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Environmental health Perspectives 2 August 2021 Free

Investigating the health impacts of the Ranger uranium mine on Aboriginal people

Stillbirth and cancer rates are significantly elevated among Aboriginal people living near the Ranger uranium mine Stillbirth and cancer incidence rates are significantly higher among Aboriginal people living near the Ranger uranium mine than among Aboriginal people elsewhere in the Top End of the Northern Territory, with a stillbirth rate over twice as high and cancer incidence almost 50% higher.1 The NT Chief Health Officer commissioned an investigation into the excess stillbirths and cancers in 2014, but a November 2020 report found no explanatory cause.1 The Ranger uranium mine ceased operations as planned in January 2021.2 Communities expect health departments to respond to reports of clusters of adverse health outcomes such as the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine.3 However, investigating clusters of health outcomes which have complex aetiologies rarely provides definitive answers.3 Even when associations are identified, cluster investigations cannot demonstrate that these associations are responsible for the disease cluster. Nonetheless, important environmental, public health and social problems may be identified through cluster investigations, enabling health education and promotion, and potentially, mitigation of contributing causes.3 The Ranger mine cluster investigation focused on ionising radiation as a potential cause of the excess stillbirths and cancers because this was considered the worst‐case scenario.1 There are well established causative associations between ionising radiation and increased rates of some cancers, particularly lung, head and neck, thyroid cancer in childhood and leukaemia, and fetal malformations that lead to stillbirth.1 Tobacco and alcohol consumption likewise contribute to stillbirths and cancers, and these were also examined in the cluster investigation, together with markers of poor nutrition.1 High levels of alcohol consumption by Aboriginal people in the Ranger mine region have long been a concern.4,5 The Ranger uranium mine in Kakadu National Park Uranium mining began at a location labelled “Ranger” in 1980 on land excised from the Kakadu National Park World Heritage site.6 Aboriginal rights to veto mining were overridden in legislation, and detrimental impacts on Aboriginal people were anticipated, but market prospects for uranium appeared strong and the mine was considered to be in the national interest. Mining was allowed to proceed, with recommendations to monitor and reduce harmful impacts on the region’s Aboriginal people.4,7 Health, social and ecological aspects of the Ranger uranium mine were explored in a 1984 report, whose authors recognised that their immersion into Aboriginal communities gave them deep concern about how uranium mining could affect Aboriginal people.5 They recommended that uranium mining not expand without interventions to mitigate harmful and strengthen positive effects of mining on Aboriginal people.5 Mining continued for 40 years, and the Ranger uranium mine contributed up to $388 million annually to the NT economy before its 2021 closure.2,8 During the period of mine operation, more than 200 leaks, spills and other incidents were documented.9 Five major incidents are outlined in Box 1, highlighting threats to ecosystems and employees more than radiation exposure among Aboriginal community residents.9,10 The Gundjeihmi Aboriginal Corporation represents the Mirarr people of the region and for decades has expressed grave concerns about continuing incidents and the lack of effective government response.7 While the Mirarr people maintain the right to live on their lands, their lives are disrupted by mining operations and incidents that threaten biodiversity, landscapes and livelihoods.7,9 In 2014, the mine operators lodged a proposal to expand. A submission on the proposal by the NT Department of Health noted that rates of stillbirth