follow-up.” They argue that “adherence may need to be viewed more broadly as encompassing a cluster of health-related behaviours that may influence the outcome of treatment.” The argument advanced in our paper is that such a broader view should also encompass necessary adaptation strategies which introduce positive influences to the formation of patient identity. Compliance with therapeutic and medical regimes has been linked to increased self esteem (Burkhart and Rayens), and the combination of compliance with a positive patient identity may well multiply beneficial health outcomes. Whereas currently a majority of recovering heart patients may be inferred as resisting a revised self-identity that takes their diagnosis and health challenges seriously, the HeartNET Website may offer an effective enticement to positive behavioural change. Bonniface et al. (“Shuffling buddies”) have demonstrated that engagement with HeartNET can influence attitudes to (and involvement in) exercise. The hypothesis regarding identity adaptation is that active HeartNET members, through Website engagement, consistently indicate a willingness to acknowledge their changed health status and work to develop a reconstituted identity as a person with a heart condition who is proactively maximising positive outcomes (and helping others to do so at the same time). This is particularly the case where the online engagement feeds into the offline world: where “shuffling buddies“ have developed mutually supportive walking and exercise regimes, involving social events, consistent with their commitment to health-enhancing activity. Adaptation strategies delivered online offer new ways to counter the maladaptive processes which can follow diagnosis. By using the raw materials of social support and Website engagement, patients can chart new and positive ways in which they progress from denial and bargaining to health-promoting acceptance. For those established patients, online engagement may progress the stages of grief beyond the level of acceptance to the end goal of “support” as they pass on their knowledge, empathy and understanding of illness to the newly diagnosed. References Ades, Philip, M. L. Waldman, W. J. McCann, and S. O. Weaver. “Predictors of Cardiac Rehabilitation Participation in Older Coronary Patients.” Archives of Internal Medicine 152.2 (1992): 1033-5. Bonniface, Leesa, Lelia Green, and Maurice Swanson. “Affect and an Effective Online Therapeutic Community.” M/C Journal 8.6 (2005). 22 Apr. 2007 . Bonniface, Leesa, Arshad Omari, and Maurice Swanson. “Shuffling Buddies—How an Online Community Supports Healthier Lifestyle Choices: An Early Indication of Physical Activity and Exercise Outcomes from the HeartNET Intervention.” Proceedings of the Fifth International Conference on Cultural Attitudes towards Technology and Communication. Eds. F Sudweeks, H Hrachovec and C Ess. Estonia, Tartu: School of Information Technology, Murdoch University, 2006. 90-101. Burkhart, Patricia, and Mary Rayens. “Self-Concept and Health Locus of Control: Factors Related to Children’s Adherence to Recommended Asthma Regimen.” Pediatric Nursing 31.5 (2005): 404-9. Campbell, Colin, and Thomas Campbell. The China Study: Startling Implications for Diet, Weight Loss and Long-Term Health. Dallas, TX: Benbella Books, 2004. Cooper, A., G., Lloyd, J. Weinman, and G. Jackson. “Why Patients Do Not Attend Cardiac Rehabilitation: Role of Intentions and Illness Beliefs.” Heart 82.2 (1999): 234-6. Horwitz, Ralph, Catherine Viscoli, Lisa Berkman, Robert Donaldson, Sarah Horwitz, Carolyn Murray, David Ransohoff, and Jody Sindelar. “Treatment Adherence and Risk of Death after a Myocardial Infarction.” The Lancet 336 (1990): 542-5. Hugtenburg, J. G., A. T. G. Blom, and S. U. Kisoensingh. “Initial Phase of Chronic Medication Use; Patients’ Reasons for Discontinuation.” British Journal of Clinical Pharmacology 61.3 (2005): 352-4. Kubler-Ross, Elisabeth. On Death and Dying: What the Dying Have to Teach Doctors, Nurses, Clergy, and Their Own Families. New York: Macmillan, 1969. Ladwig, Karl-Heinz, Andreas Schoefinius, Gerhard Dammann, Reinhold Danner, Rolf Gurtler, and Robert Hermann. “Long-Acting Psychotraumatic Properties of a Cardiac Arrest Experience.” American Journal of Psychiatry 156.6 (1999): 912-9. Esselstyn, C.B. Jr. Prevent and Reverse Heart Disease. New York: Penguin Group, 2007. Petrie, Keith, John Weinman, Sharpe Norman, and Judith Buckley. “Role of Patients’ View of Their Illness in Predicting Return to Work and Functioning after Myocardial Infarction: Longitudinal Study.” British Medical Journal 312 (1996): 1191-4. Weis, Robert, Keith Stamm, Craig Smith, Michael Nilan, Fiona Clark, Joan Weis, and Kate Kennedy. “Communities of Care and Caring: The Case of Mswatch.Com.” Journal of Health Psychology 8.1 (2003): 135-48. Citation reference for this article MLA Style Green, Lelia, Leesa Bonniface, and Tami McMahon. "Adapting to a New Identity: Reconstituting the Self as a Heart Patient." M/C Journal 10.2 (2007). echo date('d M. Y'); ?> <http://journal.media-culture.org.au/0705/13-bonnifacegreenmcmahon.php>. APA Style Green, L., L. Bonniface, and T. McMahon. (May 2007) "Adapting to a New Identity: Reconstituting the Self as a Heart Patient," M/C Journal, 10(2). Retrieved echo date('d M. Y'); ?> from <http://journal.media-culture.org.au/0705/13-bonnifacegreenmcmahon.php>.

Introduction In The X-Files episode “Humbug”, agents Scully and Mulder travel to Florida to investigate a series of murders taking place in a community of sideshow performers, or freaks. At the episode’s end, one character, a self-made freak and human blockhead, muses on the future of the freak community:twenty-first century genetic engineering will not only eradicate the Siamese twins and the alligator-skinned people, but you’re going to be hard-pressed to find a slight overbite or a not-so-high cheek bone … . Nature abhors normality. It can’t go very long without creating a mutant. (“Humbug”) Freaks, he says, are there to remind people of the necessity of mutations. His observation that genetic engineering will eradicate anomalies of nature accurately illustrates the gradual shift that society was witnessing in the late twentieth century away from the anomalous freak and toward surgical perfection. Yet this desire for perfection, which has manifested itself in often severe surgical deformities, has seen a shift in what constitutes the freak for a contemporary audience, turning what was once an anomaly into a mass-produced creation. While the freaks of the nineteenth and early twentieth century were born with facial or anatomical deformities that warranted their place in the sideshow performance (bearded ladies, midgets, faints, lobster men, alligator-skinned people, etc.), freaks of the twenty-first century can be seen as something created by a plastic surgeon, a shift which undermines the very understanding of freak ontology. As Katherine Dunne put it: “a true freak cannot be made. A true freak must be born” (28). In her discussion of the monstrous body, Linda Williams writes that “the monster’s body is perceived as freakish in its possession of too much or too little” (63). This may have included a missing or additional limb, distorted sizes and heights, and anatomical growths. John Merrick, or the “Elephant Man” (fig. 1), as he was famously known, perfectly embodied this sense of excess that is vital to what people perceive as the monstrous body. In his discussion of freaks and the freakshow, Robert Bogdan notes that promotional posters exaggerated the already-deformed nature of freaks by emphasising certain physical anomalies and turning them into mythological creatures: “male exhibits with poorly formed arms were billed as ‘The Seal Man’; with poorly formed legs, ‘the Frog Man’; with excesses of hair, ‘The Lion Man’ or ‘Dog Boy’” (100). Figure 1: John Merrick (the Elephant Man) <https://www.pinterest.com.au/pin/193584483966192229/>.The freak’s anomalous nature made them valuable, financially but also culturally: “in many ways, the concept of ‘freak,’ is an anomaly in current social scientific thinking about demonstrable human variation. During its prime the freak show was a place where human deviance was valuable, and in that sense valued” (Bogdan 268). Many freaks were presented as “human wonders”, while “their claims to fame were quite commonplace” (Bogdan 200). Indeed, Bogdan argues that “while highly aggrandized exhibits really were full of grandeur, with respectable freaks the mundane was exploited as amazing and ordinary people were made into human wonders” (200). Lucian Gomoll similarly writes that freakshows “directed judgement away from the audience and onto the performers, assuring observers of their own unmarked normalcy” (“Objects of Dis/Order” 205).The anomalous nature of the freak therefore promoted the safety of normality at the same time as it purported to showcase the brilliance of the extraordinary. While the freaks themselves were normal, intelligent people, the freakshow served as a vehicle to gaze at oneself with a sense of relief. As much as many freakshows attempt to dismantle notions of normality, they serve to emphasise empathy, not envy. The anomalous freak is never an envied body; the particular dimensions of the freakshow mean that it is the viewer who is to be envied, and the freak who is to be pitied. From Freakshow to SideshowIn nineteenth-century freakshows, exploitation was rife; as Alison Piepmeier explains, “many of the so-called Aztecs, Pinheads, and What Is Its?”, were, in fact, “mentally disabled people dressed in wild costumes and forced to perform” (53). As a result, “freakishness often implied loss of control over one’s self and one’s destiny” (53). P.T. Barnum profited from his exploitation of freaks, while many freaks themselves also benefited from being exhibited. As Jessica Williams writes, “many freak show performers were well paid, self-sufficient, and enjoyed what they did” (69). Bogdan similarly pointed out that “some [freaks] were exploited, it is true, but in the culture of the amusement world, most human oddities were accepted as showmen. They were congratulated for parlaying into an occupation [that], in another context, might have been a burden” (268). Americans of all classes, Anissa Janine Wardi argues, enjoyed engaging in the spectacle of the freak. She writes that “it is not serendipitous that the golden age of the freak show coincided with the building of America’s colonial