and cancer among Aboriginal people in the region were elevated.1 NT Department of Health investigation In 2014, the NT Chief Health Officer commissioned an investigation into stillbirth and cancer rates in long term Aboriginal residents around the Ranger mine. The investigation aimed to quantify rates and identify exposures that may have contributed to the excess stillbirths and cancers. Stakeholders including Aboriginal health and land corporations and public health and politics experts oversaw the investigation to ensure transparency, while independent epidemiologists scrutinised the investigation’s scope, design and conduct. The investigation report was released publicly in November 2020.1 The investigation identified all Aboriginal people who had spent more than half of their lives in the mine region during the 1991–2014 study period, with an exposed cohort of about 2200 people. The focus was ionising radiation because this exposure was considered the worst‐case scenario.1 The mine employed few local Aboriginal people, so occupational exposures were not considered.1,2 The comparison group comprised all other Aboriginal people in the Top End.1 Elevated stillbirth and cancer incidence rates among Aboriginal people living near the Ranger mine compared with other Aboriginal people in the Top End were confirmed. Stillbirth was over twice as common (odds ratio, 2.17; 95% CI, 1.13–3.82) and cancer about 50% more common (total cancer incidence ratio, 1.48; 95% CI, 1.17‐1.85).1 Examination of the cancer types showed that no specific cancer was responsible for the excess of total cancers. Cancers of the lip, mouth and pharynx together were the most common cancers and made up 42% of the excess: 16 cases, compared with 5.5 expected. These cancers are not considered to be caused by ionising radiation, but they are associated with tobacco smoking and alcohol consumption.1 The Aboriginal people living near the mine had higher prevalence of tobacco smoking (prevalence ratio, 1.08; 95% CI, 1.04–1.13), alcohol use (prevalence ratio, 1.21; 95% CI, 1.13–1.31) and infrequent intake of vegetables indicating poor nutrition (prevalence ratio, 1.08; 95% CI, 1.02–1.24) compared with other Aboriginal people in the Top End. Other risk factors were not statistically different between the groups. Multivariable analysis did not show that these risk factors contributed to the excess cancer incidence in the people living near the mine (Box 2). However, this analysis had low statistical power because of a lack of risk factor data.1 The investigation found “little evidence that the risk factors investigated … were associated with increased risk of cancer in study participants” in the period for which risk factor data were available.1 Despite this statistical conclusion, higher rates of tobacco smoking and alcohol use and poor diets among Aboriginal people in the mine region were highlighted in relation to the excess stillbirths and cancers. The investigation concluded by recommending that Aboriginal people follow advice about smoking, alcohol and diet.1 Discussion The Ranger uranium mine has had an impact on surrounding Aboriginal communities for over 40 years. The investigation by the NT Department of Health into the rates of stillbirths and cancers among people in the region invested significant resources and expertise in gathering data on stillbirths, cancers, ionising radiation and behavioural risk factors. It focused on cause–effect relationships between possible exposure to ionising radiation and behavioural risk factors, and the increased stillbirth and cancer rates. The investigation was not designed to consider the impact of the imposition of uranium mining on Aboriginal lands, as was recommended when the mine was proposed and developed.4,5 Development of the Ranger mine entailed nullification of veto rights, disempowering Aboriginal communities and threatening their livelihoods.7 With mining came royalty money, expensive commodities, money‐hunger and alcohol.5 Economic development from the mine has increased inequity among Aboriginal people in the region.5 Inequity may contribute to both stillbirths and cancer, although this would not be detected in a cluster investigation.3,11,12 Employment and educational opportunities associated with the Ranger mine did not promote socio‐economic development of the Aboriginal community; rather, Aboriginal wellbeing deteriorated through people relying on royalty income.2,7 Aboriginal people’s rights were ignored, and their expertise, authority and lifeways were devalued by the mine.7 Aboriginal community perspectives, knowledge and research methodologies may offer important insights into adverse Aboriginal health outcomes, while marginalising Aboriginal expertise perpetuates the impacts of colonisation.13 Excess stillbirths and cancers may be associated with a web of interrelationships between individuals, communities and wider ecological, sociological and political environments, which a biomedically focused investigation may overlook.14 Further research is needed to unravel this web, and explain the disparity in stillbirth and cancer rates between Aboriginal people in the region of the mine and the other Aboriginal people in the Top End. The NT Department of Health stillbirth and cancer cluster investigation recommended that Aboriginal people in the region reduce their tobacco and excessive alcohol consumption, although these were not considered the causes of the raised stillbirth and cancer rates.1 This response could be strengthened by a foundational approach to improve understanding and relationships between government, mining companies and Aboriginal community members.2 Conclusion The investigation by the NT Department of Health into the excess stillbirths and cancers among Aboriginal people living near the Ranger uranium mine was transparent, detailed and publicly available. High level expertise was engaged, although stronger Aboriginal contribution to the investigation’s grounding and methodology may have enhanced two‐way intercultural learning.13 Research from Aboriginal community perspectives that focuses on improving health and wellbeing may lead to possible interventions. While the mine is now closed and undergoing rehabilitation, there is an opportunity for further research to better understand and close the gap in health risk exposures and outcomes between Aboriginal people in the region of the mine and other Aboriginal people in the Top End. Box 1 – Major incidents at the Ranger uranium mine, 1979–20139,10 Date Location Incident Outcome Risk minimisation December 1995 Retention pond 2 at power station 12 000 litres of diesel fuel spilled World’s richest tropical waterbird breeding ground threatened; 40 identified waterbirds perished Office of Supervising Scientist designated this as unacceptable environmental impact. Increases in monitoring not implemented due to mine operator’s other commitments January–April 2002 Headwaters of Corridor Creek, southern side of mine Incorrect stockpiling of low grade uranium ore Water contaminated by leakage of uranium Remedial works undertaken in February 2002. No source found for ongoing run‐off identified in April March 2004 Ranger mine utility site Process water connected to drinking water, leading to water uranium levels 400 times Australian standards 159 workers potentially exposed to contaminated water for drinking and washing Mine operator prosecuted and fined $150 000 January–June 2011 Region wide Extreme wet season Risk of overflow from tailings dam Uranium mill was shut for duration of wet season December 2013 Ranger mine site Collapse of acid leach tank 1 million litres of radioactive ore slurry spilled Area was evacuated until spill contained Box 2 – Total cancer incidence rate ratios for Aboriginal people living near the mine compared with other Aboriginal people in the Top End of the Northern Territory, by selected risk factors*,1 Risk factor Cancer incidence rate ratio (95% CI) Tobacco smoking 1.53 (0.75–3.12) Alcohol use 1.54 (0.76–3.15) Infrequent vegetable intake 1.49 (0.73–3.06) * Poisson regression model adjusted for age and sex.