empire” (518). Indeed, the “exploration of the non-Western world, coupled with the transatlantic slave trade, provided the backdrop for America’s imperialist gaze, with the native ‘other’ appearing not merely in the arena of popular entertainment, but particularly in scientific and medical communities” (518). Despite the accusations levelled against Barnum, his freakshows were seen as educational and therefore beneficial to both the public and the scientific community, who, thanks to Barnum, directly benefited from the commercialisation of and rising public interest in the freak. Discussing “western conventions of viewing exotic others”, Lucian Gomoll writes that “the freak and the ‘normal’ subject produced each other in a relationship of uneven reciprocity” (“Feminist Pleasures” 129). He writes that Barnum “encouraged onlookers to define their own identities in contrast to those on display, as not disabled, not animalistic, not androgynous, not monstrous and so on”. By the twentieth century, he writes, “shows like Barnum’s were banned from public spaces as repugnant and intolerable, and forced to migrate to the margins” (129).Gomoll commends the Freakatorium, a museum curated by the late sword swallower Johnny Fox, as “demonstrating and commemorating the resourcefulness and talents of those pushed to the social margins” (“Objects of Dis/Order” 207). Gomoll writes that Fox did not merely see freaks as curiosities in the way that Barnum did. Instead, Fox provided a dignified memorial that celebrated the uniqueness of each freak. Fox’s museum displays, he writes, are “respectable spaces devoted to the lives of amazing people, which foster potential empathy from the viewers – a stark contrast to nineteenth-century freakshows” (205). Fox himself described the necessity of the Freakatorium in the wake of the sideshow: New York needs a place where people can come see the history of freakdom. People that were born with deformities that were still amazing and sensitive people and they allowed themselves to be viewed and exhibited. They made a good living off doing that. Those people were to be commended for their courageousness and bravery for standing in front of people. (Hartzman)Fox also described the manner in which the sideshow circuit was banned over time:then sideshows went out because some little girl was offended because she thought the only place she could work was the sideshow. Her mother thought it was disgraceful that people exhibited themselves so she started calling the governor and state’s attorney trying to get sideshows banned. I think it was Florida or South Carolina. It started happening in other states. They said no exhibiting human anomalies. These people who had been working in sideshows for years had their livelihood taken away from them. What now, they’re supposed to go be institutionalized? (Hartzman) Elizabeth Stephens argues that a shift occurred in the early twentieth century, and that by the late ‘30s “people with physical anomalies had been transformed in the cultural imagination from human oddities or monsters to sick people requiring diagnoses and medical intervention” (Stephens). Bogdan noted that by the 1930s, “the meaning of being different changed in American society. Scientific medicine had undermined the mystery of certain forms of human variation, and the exotic and aggrandized modes had lost their flamboyant attractiveness” (274). So-called freaks became seen as diseased bodies who “were now in the province of physicians, not the general public” (274). Indeed, scientific interest transformed the freak into a medical curiosity, contributing to the waning popularity of freakshows. Ironically, although the freaks declined in popularity as they moved into the medical community, medicine would prove to be the domain of a new kind of freak in the ensuing years. The Manufactured Freak As the freakshow declined in popularity, mainstream culture found other subjects whose appearance provoked curiosity, awe, and revulsion. Although plastic surgery is associated with the mid-to-late twentieth century and beyond, it has a long history in the medical practice. In A History of Plastic Surgery, Paolo Santoni-Rugiu and Philip J. Sykes note that “operations for the sole purpose of improving appearances came on the scene in 1906” (322). Charles C. Miller was one of the earliest pioneers of plastic surgery; Santoni-Rugiu and Sykes write that “he never disguised the fact that his ambition was to do Featural Surgery, correcting imperfections that from a medical point of view were not considered to be deformities” (302). This attitude would fundamentally transform notions of the “normal” body. In the context of cosmetic surgery, it is the normal body that becomes manipulated in order to produce something which, despite intentions, proves undoubtedly freakish. Although men certainly engage in plastic surgery (notably Igor and Grichka Bogdanoff) the twenty-first century surgical freak is synonymous with women. Kirsty Fairclough-Isaacs points out the different expectations levelled against men and women with respect to ageing and plastic surgery. While men, she says, “are closely scrutinised for attempting to hide signs of ageing, particularly hair loss”, women, in contrast, “are routinely maligned if they fail to hide the signs of ageing” (363). She observes that while popular culture may accept the ageing man, the ageing woman is less embraced by society. Consequently, women are encouraged—by the media, their fans, and by social norms around beauty—to engage in surgical manipulation, but in such a way as to make their enhancements appear seamless. Women who have successful plastic surgery—in the sense that their ageing is well-hidden—are accepted as having successfully manipulated their faces so as to appear flawless, while those whose surgical exploits are excessive or turn out badly become decidedly freakish. One of the most infamous plastic surgery cases is that of Jocelyn Wildenstein, also known as “catwoman”. Born Jocelynnys Dayannys da Silva Bezerra Périsset in 1940, Wildenstein met billionaire art dealer Alec N. Wildenstein whom she married in the late 1970s. After discovering her husband was being unfaithful, Wildenstein purportedly turned to cosmetic surgery in order to sculpt her face to resemble a cat, her husband’s favourite animal. Ironically but not surprisingly, her husband purportedly screamed in terror when he saw his wife’s revamped face for the first time. And although their relationship ended in divorce, Wildenstein, dubbed “the Bride of Wildenstein”, continued to visit her plastic surgeon, and her face became progressively more distorted over the years (Figure 2). Figure 2: Jocelyn Wildenstein over the years <https://i.redd.it/vhh3yp6tgki31.jpg>. The exaggerated and freakish contours of Wildenstein’s face would undoubtedly remind viewers of the anatomical exaggerations seen in traditional freaks. Yet she does not belong to the world of the nineteenth century freak. Her deformities are self-inflicted in an attempt to fulfil certain mainstream beauty ideals to exaggerated lengths. Like many women, Wildenstein has repeatedly denied ever having received plastic surgery, claiming that her face is natural, while professing admiration for Brigitte Bardot, her beauty idol. Such denial has made her the target of further criticism, since women are not only expected to conceal the signs of ageing successfully but are also ironically expected to be honest and transparent about having had work done to their faces and bodies, particularly when it is obvious. The role that denial plays not just in Wildenstein’s case, but in plastic surgery cases more broadly, constitutes a “desirability of naturalness” (122), according to Debra Gimlin. There is, she argues, an “aesthetic preference for (surgically enhanced) ‘naturalness’” (122), a desire that sits between the natural body and the freak. This kind of appearance promotes more of an uncanny naturalness that removes signs of ageing but without being excessive; as opposed to women whose use of plastic surgery is obvious (and deemed excessive according to Williams’ “monstrous body”) the unnatural look that some plastic surgery promotes is akin to an absence of normal features, such as wrinkles. One surgeon that Gimlin cites argues that he would not remove the wrinkles of a woman in her 60s: “she’s gonna look like a freak without them”, he says. This admission signifies a clear distinction between what we understand as freakish plastic surgery (Wildenstein) and the not-yet-freakish appearance of women whose surgically enhanced appearance is at once uncanny and accepted, perpetuating norms around plastic surgery and beauty. Denial is thus part of the fabric of performing naturalness and the desire to make the unnatural seem natural, adding another quasi-freakish dimension to the increasingly normalised appearance of surgically enhanced women. While Wildenstein is mocked for her grotesque appearance, in addition to her denial of having had plastic surgery, women who have navigated plastic surgery successfully are congratulated and envied. Although contemporary media increasingly advocates the ability to age naturally, with actresses like Helen Mirren and Meryl Streep frequently cited as natural older beauties, natural ageing is only accepted to the extent that this look of naturalness is appeasing. Unflattering, unaltered naturalness, on the other hand, is demonised, with such women encouraged to turn to the knife after all in order to achieve a more acceptable look of natural ageing, one that will inevitably and ironically provoke further criticism. For women considering plastic surgery, they are damned if they do and damned if they don’t. Grant McCracken notes the similarities between Wildenstein and the famous French body artist Orlan: “like Orlan, Wildenstein had engaged in an extravagant, destructive creativity. But where Orlan sought transformational opportunity by moving upward in the Renaissance hierarchy, toward saints and angels, Wildenstein moved downwards, toward animals” (25). McCracken argues that it isn’t entirely clear whether Orlan and Wildenstein are “outliers or precursors” to the contemporary obsession with plastic surgery. But he notes how the transition of plastic surgery from a “shameful secret” to a ubiquitous if not obligatory phenomenon coincides with the surgical work of Orlan and Wildenstein. “The question remains”, he says, “what will we use this surgery to do to ourselves? Orlan and