Rosalie Schultz

Mja2 51198
General medicine Perspectives 19 July 2021 Free

Low value care is a health hazard that calls for patient empowerment

To protect themselves from the potential harms of low value care, patients must take an active role in clinical decision making Low value care is care that is ineffective, harmful or confers marginal benefit at disproportionately high cost.1 Professionally‐led campaigns such as Choosing Wisely Australia and the Royal Australasian College of Physicians’ EVOLVE program aim to reduce the prevalence of such care. However, similar overseas campaigns have been marred by selective focus on infrequent, low impact, or less financially lucrative practices;2 uncertainty about the most effective de‐adoption strategies;3 and limited success to date in reducing overuse.4 While clinician‐targeted education programs, audit and feedback, and decision support feature prominently, evidence appears stronger and impact seems greater for strategies directed to, or mediated by, patients.5 Framing low value care as a health hazard for patients Although clinicians accept responsibility for resource stewardship, they also believe their primary care obligation is to the individual patient, with costs being a secondary consideration.6 Most patients hold similar views, until out‐of‐pocket expenses become unaffordable.7 Reframing low value care as having negative consequences, not just “worth a go” or “better safe than sorry”, may incentivise patients, clinicians and policymakers to engage more in mitigation efforts.8 Negative consequences can arise directly from an episode of low value care, or indirectly from subsequent downstream care cascades, such as invasively investigating incidental but benign findings from a previous unnecessary investigation. Harms can be physical, psychological, social, financial and relational (mistrust). Even providing potentially beneficial care to patients who do not want it can cause harm, at least psychologically. Moreover, giving low value care to one individual may result in delayed delivery of high value care to another individual, who may then suffer preventable harm. The burden of negative consequences Recent studies have begun to quantify the negative consequences of different forms of low value care. A review of 54 case descriptions of 63 overused services revealed an average of 3.2 negative consequences per case, most (33/54, 61%) featuring an overuse cascade feedback loop.9 Reported harms (91 in total) comprised injury (69%), psychological harm (16%), treatment burden (9%), financial loss (3%), and dissatisfaction (2%).9 Recent care cascades were reported by 374 internists in the United States following incidental findings from tests that a third deemed clinically inappropriate but which led to a new invasive test (77.2% of instances), an emergency department visit (54.8%), or hospitalisation (50.6%).10 These caused patients physical (15.6%) or psychological harm (68.4%), financial loss (57.5%), social disruptions (8.7%), and dissatisfaction (27.6%).10 Seven low value procedures characterised 9330 admissions to 225 Australian hospitals, including endoscopy for dyspepsia or colonoscopy for constipation in young people, knee arthroscopy for osteoarthritis or meniscal tears, and spinal fusion for uncomplicated low back pain.11 Between 0.2% and 15.0% of patients, depending on the procedure, developed one or more hospital‐acquired complications, most commonly infection (26.3% of instances), with a twofold or more increase in the median length of stay.11 Among 72 unnecessary admissions to one US hospital of low risk syncope patients, one in eight had an adverse event from tests and treatments.12 In a study of 405 695 individuals with new onset, non‐specific low back pain, those receiving lumbar spine magnetic resonance imaging (MRI) within 6 weeks, compared with matched controls without an early MRI, incurred significantly more surgery (1.48% v 0.12%), greater opioid use (35.1% v 28.6%), and worse pain scores (3.99 v 3.87).13Among 5057 individuals with incidentally detected lung nodules on chest x‐rays, those receiving intense diagnostic investigation versus guideline‐concordant care had more procedure‐related adverse events (8.1% absolute increase) and more radiation exposure, with no higher incidence of advanced cancer at 2 years’ follow‐up.14 In a study of 1488 hospitalised patients who received antibiotics for at least 24 hours, 287 (19%) of the antibiotic regimens were not indicated (eg, asymptomatic bacteriuria, aspiration pneumonitis, congestive heart failure), with 56 (20%) being associated with an adverse drug event, including seven cases of Clostridium difficile infection.15 Adding aspirin with no clear indication to 1107 of 3280 patients (33.8%) prescribed direct oral anticoagulants (DOACs) for confirmed indications was associated with more bleeding events (31.6 v 26.0 bleeding events per 100 patient years) and hospitalisations (9.1 v 6.5) than matched controls receiving direct oral anticoagulants only.16 The role of patients in reducing low value care While clinicians often complain of patients demanding inappropriate care,7 many patients perceive the negative consequences of overuse,17 and interventions that empower patients to challenge such overuse are effective in decreasing it by 25–40%.18 In a review of 22 studies, 19 (86%) reported significant reductions in unnecessary use of antibiotics and benzodiazepines, Caesarean