Wildenstein suggest two possibilities” (26).Meredith Jones, in her discussion of Wildenstein, echoes the earlier sentiments of Williams in regards to the monster’s body possessing too much or too little. In Wildenstein’s case, her freakishness is provoked by excess: “when too many body parts become independent they are deemed too disparate: wayward children who no longer lend harmony or respect to their host body. Jocelyn Wildenstein’s features do this: her cheeks, her eyes, her forehead and her lips are all striking enough to be deemed untoward” (125). For Jones, the combination of these features “form a grotesquery that means their host can only be deemed, at best, perversely beautiful” (125). Wildenstein has been referred to as a “modern-day freak”, and to a certain extent she does share something in common with the nineteenth century freak, specifically through the manner in which her distorted features invite viewers to gawk. Like the Elephant Man, her freakish body possesses “too much”, as Williams put it. Yet her appearance evokes none of the empathy afforded traditional freaks, whose facial or anatomical deformities were inherent and thus cause for empathy. They played no role in the formation of their deformities, only reclaiming agency once they exhibited themselves. While Wildenstein is, certainly, an anomaly in the sense that she is the only known woman who has had her features surgically altered to appear cat-like, her appearance more broadly represents an unnerving trajectory that reconstructs the freak as someone manufactured rather than born, upending Katherine Dunne’s assertion that true freaks are born, not made. Indeed, Wildenstein can be seen as a precursor to Nannette Hammond and Valeria Lukyanova, women who surgically enhanced their faces and bodies to resemble a real-life Barbie doll. Hammond, a woman from Cincinnati, has been called the first ‘Human Barbie’, chronicling the surgical process on her Instagram account. She states that her children and husband are “just so proud of me and what I’ve achieved through surgery” (Levine). This surgery has included numerous breast augmentations, botox injections and dental veneers, in addition to eyelash extensions and monthly fake tans. But while Hammond is certainly considered a “scalpel junkie”, Valeria Lukyanova’s desire to transform herself into a living Barbie doll is particularly uncanny. Michael’s Idov’s article in GQ magazine titled: “This is not a Barbie Doll. This is an Actual Human Being” attests to the uncanny appearance of Lukyanova. “Meeting Valeria Lukyanova is the closest you will come to an alien encounter”, Idov writes, describing the “queasy fear” he felt upon meeting her. “A living Barbie is automatically an Uncanny Valley Girl. Her beauty, though I hesitate to use the term, is pitched at the exact precipice where the male gaze curdles in on itself.” Lukyanova, a Ukrainian, admits to having had breast implants, but denies that she has had any more modifications, despite the uncanny symmetry of her face and body that would otherwise allude to further surgeries (Figure 3). Importantly, Lukyanova’s transformation both fulfils and affronts beauty standards. In this sense, she is at once freakish but does not fit the profile of the traditional freak, whose deformities are never confused with ideals of beauty, at least not in theory. While Johnny Fox saw freaks as talented, unique individuals, their appeal was borne of their defiance of the ideal, rather than a reinforcement of it, and the fact that their appearance was anomalous and unique, rather than reproducible at whim. Figure 3: Valeria Lukyanova with a Barbie Doll <http://shorturl.at/mER06>.Conclusion As a modern-day freak, these Barbie girls are a specific kind of abomination that undermines the very notion of the freak due to their emphasis on acceptance, on becoming mainstream, rather than being confined to the margins. As Jones puts it: “if a trajectory […] is drawn between mainstream cosmetic surgery and these individuals who have ‘gone too far’, we see that while they may be ‘freaks’ now, they nevertheless point towards a moment when such modifications could in fact be near mainstream” (188). The emphasis that is placed on mainstream acceptance and reproducibility in these cases affronts traditional notions of the freak as an anomalous individual whose features cannot be replicated. But the shift that society has seen towards genetic and surgical perfection has only accentuated the importance of biological anomalies who affront the status quo. While Wildenstein and the Barbie girls may provoke a similar sense of shock, revulsion and pity as the Elephant Man experienced, they possess none of the exceptionality or cultural importance of real freaks, whose very existence admonishes mainstream standards of beauty, ability, and biology. References Bogdan, Robert. Freak Show: Presenting Human Oddities for Amusement and Profit. Chicago and London: U of Chicago P, 1990. Dunne, Katherine. Geek Love. London: Abacus, 2015. Fairclough-Isaacs, Kirsty. "Celebrity Culture and Ageing." Routledge Handbook of Cultural Gerontology. Eds. Julia Twigg and Wendy Martin. New York: Routledge, 2015. 361-368.Gimlin, Debra. Cosmetic Surgery Narratives: A Cross-Cultural Analysis of Women’s Accounts. New York: Palgrave Macmillan, 2012. Gommol, Lucian. “The Feminist Pleasures of Coco Rico’s Social Interventions.” Art and the Artist in Society. Eds. José Jiménez-Justiniano, Elsa Luciano Feal, and Jane Elizabeth Alberdeston. Newcastle upon Tyne: Cambridge Scholars Publishing, 2013. 119-134. ———. “Objects of Dis/Order: Articulating Curiosities and Engaging People at the Freakatorium.” Defining Memory: Local Museums and the Construction of History in America’s Changing Communities. Eds. Amy K. Levin and Joshua G. Adair. Lanham: Rowman & Littlefield, 2017. 197-212. Hartzman, Marc. “Johnny Fox: A Tribute to the King of Swords.” Weird Historian. 17 Dec. 2017. <https://www.weirdhistorian.com/johnny-fox-a-tribute-to-the-king-of-swords/>.“Humbug.” The X-Files: The Complete Season 3. Writ. Darin Morgan. Dir. Kim Manners. Fox, 2007. Idov, Michael. “This Is Not a Barbie Doll. This Is an Actual Human Being.” GQ. 12 July 2017. <https://www.gq.com/story/valeria-lukyanova-human-barbie-doll>.Jones, Meredith. Skintight: An Anatomy of Cosmetic Surgery. Oxford: Berg, 2008.McCracken, Grant. Transformations: Identity Construction in Contemporary Culture. Bloomington and Indianapolis: Indiana UP, 2008.Levine, Daniel D. “Before and After: What $500,000 of Plastic Surgery Bought Human Barbie.” PopCulture.com. 7 Dec. 2017. <https://popculture.com/trending/news/nannette-hammond-before-human-barbie-cost-photos/>. Piepmeier, Alison. Out in Public: Configurations of Women's Bodies in Nineteenth-Century America. Chapel Hill and London: U of North Carolina P, 2004. Santoni-Rugiu, Paolo, and Philip J. Sykes. A History of Plastic Surgery. Berlin: Springer-Verlag, 2017. Stephens, Elizabeth. “Twenty-First Century Freak Show: Recent Transformations in the Exhibition of Non-Normative Bodies.” Disability Studies Quarterly 25.3 (2005). <https://dsq-sds.org/article/view/580/757>.Wardi, Anissa Janine. “Freak Shows, Spectacles, and Carnivals: Reading Jonathan Demme’s Beloved.” African American Review 39.4 (Winter 2005): 513-526.Williams, Jessica L. Media, Performative Identity, and the New American Freak Show. London and New York: Palgrave MacMillan, 2017. Williams, Linda. “When the Woman Looks.” Horror, The Film Reader. Ed. Mark Jancovich. London and New York: Routledge, 2002. 61-66.

“I’m fat–and it’s okay! It doesn’t mean I’m stupid, or ugly, or lazy, or selfish. I’m fat!” so proclaims Joy Nash in her YouTube video, A Fat Rant. “Fat! It’s three little letters–what are you afraid of?!” This is the question I pose to my class on day one of Fat Studies. Sadly, many college students do fear fat, and negative attitudes toward fat people are quite prevalent in this population (Ambwani et al. 366). As I teach it, Fat Studies is cross-listed between Psychology and Gender Studies. However, most students who enrol have majors in Psychology or other behavioural health science fields in which weight bias is particularly pronounced (Watkins and Concepcion 159). Upon finding stronger bias among third- versus first-year Physical Education students, O’Brien, Hunter, and Banks (308) speculated that the weight-centric curriculum that typifies this field actively engenders anti-fat attitudes. Based on their exploration of textbook content, McHugh and Kasardo (621) contend that Psychology too is complicit in propagating weight bias by espousing weight-centric messages throughout the curriculum. Such messages include the concepts that higher body weight invariably leads to poor health, weight control is simply a matter of individual choice, and dieting is an effective means of losing weight and improving health (Tylka et al.). These weight-centric tenets are, however, highly contested. For instance, there exists a body of research so vast that it has its own name, the “obesity paradox” literature. This literature (McAuley and Blair 773) entails studies that show that “obese” persons with chronic disease have relatively better survival rates and that a substantial portion of “overweight” and “obese” individuals have levels of metabolic health similar to or better than “normal” weight individuals (e.g., Flegal et al. 71). Finally, the “obesity paradox” literature includes studies showing that cardiovascular fitness is a far better predictor of mortality than weight. In other words, individuals may be both fit and fat, or conversely, unfit and thin (Barry et al. 382). In addition, Tylka et al. review literature attesting to the complex causes of weight status that extend beyond individual behaviour, ranging from genetic predispositions to sociocultural factors beyond personal control. Lastly, reviews of research on dieting interventions show that these are overwhelmingly ineffective in producing lasting weight loss or actual improvements in health and may in fact lead to disordered eating and other unanticipated adverse consequences (e.g., Bacon and Aphramor; Mann et al. 220; Salas e79; Tylka et al.).The newfound, interdisciplinary field of scholarship known as Fat Studies aims to debunk weight-centric misconceptions by elucidating findings that counter these mainstream suppositions. Health At Every Size® (HAES), a weight-neutral approach to holistic well-being, is an important facet of Fat Studies. The HAES paradigm advocates intuitive eating and pleasurable physical activity for health rather than restrictive dieting and regimented exercise for weight loss. HAES further encourages body acceptance of self and others regardless of size. Empirical evidence shows that HAES-based interventions improve physical and psychological health without harmful side-effects or high dropout rates associated with weight loss interventions (Bacon and Aphramor; Clifford et al. “Impact of Non-Diet Approaches” 143). HAES, like the broader field of Fat Studies, seeks to eradicate weight-based discrimination, positioning weight bias as a social justice issue that intersects with oppression based on other areas of difference such as gender, race, and social class. Much like Queer Studies, Fat Studies seeks to reclaim the word, fat, thus stripping it of its pejorative connotations. As Nash asserts in her video, “Fat is a descriptive physical characteristic. It’s not an insult, or an obscenity, or a death sentence!” As an academic discipline, Fat Studies is expanding its visibility and reach. The Fat Studies Reader, the primary source of reading for my course, provides a comprehensive overview of the field (Rothblum and Solovay 1). This interdisciplinary anthology addresses fat history and activism, fat as social inequality, fat in healthcare, and fat in popular culture. Ward (937) reviews this and other recently-released fat-friendly texts. The field features its own journal, Fat Studies: An Interdisciplinary Journal of Body Weight and Society, which publishes original research, overview articles, and reviews of assorted media. Both the Popular Culture Association and National Women’s Studies Association have special interest groups devoted to Fat Studies, and the American Psychological Association’s Division on the Psychology of Women has recently formed a task force on sizism (Bergen and Carrizales 22). Furthermore, Fat Studies conferences have been held in Australia and New Zealand, and the third annual Weight Stigma Conference will occur in Iceland, September 2015. Although the latter conference is not necessarily limited to those who align themselves with Fat Studies, keynote speakers include Ragen Chastain, a well-known member of the fat acceptance movement largely via her blog, Dances with Fat. The theme of this year’s conference, “Institutionalised Weightism: How to Challenge Oppressive Systems,” is consistent with Fat Studies precepts:This year’s theme focuses on the larger social hierarchies that favour thinness and reject fatness within western culture and how these systems have dictated the framing of fatness within the media, medicine, academia and our own identities. What can be done to oppose systemised oppression? What can be learned from the fight for social justice and equality within other arenas? Can research and activism be united to challenge prevailing ideas about fat bodies?Concomitantly, Fat Studies courses have begun to appear on college campuses. Watkins, Farrell, and Doyle-Hugmeyer (180) identified and described four Fat Studies and two HAES courses that were being taught in the U.S. and abroad as of 2012. Since then, a Fat Studies course has been taught online at West Virginia University and another will soon be offered at Washington State University. Additionally, a new HAES class has been taught at Saint Mary’s College of California during the last two academic years. Cameron (“Toward a Fat Pedagogy” 28) describes ways in which nearly 30 instructors from five different countries have incorporated fat studies pedagogy into university courses across an array of academic areas. This growing trend is manifested in The Fat Pedagogy Reader (Russell and Cameron) due out later this year. In this article, I describe content and pedagogical strategies that I use in my Fat Studies course. I then share students’ qualitative reactions, drawing upon excerpts from written assignments. During the term reported here, the class was comprised of 17 undergraduate and 5 graduate students. Undergraduate majors included 47% in Psychology, 24% in Women Studies, 24% in various other College of Liberal Arts fields, and 6% in the College of Public Health. Graduate majors included 40% in the College of Public Health and 60% in the College of Education. Following submission of final grades, students provided consent via email allowing written responses on assignments to be anonymously incorporated into research reports. Assignments drawn upon for this report include weekly reading reactions to specific journal articles in which students were to summarise the main points, identify and discuss a specific quote or passage that stood out to them, and consider and discuss applicability of the information in the article. This report also utilises responses to a final assignment in which students were to articulate take-home lessons from the course.Despite the catalogue description, many students enter Fat Studies with a misunderstanding of what the course entails. Some admitted that they thought the course was about reducing obesity and the presumed health risks associated with this alleged pathological condition (Watkins). Others understood, but were somewhat dubious, at least at the outset, “Before I began this class, I admit that I was skeptical of what Fat Studies meant.” Another student experienced “a severe cognitive dissonance” between the Fat Studies curriculum and that of a previous behavioural health class:My professor spent the entire quarter spouting off statistics, such as the next generation of children will be the first generation to have a lower life expectancy than their parents and the ever increasing obesity rates that are putting such a tax on our health care system, and I took her words to heart. I was scared for myself and for the populations I would soon be working with. I was worried that I was destined to a chronic disease and bothered that my BMI was two points above ‘normal.’ I believed everything my professor alluded to on the danger of obesity because it was things I had heard in the media and was led to believe all my life.Yet another related, “At first, I will be honest, it was hard for me to accept a lot of this information, but throughout the term every class changed my mind about my view of fat people.” A few students have voiced even greater initial resistance. During a past term, one student lamented that the material represented an attack on her intended behavioural health profession. Cameron (“Learning to Teach Everybody”) describes comparable reactions among students in her Critical Obesity course taught within a behavioural health science unit. Ward (937) attests that, even in Gender Studies, fat is the topic that creates the most controversy. Similarly, she describes students’ immense discomfort when asked to entertain perspectives that challenge deeply engrained ideas inculcated by our culture’s “obesity epidemic.” Discomfort, however, is not necessarily antithetical to learning. In prompting students to unlearn “the biomedically-informed truth of obesity, namely that fat people are unfit, unhealthy, and in need of ‘saving’ through expert interventions,” Moola at al. recommend equipping them with an “ethics of discomfort” (217). No easy task, “It requires courage to ask our students to forgo the security of prescriptive health messaging in favour of confusion and uncertainty” (221). I encourage students to entertain conflicting perspectives by assigning empirically-based articles emanating from peer-reviewed journals in their own disciplines that challenge mainstream discourses on obesity (e.g., Aphramor; Bombak e60; Tomiyama, Ahlstrom, and Mann 861). Students whose training is steeped in the scientific method seem to appreciate having quantitative data at their disposal to convince themselves–and their peers and professors–that widely held weight-centric beliefs and practices may not be valid. One student remarked, “Since I have taken this course, I feel like I am prepared to discuss the fallacy of the weight-health relationship,” citing specific articles that would aid in the effort. Likewise, Cameron’s (“Learning to Teach Everybody”) students reported a need to read research reports in order to begin questioning long-held beliefs.In addition, I assign readings that provide students with the opportunity to hear the voices of fat people themselves, a cornerstone of Fat Studies. Besides chapters in The Fat Studies Reader authored by scholars and activists who identify as fat, I assign qualitative articles (e.g., Lewis et al.) and narrative reports (e.g., Pause 42) in which fat people describe their experiences with weight and weight bias. Additionally, I provide positive images of fat people via films and websites (Clifford et al. HAES®; Watkins; Watkins and Doyle-Hugmeyer 177) in order to counteract the preponderance of negative, dehumanising portrayals in popular media (e.g., Ata and Thompson 41). In response, a student stated:One of the biggest things I took away from this term was the confidence I found in fat women through films and stories. They had more confidence than I have seen in any tiny girl and owned the body they were given.I introduce “normal” weight allies as well, most especially Linda Bacon whose treatise on thin privilege tends to set the stage for viewing weight bias as a form of oppression (Bacon). One student observed, “It was a relief to be able to read and talk about weight oppression in a classroom setting for once.” Another appreciated that “The class did a great job at analysing fat as oppression and not like a secondhand oppression as I have seen in my past classes.” Typically, fat students were already aware of weight-based privilege and oppression, often painfully so. Thinner students, however, were often astonished by this concept, several describing Bacon’s article as “eye-opening.” In reaction, many vowed to act as allies:This class has really opened my eyes and prepared me to be an ally to fat people. It will be difficult for some time while I try to get others to understand my point of view on fat people but I believe once there are enough allies, people’s minds will really start changing and it will benefit everyone for the better.Pedagogically, I choose to share my own experiences as they relate to course content and encourage students, at least in their written assignments, to do the same. Other instructors refrain from this practice for fear of reinforcing traditional discourses or eliciting detrimental reactions from