deliveries, elective labour inductions, surgery for knee and hip osteoarthritis, non‐beneficial intensive care treatments, computed tomography scans for mild head injury in children, cardiac stress testing in low risk adults, and routine screening tests (full blood counts, electrocardiograms).18 These empowerment interventions comprised patient‐oriented educational materials and shared decision‐making protocols, the latter having greater effect. In another study, encouraging patients to identify their health concerns before a clinical encounter, and increasing their knowledge about their condition and care options, also rendered clinician advice more concordant with best practice by 33–60%.19 However, successful engagement depends on several factors: motivation and ability of clinicians to engage patients in decision making; clinician knowledge of, and agreement with, what constitutes low value care; the clinical context; and availability of decision support resources for both parties within clinical workflows. Clinicians do not always attempt to facilitate patient involvement and may not adjust care to patient preferences.20 Such engagement is time‐consuming for clinicians and inadequately remunerated, impractical in emergency situations or for patients unable or unwilling to engage, and may incite patient anxiety or dissuade them from further consultations. In response, evidence‐based strategies can overcome these barriers21 and reinforce patient perceptions of receiving optimal care and their desire to reconsult. More research needs to define the most effective mix of techniques for supporting patient engagement (eg, educating clinicians on communication techniques, deploying multidisciplinary teams, using trained decision coaches and patient decision aids), and their effects on consultation time and costs.22 Whether such engagement, by specifically reducing low value care, actually improves patient health remains uncertain, although its absence predisposes to worse clinical outcomes, lower quality care and increased health care utilisation.23 Empowering patients to engage in reducing low value care Many patients refrain from participating in discussions aimed at avoiding overuse because of a power asymmetry wherein they sense the need to seek clinician permission to discuss their options, feel they have insufficient knowledge to ask pertinent questions or understand the jargon (“doctor knows best”), and fear repercussions from being seen to challenge clinician credibility (desire to be a good patient). Alternatively, patients may want to avoid responsibility for making a wrong decision they will later regret, or feel unable to participate because of illness symptoms, cognitive impairment, language or cultural barriers, or need for emergency or intensive care.17 Nevertheless, clinicians must avoid making false assumptions about how much a patient desires involvement in decision making. Methods are needed for identifying which patients, encounters and clinicians need more support to enact the most appropriate form of shared decision making. Patients usually desire a more active role when the matter is serious, invasive interventions are being considered, or if significant out‐of‐pocket costs, lengthy time off work, or interruptions to social activities may be incurred. Younger patients, women and those with higher educational and socio‐economic status are more likely to participate.24 Greater engagement and less overuse are seen within long term clinician–patient relationships characterised by mutual trust and continuity of care,25 and where public messaging within practice environments encourages and legitimates engagement.26 Patients can be trained to ask questions, and adult learning programs can assist those with low health literacy.27 Choosing Wisely Australia (www.choosingwisely.org.au) and other organisations28 provide conversation starter patient resources; other sources provide topic‐specific lists of questions (eg, www.prosdex.com for prostate‐specific cancer antigen testing, and www.bresdex.com for breast cancer surgery). Decision aids, option grids and fact boxes can also assist. As a minimum, patients should be encouraged to ask these questions: Is there a decision we need to make? In urgent situations, clinicians may need to reach out and not wait for patients to ask. What are my options? All clinically viable options should be presented, including doing nothing. What are potential benefits and harms of each option? Where possible, these should be expressed using natural numbers (eg, four out of 100 people like you will experience a stroke every year; this treatment will reduce that to two out of 100, although one person of 100 will have a significant bleeding event). How will each option affect me in terms of what I consider important? Patients may want to know costs involved, duration of inability to work or perform social activities, skill and place of those performing a procedure. Consumer organisations should be resourced to run community education campaigns focused on engagement, while clinicians must be educated about the benefits of patient engagement and receive the tools, time and remuneration to support it within busy work schedules. Conclusion Efforts to increase patient empowerment in decision making should be seen as foundational for reducing low value care, and should underpin all other strategies targeting clinicians, payers and policymakers.