students (Watkins, Farrell, and Doyle-Hugmeyer 191). Nevertheless, this tack seems to work well in my course, with many students opting to disclose their relevant circumstances during classroom discussions: Throughout the term I very much valued and appreciated when classmates would share their experiences. I love listening and hearing to others experiences and I think that is a great way to understand the material and learn from one another.It really helped to read different articles and hear classmates discuss and share stories that I was able to relate to. The idea of hearing people talk about issues that I thought I was the only one who dealt with was so refreshing and enlightening.The structure of this class allowed me to learn how this information is applicable to my life and made it deeper than just memorising information.Thus far, across three terms, no student has described iatrogenic effects from this process. In fact, most attribute positive transformations to the class. These include enhanced body acceptance of self and others: This class decreased my fat phobia towards others and gave me a better understanding about the intersectionality of one’s weight. For example, I now feel that I no longer view my family in a fat phobic way and I also feel responsible for educating my brother and helping him develop a strong self-esteem regardless of his size.I never thought this class would change my life, almost save my life. Through studies shown in class and real life people following their dreams, it made my mind completely change about how I view my body and myself.I can only hope that in the future, I will be more forgiving, tolerant, and above all accepting of myself, much less others. Regardless of a person’s shape and size, we are all beautiful, and while I’m just beginning to understand this, it can only get better from here.Students also reported becoming more savvy consumers of weight-centric media messages as well as realigning their eating and exercise behaviour in accordance with HAES: I find myself disgusted at the television now, especially with the amount of diet ads, fitness club ads, and exercise equipment ads all aimed at making a ‘better you.’ I now know that I would never be better off with a SlimFast shake, P90X, or a Total Gym. I would be better off eating when I’m hungry, working out because it is fun, and still eating Thin Mints when I want to. Prior to this class, I would work out rigorously, running seven miles a day. Now I realise why at times I dreaded to work out, it was simply a mathematical system to burn the energy that I had acquired earlier in the day. Instead what I realise I should do is something I enjoy, that way I will never get tired of whatever I am doing. While I do enjoy running, other activities would bring more joy while engaging in a healthy lifestyle like hiking or mountain biking.I will never go on another diet. I will stop choosing exercises I don’t love to do. I will not weigh myself every single day hoping for the number on the scale to change.A reduction in self-weighing was perhaps the most frequent behaviour change that students expressed. This is particularly valuable in that frequent self-weighing is associated with disordered eating and unhealthy weight control behaviours (Neumark-Sztainer et al. 811):I have realised that the number on the scale is simply a number on the scale. That number does not define who you are. I have stopped weighing myself every morning. I put the scale in the storage closet so I don’t have to look at it. I even encouraged my roommate to stop weighing herself too. What has been most beneficial for me to take away from this class is the notion that the number on the scale has so much less to do with fitness levels than most people understand. Coming from a numbers obsessed person like myself, this class has actually gotten me to leave the scales behind. I used to weigh myself every single day and my self-confidence reflected whether I was up or down in weight from the day before. It seems so silly to me now. From this class, I take away a new outlook on body diversity. I will evaluate who I am for what I do and not represent myself with a number. I’m going to have my cake this time, and actually eat it too!Finally, students described ways in which they might carry the concepts from Fat Studies into their future professions: I want to go to law school. This model is something I will work toward in the fight for social justice.As a teacher and teacher of teachers, I plan to incorporate discussions on size diversity and how this should be addressed within the field of adapted physical education.I do not know how I would have gone forward if I had never taken this class. I probably would have continued to use weight loss as an effective measure of success for both nutrition and physical activity interventions. I will never be able to think about the obesity prevention movement in the same way.Since I am working toward being a clinical psychologist, I don’t want to have a client who is pursuing weight loss and then blindly believe that they need to lose weight. I’d rather be of the mindset that every person is unique, and that there are other markers of health at every size.Jones and Hughes-Decatur (59) call for increased scholarship illustrating and evaluating critical body pedagogies so that teachers might provide students with tools to critique dominant discourses, helping them forge healthy relationships with their own bodies in the process. As such, this paper describes elements of a Fat Studies class that other instructors may choose to adopt. It additionally presents qualitative data suggesting that students came to think about fat and fat people in new and divergent ways. Qualitative responses also suggest that students developed better body image and more adaptive eating and exercise behaviours throughout the term. Although no students have yet described lasting adverse effects from the class, one stated that she would have preferred less of a focus on health and more of a focus on issues such as fat fashion. Indeed, some Fat Studies scholars (e.g., Lee) advocate separating discussions of weight bias from discussions of health status to avoid stigmatising fat people who do experience health problems. While concerns about fostering healthism within the fat acceptance movement are valid, as a behavioural health professional with an audience of students training in these fields, I have chosen to devote three weeks of our ten week term to this subject matter. Depending on their academic background, others who teach Fat Studies may choose to emphasise different aspects such as media representations or historical connotations of fat.Nevertheless, the preponderance of positive comments evidenced throughout students’ assignments may certainly be a function of social desirability. Although I explicitly invite critique, and in fact assign readings (e.g., Welsh 33) and present media that question HAES and Fat Studies concepts, students may still feel obliged to articulate acceptance of and transformations consistent with the principles of these movements. As a more objective assessment of student outcomes, I am currently conducting a quantitative evaluation, in which I remain blind to students’ identities, of this year’s Fat Studies course compared to other upper division/graduate Psychology courses, examining potential changes in weight bias, body image and dieting behaviour, adherence to appearance-related media messages, and obligatory exercise behaviour. I postulate results akin to those of Humphrey, Clifford, and Neyman Morris (143) who found reductions in weight bias, improved body image, and improved eating behaviour among college students as a function of their HAES course. As Fat Studies pedagogy proliferates, instructors are called upon to share their teaching strategies, document the effects, and communicate these results within and outside of academic spheres.ReferencesAmbwani, Suman, Katherine M. Thomas, Christopher J. Hopwood, Sara A. Moss, and Carlos M. Grilo. “Obesity Stigmatization as the Status Quo: Structural Considerations and Prevalence among Young Adults in the U.S.” Eating Behaviors 15.3 (2014): 366-370. Aphramor, Lucy. “Validity of Claims Made in Weight Management Research: A Narrative Review of Dietetic Articles.” Nutrition Journal 9 (2010): n. pag. 15 May 2015 ‹http://www.nutritionj.com/content/9/1/30›.Ata, Rheanna M., and J. Kevin Thompson. “Weight Bias in the Media: A Review of Recent Research.” Obesity Facts 3.1 (2010): 41-46.Bacon, Linda. “Reflections on Fat Acceptance: Lessons Learned from Thin Privilege.” 2009. 23 Apr. 2015 ‹http://www.lindabacon.org/Bacon_ThinPrivilege080109.pdf›.Bacon, Linda, and Lucy Aphramor. “Weight Science: Evaluating the Evidence for a Paradigm Shift.” Nutrition Journal 10 (2011). 23 Apr. 2015 ‹http://www.nutritionj.com/content/10/1/9›.Barry, Vaughn W., Meghan Baruth, Michael W. Beets, J. Larry Durstine, Jihong Liu, and Steven N. Blair. “Fitness vs. Fatness on All-Cause Mortality: A Meta-Analysis.” Progress in Cardiovascular Diseases 56.4 (2014): 382-390.Bergen, Martha, and Sonia Carrizales. “New Task Force Focused on Size.” The Feminist Psychologist 42.1 (2015): 22.Bombak, Andrea. “Obesity, Health at Every Size, and Public Health Policy.” American Journal of Public Health 104.2 (2014): e60-e67.Cameron, Erin. “Learning to Teach Everybody: Exploring the Emergence of an ‘Obesity” Pedagogy’.” The Fat Pedagogy Reader: Challenging Weight-Based Oppression in Education. Eds. Erin Cameron and Connie Russell. New York: Peter Lang Publishing, in press.Cameron, Erin. “Toward a Fat Pedagogy: A Study of Pedagogical Approaches Aimed at Challenging Obesity Discourses in Post-Secondary Education.” Fat Studies 4.1 (2015): 28-45.Chastain, Ragen. Dances with Fat. 15 May 2015 ‹https://danceswithfat.wordpress.com/blog/›.Clifford, Dawn, Amy Ozier, Joanna Bundros, Jeffrey Moore, Anna Kreiser, and Michele Neyman Morris. “Impact of Non-Diet Approaches on Attitudes, Behaviors, and Health Outcomes: A Systematic Review.” Journal of Nutrition Education and Behavior 47.2 (2015): 143-155.Clifford, Dawn, Patti Lou Watkins, and Rebecca Y. Concepcion. “HAES® University: Bringing a Weight Neutral Message to Campus.” Association for Size Diversity and Health, 2015. 23 Apr. 2015 ‹https://www.sizediversityandhealth.org/content.asp?id=258›.Fat Studies: An Interdisciplinary Journal of Body Weight and Society. 23 Apr. 2015 ‹http://www.tandfonline.com/toc/ufts20/current#.VShpqdhFDBC›.Flegal, Katherine M., Brian K. Kit, Heather Orpana, and Barry L. Graubard. “Association of All-Cause Mortality with Overweight and Obesity Using Standard Body Mass Index Categories: A Systematic Review and Meta-Analysis.” Journal of the American Medical Association 309.1 (2013): 71-82.Humphrey, Lauren, Dawn Clifford, and Michelle Neyman Morris. “Health At Every Size College Course Reduces Dieting Behaviors and Improves Intuitive Eating, Body Esteem, and Anti-Fat Attitudes.” Journal of Nutrition Education and Behavior, in press.Jones, Stephanie, and Hilary Hughes-Decatur. “Speaking of Bodies in Justice-Oriented Feminist Teacher Education.” Journal of Teacher Education 63.1 (2012): 51-61.Lee, Jenny. Embodying Stereotypes: Memoir, Fat and Health. Fat Studies: Reflective Intersections, July 2012, Wellington, NZ. Unpublished conference paper.Lewis, Sophie, Samantha L. Thomas, Jim Hyde, David Castle, R. Warwick Blood, and Paul A. Komesaroff. “’I Don't Eat a Hamburger and Large Chips Every Day!’ A Qualitative Study of the Impact of Public Health Messages about Obesity on Obese Adults.” BMC Public Health 10.309 (2010). 23 Apr 2015 ‹http://www.biomedcentral.com/1471-2458/10/309›.Mann, Traci, A. Janet Tomiyama, Erika Westling, Ann-Marie Lew, Barbara Samuels, and Jason Chatman. “Medicare’s Search for Effective Obesity Treatments: Diets Are Not the Answer.” American Psychologist 62.3 (2007): 220-233.McAuley, Paul A., and Steven N. Blair. “Obesity Paradoxes.” Journal of Sports Sciences 29.8 (2011): 773-782. McHugh, Maureen C., and Ashley E. Kasardo. “Anti-Fat Prejudice: The Role of Psychology in Explication, Education and Eradication.” Sex Roles 66.9-10 (2012): 617-627.Moola, Fiona J., Moss E. Norman, LeAnne Petherick, and Shaelyn Strachan. “Teaching across the Lines of Fault in Psychology and Sociology: Health, Obesity and Physical Activity in the Canadian Context.” Sociology of Sport Journal 31.2 (2014): 202-227.Nash, Joy. “A Fat Rant.” YouTube, 17 Mar. 2007. 23 Apr. 2015 ‹https://www.youtube.com/watch?v=yUTJQIBI1oA›.Neumark-Sztainer, Dianne, Patricia van den Berg, Peter J. Hannan, and Mary Story. “Self-Weighing in Adolescents: Helpful or Harmful? Longitudinal Associations with Body Weight Changes and Disordered Eating.” Journal of Adolescent Health 39.6 (2006): 811–818.O’Brien, K.S., J.A. Hunter, and M. Banks. “Implicit Anti-Fat Bias in Physical Educators: Physical Attributes, Ideology, and Socialization.” International Journal of Obesity 31.2 (2007): 308-314.Pause, Cat. “Live to Tell: Coming Out as Fat.” Somatechnics 2.1 (2012): 42-56.Rothblum, Esther, and Sondra Solovay, eds. The Fat Studies Reader. New York: New York University Press, 2009.Russell, Connie, and Erin Cameron, eds. The Fat Pedagogy Reader: Challenging Weight-Based Oppression in Education. New York: Peter Lang Publishing, in press. Salas, Ximena Ramos. “The Ineffectiveness and Unintended Consequences of the Public Health War on Obesity.” Canadian Journal of Public Health 106.2 (2015): e79-e81. Tomiyama, A. Janet, Britt Ahlstrom, and Traci Mann. “Long-Term Effects of Dieting: Is Weight Loss Related to Health?” Social and Personality Psychology Compass 7.12 (2013): 861-877.Tylka, Tracy L., Rachel A. Annunziato, Deb Burgard, Sigrun Daníelsdóttir, Ellen Shuman, Chad Davis, and Rachel M. Calogero. “The Weight-Inclusive versus Weight-Normative Approach to Health: Evaluating the Evidence for Prioritizing Well-Being over Weight Loss.” Journal of Obesity (2014). 23 Apr. 2015 ‹http://www.hindawi.com/journals/jobe/2014/983495/›.Ward, Anna E. “The Future of Fat.” American Quarterly 65.4 (2013): 937-947.Watkins, Patti Lou. “Inclusion of Fat Studies in a Difference, Power, and Discrimination Curriculum.” The Fat Pedagogy Reader: Challenging Weight-Based Oppression in Education. Eds. Erin Cameron and Connie Russell. New York: Peter Lang Publishing, in press. Watkins, Patti Lou, and Rebecca Y. Concepcion. “Teaching HAES to Health Care Students and Professionals.” Wellness Not Weight: Motivational Interviewing and a Non-Diet Approach. Ed. Ellen Glovsky. San Diego: Cognella Academic Publishing, 2014: 159-169. Watkins, Patti Lou, and Andrea Doyle-Hugmeyer. “Teaching about Eating Disorders from a Fat Studies Perspective. Transformations 23.2 (2013): 147-158. Watkins, Patti Lou, Amy E. Farrell, and Andrea Doyle Hugmeyer. “Teaching Fat Studies: From Conception to Reception. Fat Studies 1.2 (2012): 180-194. Welsh, Taila L. “Healthism and the Bodies of Women: Pleasure and Discipline in the War against Obesity.” Journal of Feminist Scholarship 1 (2011): 33-48. Weight Stigma Conference. 23 Apr. 2015 ‹http://stigmaconference.com/›.

In Australia the “intimacy” of citizenship (Berlant 2), is often used to reinforce subscription to heteronormative romantic and familial structures. Because this framing promotes discourses of moral failure, recent political attention to sexuality and same-sex couples can be filtered through insights into coalitional affiliations. This paper uses contemporary shifts in Australian politics and culture to think through the concept of coalition, and in particular to analyse connections between sexuality and governmentality (or more specifically normative bias and same-sex relationships) in what I’m calling post-coalitional Australia. Against the unpredictability of changing parties and governments, allegiances and alliances, this paper suggests the continuing adherence to a heteronormatively arranged public sphere. After the current Australian Prime Minister Julia Gillard deposed the previous leader, Kevin Rudd, she clung to power with the help of independents and the Greens, and clichés of a “rainbow coalition” and a “new paradigm” were invoked to describe the confused electorate and governmental configuration. Yet in 2007, a less confused Australia decisively threw out the Howard–led Liberal and National Party coalition government after eleven years, in favour of Rudd’s own rainbow coalition: a seemingly invigorated party focussed on gender equity, Indigenous Australians, multi-cultural visibility, workplace relations, Austral-Asian relations, humane refugee processing, the environment, and the rights and obligations of same-sex couples. A post-coalitional Australia invokes something akin to “aftermath culture” (Lambert and Simpson), referring not just to Rudd’s fall or Howard’s election loss, but to the broader shifting contexts within which most Australian citizens live, and within which they make sense of the terms “Australia” and “Australian”. Contemporary Australia is marked everywhere by cracks in coalitions and shifts in allegiances and belief systems – the Coalition of the Willing falling apart, the coalition government crushed by defeat, deposed leaders, and unlikely political shifts and (re)alignments in the face of a hung parliament and renewed pushes toward moral and cultural change. These breakdowns in allegiances are followed by swift symbolically charged manoeuvres. Gillard moved quickly to repair relations with mining companies damaged by Rudd’s plans for a mining tax and to water down frustration with the lack of a sustainable Emissions Trading Scheme. And one of the first things Kevin Rudd did as Prime Minister was to change the fittings and furnishings in the Prime Ministerial office, of which Wright observed that “Mr Howard is gone and Prime Minister Kevin Rudd has moved in, the Parliament House bureaucracy has ensured all signs of the old-style gentlemen's club… have been banished” (The Age, 5 Dec. 2007). Some of these signs were soon replaced by Ms. Gillard herself, who filled the office in turn with memorabilia from her beloved Footscray, an Australian Rules football team. In post-coalitional Australia the exile of the old Menzies’ desk and a pair of Chesterfield sofas works alongside the withdrawal of troops from Iraq and renewed pledges for military presence in Afghanistan, apologising to stolen generations of Indigenous Australians, the first female Governor General, deputy Prime Minister and then Prime Minister (the last two both Gillard), the repealing of disadvantageous workplace reform, a focus on climate change and global warming (with limited success as stated), a public, mandatory paid maternity leave scheme, changes to the processing and visas of refugees, and the amendments to more than one hundred laws that discriminate against same sex couples by the pre-Gillard, Rudd-led Labor government. The context for these changes was encapsulated in an announcement from Rudd, made in March 2008: Our core organising principle as a Government is equality of opportunity. And advancing people and their opportunities in life, we are a Government which prides itself on being blind to gender, blind to economic background, blind to social background, blind to race, blind to sexuality. (Rudd, “International”) Noting the political possibilities and the political convenience of blindness, this paper navigates the confusing context of post-coalitional Australia, whilst proffering an understanding of some of the cultural forces at work in this age of shifting and unstable alliances. I begin by interrogating the coalitional impulse post 9/11. I do this by connecting public coalitional shifts to the steady withdrawal of support for John Howard’s coalition, and movement away from George Bush’s Coalition of the Willing and the War on Terror. I then draw out a relationship between the rise and fall of such affiliations and recent shifts within government policy affecting same-sex couples, from former Prime Minister Howard’s amendments to The Marriage Act 1961 to the Rudd-Gillard administration’s attention to the discrimination in many Australian laws. Sexual Citizenship and Coalitions Rights and entitlements have always been constructed and managed in ways that live out understandings of biopower and social death (Foucault History; Discipline). The disciplining of bodies, identities and pleasures is so deeply entrenched in government and law that any non-normative claim to rights requires the negotiation of existing structures. Sexual citizenship destabilises the post-coalitional paradigm of Australian politics (one of “equal opportunity” and consensus) by foregrounding the normative biases that similarly transcend partisan politics. Sexual citizenship has been well excavated in critical work from Evans, Berlant, Weeks, Richardson, and Bell and Binnie’s The Sexual Citizen which argues that “many of the current modes of the political articulation of sexual citizenship are marked