Ian A Scott · Adam G Elshaug · Melissa Fox

Mja2 51168
Environmental health Perspectives 12 July 2021 Free

An Australian glossary to aid multisectoral research and collaborations to address health and climate change

A shared language will promote climate change and health research and underpin a sustainable future Climate change requires collective action across many government, non‐government and private sectors.1 The development of a shared terminology to conduct, share and use research will be critical to the effective communication and collaboration needed to achieve this collective action.2 At the same time, climate change mitigation and adaptation is an exponentially growing field of multidisciplinary research and practice, augmenting the scale of the challenge.3,4 It will be vital that this cross‐disciplinary research effort is supported, but currently, there is poor alignment in the use of relevant terms across different research and policy fields, with little standardisation of terminology in the national and international literature. This article builds on other international efforts to address the need for shared terminology. A 2018 article provides definitions for the fields linking human health to ecosystems and environments and highlights planetary health.5 Another publication defines key terms that focus on vulnerability assessments and health equity implications.6 Leading international organisations, including the Intergovernmental Panel on Climate Change (IPCC)7 and the World Health Organization,8 have developed glossaries relevant to climate change and health. However, many terms require refinement for the Australian context. In an Australian collaborative endeavour, we developed an Australia-specific glossary of 55 terms that we believe are key to enhancing local intersectoral communication and collaboration on climate change and health.9 The methods included a systematic search and review of existing glossaries relevant to climate change and health, plus three rounds of stakeholder engagement including an online survey, a workshop and further discussion via a shared online document (Supporting Information). The glossary’s target audiences are researchers from various disciplines needing to collaborate to address health and climate change, and partners who need to understand and use that research to drive change (eg, government, policy, private sector, and otherdecision makers). We acknowledge that the language and priority issues in health and climate change will continue to evolve, and welcome contributions from other stakeholders to further develop and refine the terminology in the glossary. The need for multidisciplinary collaboration on health and climate change issues in Australia is reflected in the recent National Health and Medical Research Council’s Special Initiative in Human Health and Environmental Change.10 This initiative will support a multidisciplinary, collaborative network of researchers across Australia. It is hoped that this glossary could assist multisectoral collaborations. Key terms This section outlines and discusses some of the essential principles, considerations and challenges identified in developing the glossary and illustrates these with some of the most debated key terms. Notably, several definitions integrated Aboriginal and Torres Strait Islander perspectives. We included the term “Indigenous knowledges” for its Australian relevance and its importance in sustaining and caring for the land on which we live. Furthermore, we applied an eco‐social interpretation of health and climate change relationships, recognising that human and environmental health are inextricably linked. We amended several pre‐existing definitions to include considerations of other sentient beings and ecosystems. Components of climate change Challenges in defining climate‐related terms are illustrated by the definitions of climate change from the IPCC and the United Nations Framework Convention on Climate Change (UNFCCC).7,11 Despite both being derived for United Nations processes, there are stark differences. Both refer to two components of the changing climate: anthropogenic climate change (human component) and natural variability in the Earth’s climate. While the IPCC distinguishes between these in their climate change definition, the UNFCCC has split them into separate terms: “climate change” (anthropogenic causes) and “climate variability” (natural causes). Our stakeholders recommended distinguishing between the two components and explicitly stating the existential threat of climate change to create a greater sense of urgency, and also chose “health emergency” to urge immediate action as many Australian health and medical professional organisations (eg, the Australian Medical Association12 and the Royal Australasian College of Physicians13) have declared climate change a health emergency. Equity and justice Previous definitions for “climate equity” and “climate justice” appear to be human‐centric. Our proposed definitions for climate justice and climate equity are broader, to capture the links between human health and other species and ecological systems. In Australia, the destruction of biodiversity, wetlands, mangrove swamps, and rainforests is an indiscriminate loss of sensitive ecological systems and a form of injustice. There is an even more expansive notion of climate justice which includes attention to inequity in impacts, to participation and procedural justice, and to the functioning and provision of basic needs of vulnerable communities.14 Related to climate justice is “just transition”. A policy report by the Australian Council of Trade Unions15 notes that a just transition should ensure that communities facing transitions can flourish rather than simply survive. We amended a pre‐existing definition to explicitly state that transition should be towards sustainable economic systems that promote social justice. It is also important to acknowledge Aboriginal and Torres Strait Islander perspectives for just transitions, and that Aboriginal and Torres Strait Islander peoples be at the centre of decision making to ensure that environmental stewardship is promoted.16 Anxiety, grief and solastalgia Climate change is adversely affecting mental health, with visible impacts and increasing trauma from extreme weather events (eg, Australia’s unprecedented 2019–20 bushfire season). Terms that acknowledge and highlight the psychosocial and emotional harms of climate change include “climate anxiety/grief” and “solastalgia”, coined by Australian environmental philosopher Glenn Albrecht.17 This is especially relevant to Aboriginal and Torres Strait Islander peoples.18 Our climate anxiety/grief definition explicitly states the anxiety felt around losses for future generations. We also recognise that different generations may have varying baselines for how they think of climate change. Fires There are many variations in terminology used around fires, particularly international definitions, which may cause misunderstanding and inappropriate use of some terms in the context of climate change. In Australia, the term “bushfire” is very widely used and is therefore the term included in our glossary. The management of fires in Australia involves burning, often referred to as “hazard reduction burning”, which itself carries fire‐related health risks and consequences. In Australia, “cultural burning” describes burning practices developed by Aboriginal and Torres Strait Islander peoples to enhance the health of the land and its people.19 A commonly confused fire‐related term is “fire disasters”, which is often misused when discussing fires in Australia integral to ecosystem functioning and not classified as disasters; for example, annual savanna fires, which are part of the seasonal cycle of those ecosystems involved. A bushfire is classified as a disaster when it is uncontrollable and adversely affects lives, properties or the environment. Heat In Australia, extreme heat events have claimed more lives than all other extreme weather events combined.20 Many ways of defining “heatwave” exist in global and Australian contexts, with variations across sectors and regions. It is generally agreed that heatwaves are prolonged periods of excessive heat, with “prolonged” usually defined as multiple consecutive days and “excessive” being the exceedance of an extreme threshold. Our stakeholders decided to include a detailed definition from the Bureau of Meteorology21 which also considers overnight temperatures. High night‐time temperatures affect health and wellbeing by limiting respite from heat and reducing sleep quality, with relevance for a health‐focused glossary. Responses Actions, strategies and interventions to address the health impacts of climate change fall into either adaptation or mitigation categories.6 Mitigation aims to reduce the human contribution to climate change, and adaptation is a process or strategy to manage the inevitable changes that are already beginning to occur.7 The IPCC definition of maladaptation was selected and adapted for our glossary because it allows for flexible interpretations across sectors. Our version of the IPCC definition recognises that “maladaptation” refers to the situation where an adaptation strategy causes unintended consequences. For example, one proposed strategy for bushfires is to remove bush, but this was based on a flawed argument that less bush equates to fewer bushfires. The resulting loss of biodiversity from this strategy would be an unintended consequence and thus a maladaptation. Resilience Although not commonly used in Australia at present, the term “climate resilience” is widely used internationally and has growing relevance here. Climate resilience in the Australian context involves considering how communities have responded to and recovered from past natural disasters to improve their resilience for future events. Hence, our glossary’s definition builds on the IPCC’s definition to focus on strengthening for future events7 and explicitly mentions political and governance systems’ capacity to cope with future perilous events. Indigenous knowledges The United Nations Educational, Scientific and Cultural Organization (UNESCO) and IPCC definitions of Indigenous knowledges7,22 refer broadly to all First Nations peoples’ knowledge systems. We could not identify an existing definition of Indigenous knowledges for the Australian context, an important topic for further development. When referring to Indigenous knowledges in Australia, it is appropriate to refer to these knowledge systems as Aboriginal and Torres Strait Islander knowledges.23 The international definition also lacks the important spiritual and cultural aspects of Indigenous knowledges and the fact that these knowledge systems have been passed down over many thousands of years and underpin Indigenous peoples’ understandings today. Aboriginal and Torres Strait Islander knowledges include an intricate understanding and connection to Country, developed over thousands of years to care for the environment sustainably. Caring for Country, which embodies set stewardship values for land and sea environments, describes these sustainable land management practices, as well as being a key aspect in the continuation of Aboriginal and Torres Strait Islander cultures.19 Conclusion The glossary is now publicly available. We hope that policymakers, researchers and stakeholders from different sectors will refer to the glossary to facilitate their discussions and help translate research into policies and practices. Given that language is continuously evolving, as are health and climate change issues, we acknowledge the limitations in the perspectives presented in the glossary and invite contributions from various stakeholders to make this glossary a dynamic and useful tool. By doing this, we can build a shared language to underpin a just transition to a sustainable future for our country.

Matilde Breth‐Petersen · Lucie Rychetnik · Alexandra L Barratt · Ying Zhang

Mja2 51161
Environmental health Perspectives 5 July 2021 Open Access

Communicating with patients and the public about COVID‐19 vaccine safety: recommendations from the Collaboration on Social Science and Immunisation

Understanding the mental shortcuts people make and the values they bring to weighing risks is critical to informing effective risk communication

Julie Leask · Samantha J Carlson · Katie Attwell · Katrina K Clark · Jessica Kaufman · Catherine Hughes · Jane Frawley · Patrick Cashman · Holly Seal · Kerrie Wiley · Katarzyna Bolsewicz · Maryke Steffens · Margie H Danchin

Mja2 51136

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