by compromise; this is inherent in the very notion itself… the twinning of rights with responsibilities in the logic of citizenship is another way of expressing compromise… Every entitlement is freighted with a duty” (2-3). This logic extends to political and economic contexts, where “natural” coalition refers primarily to parties, and in particular those “who have powerful shared interests… make highly valuable trades, or who, as a unit, can extract significant value from others without much risk of being split” (Lax and Sebinius 158). Though the term is always in some way politicised, it need not refer only to partisan, multiparty or multilateral configurations. The subscription to the norms (or normativity) of a certain familial, social, religious, ethnic, or leisure groups is clearly coalitional (as in a home or a front, a club or a team, a committee or a congregation). Although coalition is interrogated in political and social sciences, it is examined frequently in mathematical game theory and behavioural psychology. In the former, as in Axelrod’s The Evolution of Cooperation, it refers to people (or players) who collaborate to successfully pursue their own self-interests, often in the absence of central authority. In behavioural psychology the focus is on group formations and their attendant strategies, biases and discriminations. Experimental psychologists have found “categorizing individuals into two social groups predisposes humans to discriminate… against the outgroup in both allocation of resources and evaluation of conduct” (Kurzban, Tooby and Cosmides 15387). The actions of social organisation (and not unseen individual, supposedly innate impulses) reflect the cultural norms in coalitional attachments – evidenced by the relationship between resources and conduct that unquestioningly grants and protects the rights and entitlements of the larger, heteronormatively aligned “ingroup”. Terror Management Particular attention has been paid to coalitional formations and discriminatory practices in America and the West since September 11, 2001. Terror Management Theory or TMT (Greenberg, Pyszczynski and Solomon) has been the main framework used to explain the post-9/11 reassertion of large group identities along ideological, religious, ethnic and violently nationalistic lines. Psychologists have used “death-related stimuli” to explain coalitional mentalities within the recent contexts of globalised terror. The fear of death that results in discriminatory excesses is referred to as “mortality salience”, with respect to the highly visible aspects of terror that expose people to the possibility of their own death or suffering. Naverette and Fessler find “participants… asked to contemplate their own deaths exhibit increases in positive evaluations of people whose attitudes and values are similar to their own, and derogation of those holding dissimilar views” (299). It was within the climate of post 9/11 “mortality salience” that then Prime Minister John Howard set out to change The Marriage Act 1961 and the Family Law Act 1975. In 2004, the Government modified the Marriage Act to eliminate flexibility with respect to the definition of marriage. Agitation for gay marriage was not as noticeable in Australia as it was in the U.S where Bush publicly rejected it, and the UK where the Civil Union Act 2004 had just been passed. Following Bush, Howard’s “queer moral panic” seemed the perfect decoy for the increased scrutiny of Australia’s involvement in the Iraq war. Howard’s changes included outlawing adoption for same-sex couples, and no recognition for legal same-sex marriages performed in other countries. The centrepiece was the wording of The Marriage Amendment Act 2004, with marriage now defined as a union “between a man and a woman to the exclusion of all others”. The legislation was referred to by the Australian Greens Senator Bob Brown as “hateful”, “the marriage discrimination act” and the “straight Australia policy” (Commonwealth 26556). The Labor Party, in opposition, allowed the changes to pass (in spite of vocal protests from one member) by concluding the legal status of same-sex relations was in no way affected, seemingly missing (in addition to the obvious symbolic and physical discrimination) the equation of same-sex recognition with terror, terrorism and death. Non-normative sexual citizenship was deployed as yet another form of “mortality salience”, made explicit in Howard’s description of the changes as necessary in protecting the sanctity of the “bedrock institution” of marriage and, wait for it, “providing for the survival of the species” (Knight, 5 Aug. 2003). So two things seem to be happening here: the first is that when confronted with the possibility of their own death (either through terrorism or gay marriage) people value those who are most like them, joining to devalue those who aren’t; the second is that the worldview (the larger religious, political, social perspectives to which people subscribe) becomes protection from the potential death that terror/queerness represents. Coalition of the (Un)willing Yet, if contemporary coalitions are formed through fear of death or species survival, how, for example, might these explain the various forms of risk-taking behaviours exhibited within Western democracies targeted by such terrors? Navarette and Fessler (309) argue that “affiliation defences are triggered by a wider variety of threats” than “existential anxiety” and that worldviews are “in turn are reliant on ‘normative conformity’” (308) or “normative bias” for social benefits and social inclusions, because “a normative orientation” demonstrates allegiance to the ingroup (308-9). Coalitions are founded in conformity to particular sets of norms, values, codes or belief systems. They are responses to adaptive challenges, particularly since September 11, not simply to death but more broadly to change. In troubled times, coalitions restore a shared sense of predictability. In Howard’s case, he seemed to say, “the War in Iraq is tricky but we have a bigger (same-sex) threat to deal with right now. So trust me on both fronts”. Coalitional change as reflective of adaptive responses thus serves the critical location of subsequent shifts in public support. Before and since September 11 Australians were beginning to distinguish between moderation and extremism, between Christian fundamentalism and productive forms of nationalism. Howard’s unwavering commitment to the American-led war in Iraq saw Australia become a member of another coalition: the Coalition of the Willing, a post 1990s term used to describe militaristic or humanitarian interventions in certain parts of the world by groups of countries. Howard (in Pauly and Lansford 70) committed Australia to America’s fight but also to “civilization's fight… of all who believe in progress and pluralism, tolerance and freedom”. Although Bush claimed an international balance of power and influence within the coalition (94), some countries refused to participate, many quickly withdrew, and many who signed did not even have troops. In Australia, the war was never particularly popular. In 2003, forty-two legal experts found the war contravened International Law as well as United Nations and Geneva conventions (Sydney Morning Herald 26 Feb. 2003). After the immeasurable loss of Iraqi life, and as the bodies of young American soldiers (and the occasional non-American) began to pile up, the official term “coalition of the willing” was quietly abandoned by the White House in January of 2005, replaced by a “smaller roster of 28 countries with troops in Iraq” (ABC News Online 22 Jan. 2005). The coalition and its larger war on terror placed John Howard within the context of coalitional confusion, that when combined with the domestic effects of economic and social policy, proved politically fatal. The problem was the unclear constitution of available coalitional configurations. Howard’s continued support of Bush and the war in Iraq compounded with rising interest rates, industrial relations reform and a seriously uncool approach to the environment and social inclusion, to shift perceptions of him from father of the nation to dangerous, dithery and disconnected old man. Post-Coalitional Change In contrast, before being elected Kevin Rudd sought to reframe Australian coalitional relationships. In 2006, he positions the Australian-United States alliance outside of the notion of military action and Western territorial integrity. In Rudd-speak the Howard-Bush-Blair “coalition of the willing” becomes F. Scott Fitzgerald’s “willingness of the heart”. The term coalition was replaced by terms such as dialogue and affiliation (Rudd, “Friends”). Since the 2007 election, Rudd moved quickly to distance himself from the agenda of the coalition government that preceded him, proposing changes in the spirit of “blindness” toward marginality and sexuality. “Fix-it-all” Rudd as he was christened (Sydney Morning Herald 29 Sep. 2008) and his Labor government began to confront the legacies of colonial history, industrial relations, refugee detention and climate change – by apologising to Aboriginal people, timetabling the withdrawal from Iraq, abolishing the employee bargaining system Workchoices, giving instant visas and lessening detention time for refugees, and signing the Kyoto Protocol agreeing (at least in principle) to reduce green house gas emissions. As stated earlier, post-coalitional Australia is not simply talking about sudden change but an extension and a confusion of what has gone on before (so that the term resembles postcolonial, poststructural and postmodern because it carries the practices and effects of the original term within it). The post-coalitional is still coalitional to the extent that we must ask: what remains the same in the midst of such visible changes? An American focus in international affairs, a Christian platform for social policy, an absence of financial compensation for the Aboriginal Australians who received such an eloquent apology, the lack of coherent and productive outcomes in the areas of asylum and climate change, and an impenetrable resistance to the idea of same-sex marriage are just some of the ways in which these new governments continue on from the previous one. The Rudd-Gillard government’s dealings with gay law reform and gay marriage exemplify the post-coalitional condition. Emulating Christ’s relationship to “the marginalised and the oppressed”, and with Gillard at his side, Rudd understandings of the Christian Gospel as a “social gospel” (Rudd, “Faith”; see also Randell-Moon) to table changes to laws discriminating against gay couples – guaranteeing hospital visits, social security benefits and access to superannuation, resembling de-facto hetero relationships but modelled on the administering and registration of relationships, or on tax laws that speak primarily to relations of financial dependence – with particular reference to children. The changes are based on the report, Same Sex, Same Entitlements (HREOC) that argues for the social competence of queer folk, with respect to money, property and reproduction. They speak the language of an equitable economics; one that still leaves healthy and childless couples with limited recognition and advantage but increased financial obligation. Unable to marry in Australia, same-sex couples are no longer single for taxation purposes, but are now simultaneously subject to forms of tax/income auditing and governmental revenue collection should either same-sex partner require assistance from social security as if they were married. Heteronormative Coalition Queer citizens can quietly stake their economic claims and in most states discreetly sign their names on a register before becoming invisible again. Mardi Gras happens but once a year after all. On the topic of gay marriage Rudd and Gillard have deferred to past policy and to the immoveable nature of the law (and to Howard’s particular changes to marriage law). That same respect is not extended to laws passed by Howard on industrial relations or border control. In spite of finding no gospel references to Jesus the Nazarene “expressly preaching against homosexuality” (Rudd, “Faith”), and pre-election promises that territories could govern themselves with respect to same sex partnerships, the Rudd-Gillard government in 2008 pressured the ACT to reduce its proposed partnership legislation to that of a relationship register like the ones in Tasmania and Victoria, and explicitly demanded that there be absolutely no ceremony – no mimicking of the real deal, of the larger, heterosexual citizens’ “ingroup”. Likewise, with respect to the reintroduction of same-sex marriage legislation by Greens senator Sarah Hanson Young in September 2010, Gillard has so far refused a conscience vote on the issue and restated the “marriage is between a man and a woman” rhetoric of her predecessors (Topsfield, 30 Sep. 2010). At the same time, she has agreed to conscience votes on euthanasia and openly declared bi-partisan (with the federal opposition) support for the war in Afghanistan. We see now, from Howard to Rudd and now Gillard, that there are some coalitions that override political differences. As psychologists have noted, “if the social benefits of norm adherence are the ultimate cause of the individual’s subscription to worldviews, then the focus and salience of a given individual’s ideology can be expected to vary as a function of their need to ally themselves with relevant others” (Navarette and Fessler 307). Where Howard invoked the “Judaeo-Christian tradition”, Rudd chose to cite a “Christian ethical framework” (Rudd, “Faith”), that saw him and Gillard end up in exactly the same place: same sex relationships should be reduced to that of medical care or financial dependence; that a public ceremony marking relationship recognition somehow equates to “mimicking” the already performative and symbolic heterosexual institution of marriage and the associated romantic and familial arrangements. Conclusion Post-coalitional Australia refers to the state of confusion borne of a new politics of equality and change. The shift in Australia from conservative to mildly socialist government(s) is not as sudden as Howard’s 2007 federal loss or as short-lived as Gillard’s hung parliament might respectively suggest. Whilst allegiance shifts, political parties find support is reliant on persistence as much as it is on change – they decide how to buffer and bolster the same coalitions (ones that continue to privilege white settlement, Christian belief systems, heteronormative familial and symbolic practices), but also how to practice policy and social responsibility in a different way. Rudd’s and Gillard’s arguments against the mimicry of heterosexual symbolism and the ceremonial validation of same-sex partnerships imply there is one originary form of conduct and an associated sacred set of symbols reserved for that larger ingroup. Like Howard before them, these post-coalitional leaders fail to recognise, as Butler eloquently argues, “gay is to straight not as copy is to original, but as copy is to copy” (31). To make claims to status and entitlements that invoke the messiness of non-normative sex acts and romantic attachments necessarily requires the negotiation of heteronormative coalitional bias (and in some ways a reinforcement of this social power). As Bell and Binnie have rightly observed, “that’s what the hard choices facing the sexual citizen are: the push towards rights claims that make dissident sexualities fit into heterosexual culture, by demanding equality and recognition, versus the demand to reject settling for heteronormativity” (141). The new Australian political “blindness” toward discrimination produces positive outcomes whilst it explicitly reanimates the histories of oppression it seeks to redress. The New South Wales parliament recently voted to allow same-sex adoption with the proviso that concerned parties could choose not to adopt to gay couples. The Tasmanian government voted to recognise same-sex marriages and unions from outside Australia, in the absence of same-sex marriage beyond the current registration arrangements in its own state. In post-coalitional Australia the issue of same-sex partnership recognition pits parties and allegiances against each other and against themselves from within (inside Gillard’s “rainbow coalition” the Rainbow ALP group now unites gay people within the government’s own party). Gillard has hinted any new proposed legislation regarding same-sex marriage may not even come before parliament for debate, as it deals with real business. Perhaps the answer lies over the rainbow (coalition). As the saying goes, “there are none so blind as those that will not see”. References ABC News Online. “Whitehouse Scraps Coalition of the Willing List.” 22 Jan. 2005. 1 July 2007 ‹http://www.abc.net.au/news/newsitems/200501/s1286872.htm›. Axelrod, Robert. The Evolution of Cooperation. New York: Basic Books, 1984. Berlant, Lauren. The Queen of America Goes to Washington City: Essays on Sex and Citizenship. Durham: Duke University Press, 1997. Bell, David, and John Binnie. The Sexual Citizen: Queer Politics and Beyond. Cambridge, England: Polity, 2000. Butler, Judith. Gender Trouble: Feminism and the Subversion of Identity. New York: Routledge, 1990. Commonwealth of Australia. Parliamentary Debates. House of Representatives 12 Aug. 2004: 26556. (Bob Brown, Senator, Tasmania.) Evans, David T. Sexual Citizenship: The Material Construction of Sexualities. London: Routledge, 1993. Foucault, Michel. Discipline and Punish: The Birth of the Prison. Trans. A. Sheridan. London: Penguin, 1991. ———. The Will to Knowledge: The History of Sexuality. Vol. 1. Trans. Robert Hurley. London: Penguin, 1998. Greenberg, Jeff, Tom Pyszczynski, and Sheldon Solomon. “The Causes and Consequences of the Need for Self-Esteem: A Terror Management Theory.” Public Self, Private Self. Ed. Roy F. Baumeister. New York: Springer-Verlag, 1986. 189-212. Human Rights and Equal Opportunity Commission. Same-Sex: Same Entitlements Report. 2007. 21 Aug. 2007 ‹http://www.hreoc.gov.au/human_rights/samesex/report/index.html›. Kaplan, Morris. Sexual Justice: Democratic Citizenship and the Politics of Desire. New York: Routledge, 1997. Knight, Ben. “Howard and Costello Reject Gay Marriage.” ABC Online 5 Aug. 2003. Kurzban, Robert, John Tooby, and Leda Cosmides. "Can Race Be Erased? Coalitional Computation and Social Categorization." Proceedings of the National Academy of Sciences 98.26 (2001): 15387–15392. Lambert, Anthony, and Catherine Simpson. "Jindabyne’s Haunted Alpine Country: Producing (an) Australian Badland." M/C Journal 11.5 (2008). 20 Oct. 2010 ‹http://journal.media-culture.org.au/index.php/mcjournal/article/view/81›. Lax, David A., and James K. Lebinius. “Thinking Coalitionally: Party Arithmetic Process Opportunism, and Strategic Sequencing.” Negotiation Analysis. Ed. H. Peyton Young. Michigan: University of Michigan Press, 1991. 153-194. Naverette, Carlos, and Daniel Fessler. “Normative Bias and Adaptive Challenges: A Relational Approach to Coalitional Psychology and a Critique of Terror Management Theory.” Evolutionary Psychology 3 (2005): 297-325. Pauly, Robert J., and Tom Lansford. Strategic Preemption: US Foreign Policy and Second Iraq War. Aldershot: Ashgate, 2005. Randall-Moon, Holly. "Neoliberal Governmentality with a Christian Twist: Religion and Social Security under the Howard-Led Australian Government." Eds. Michael Bailey and Guy Redden. Mediating Faiths: Religion and Socio- Cultural Change in the Twenty-First Century. Farnham: Ashgate, in press. Richardson, Diane. Rethinking Sexuality. London: Sage, 2000. Rudd, Kevin. “Faith in Politics.” The Monthly 17 (2006). 31 July 2007 ‹http://www.themonthly.com.au/monthly-essays-kevin-rudd-faith-politics--300›. Rudd, Kevin. “Friends of Australia, Friends of America, and Friends of the Alliance That Unites Us All.” Address to the 15th Australian-American Leadership Dialogue. The Australian, 24 Aug. 2007. 13 Mar. 2008 ‹http://www.theaustralian.com.au/national-affairs/climate/kevin-rudds-address/story-e6frg6xf-1111114253042›. Rudd, Kevin. “Address to International Women’s Day Morning Tea.” Old Parliament House, Canberra, 11 Mar. 2008. 1 Oct. 2010 ‹http://pmrudd.archive.dpmc.gov.au/node/5900›. Sydney Morning Herald. “Coalition of the Willing? Make That War Criminals.” 26 Feb. 2003. 1 July 2007 ‹http://www.smh.com.au/articles/2003/02/25/1046064028608.html›. Topsfield, Jewel. “Gillard Rules Out Conscience Vote on Gay Marriage.” The Age 30 Sep. 2010. 1 Oct. 2010 ‹http://www.theage.com.au/national/gillard-rules-out-conscience-vote-on-gay-marriage-20100929-15xgj.html›. Weeks, Jeffrey. "The Sexual Citizen." Theory, Culture and Society 15.3-4 (1998): 35-52. Wright, Tony. “Suite Revenge on Chesterfield.” The Age 5 Dec. 2007. 4 April 2008 ‹http://www.theage.com.au/news/national/suite-revenge-on-chesterfield/2007/12/04/1196530678384.html›.