Imported Measles Cases

In The Politics of Autism, I analyze the myth that vaccines cause autism. This bogus idea can hurt people by allowing diseases to spread.    Examples include measles, COVID, flu, and polio.  A top antivaxxer is HHS Secretary RFK Jr. He is part of the "Disinformation Dozen." He helped cause a deadly 2019 measles outbreak in Samoa.

Some social media commenters blame the increased invidence of meassles in the United States on undocumented immigrants.  There are a couple of problems with this notion.  First, ever since President Biden finally clamped down in early 2024, border crossings have declined greatly.  Second, most "imported" cases come from US residents returning from trips abroad.

Mathis AD, Raines K, Filardo TD, et al. Measles Update — United States, January 1–April 17, 2025. MMWR Morb Mortal Wkly Rep 2025;74:232–238. DOI: http://dx.doi.org/10.15585/mmwr.mm7414a1.

A multistate measles outbreak, predominantly affecting members of close-knit communities with low measles vaccination coverage in New Mexico, Oklahoma, and Texas began in January 2025. As of April 17, a total of 800 cases have been reported in the United States in 2025; 654 (82%) cases in New Mexico, Oklahoma, and Texas have been associated with the ongoing outbreak. These cases represent an approximately 180% increase over the 285 measles cases reported in the United States during all of 2024, and the second highest annual case count in the United States in 25 years. Overall, 771 (96%) patients have been unvaccinated or had unknown vaccination status (77% were unvaccinated, and 14% had unknown vaccination status when excluding 590 cases reported by Texas, which requires explicit consent by law [i.e., opt-in] to enroll in the Texas Immunization Registry), 85 (11%) patients have been hospitalized, and three patients have died. Among 48 (6%) internationally imported cases, 44 (92%) occurred among U.S. residents. 

 Lee AD, Clemmons NS, Patel M, Gastañaduy PA. International Importations of Measles Virus into the United States During the Postelimination Era, 2001-2016. J Infect Dis. 2019 Apr 19;219(10):1616-1623. doi: 10.1093/infdis/jiy701. PMID: 30535027; PMCID: PMC6474820.

Background

Although measles was declared eliminated from the United States in 2000, measles cases and outbreaks continue to occur, resulting from importations of the disease from countries where it remains endemic.
Methods

We describe the epidemiology of international importations of measles virus into the United States during the post-elimination era.
Results

From 2001 to 2016, 553 imported measles cases were reported to the Centers for Disease Control and Prevention. A median of 28 importations occurred each year (range: 18–80). The median age of imported case-patients was 18 years (range: three months–75 years); 87% were unvaccinated or had an unknown vaccination status. U.S. residents (as opposed to foreign visitors) accounted for 62% of imported measles cases. Overall, 62% of all imported case-patients reported travel to countries in the Western Pacific and European Regions of the World Health Organization during their exposure periods. The number of measles importations from specific countries was related to the incidence of measles in and the volume of travel to and from the source country.
Conclusions

Our findings emphasize the importance of measles vaccination of U.S. residents aged ≥6 months before international travel according to Advisory Committee on Immunization Practices recommendations and supporting global measles elimination efforts

1,952 Measles Cases

In The Politics of Autism, I analyze the myth that vaccines cause autism. This bogus idea can hurt people by allowing diseases to spread.    Examples include measles, COVID, flu, and polio.  A top antivaxxer is HHS Secretary RFK Jr. He is part of the "Disinformation Dozen." He helped cause a deadly 2019 measles outbreak in Samoa.

From CDC:

As of May 21, 2026, 1,952 confirmed* measles cases were reported in the United States in 2026. Among these, 1,943 measles cases were reported by 40 jurisdictions: Alaska, Arizona, California, Colorado, District of Columbia, Florida, Georgia, Idaho, Illinois, Kansas, Kentucky, Louisiana, Maine, Maryland, Massachusetts, Michigan, Minnesota, Missouri, Montana, Nebraska, New Jersey, New Mexico, New York City, New York State, North Carolina, North Dakota, Ohio, Oklahoma, Oregon, Pennsylvania, Rhode Island, South Carolina, South Dakota, Texas, Utah, Vermont, Virginia, Washington, Wisconsin, and Wyoming. A total of 9 measles cases were reported among international visitors to the United States.

There have been 29 new outbreaks** reported in 2026, and 93% of confirmed cases (1,815 of 1,952) are outbreak-associated (487 from outbreaks starting in 2026 and 1,328 from outbreaks that started in 2025).

For the full year of 2025, a total of 2,288 confirmed* measles cases were reported in the United States.

Hundreds have died from a serious outbreak in Bangladesh. Simon Ellery at CBS:

The CDC says most U.S. outbreaks begin when an unvaccinated traveler brings the virus home from a country experiencing a large outbreak.

According to the CDC, Mexico, Guatemala, parts of South Asia (where Bangladesh is) and Africa are experiencing worrying outbreaks.

CBS News medical correspondent Dr. Céline Gounder said Monday that this summer will bring a major challenge for U.S. health officials as thousands of fans visit for the soccer World Cup championship, which is being jointly hosted by the U.S., Mexico and Canada.

"My biggest concern for the World Cup is actually measles. It's not hantavirus, it is not Ebola. Measles is what has me concerned," Gounder said, noting outbreaks of the highly infectious disease "in different parts of the world."

 

Inclusion: It's Complicated

 In The Politics of Autism, I write about special education and inclusion.

Dwyer, P., Nosova, E., Kermond, C., & Leadbitter, K. (2026). Inclusion, but not necessarily integration: Centring student perspectives and needs in education. Autism, 0(0).

The concept of inclusion is central to educational research and policy, with international conventions recognising disabled children’s right to inclusive education (United Nations, 2006, art. 24). However, inclusion is defined and understood in many different ways (Cigman, 2007; Dwyer, 2023; Winzer, 2009). Sometimes, educational inclusion is a synonym for integration: physical placement of disabled and neurodivergent students alongside non-disabled and neurotypical students (e.g. Dalgaard et al., 2022), although this could involve autistic people merely being tolerated, or having to adapt to the majority’s preferences (Weaver et al., 2021). Today, the dominant definition of inclusion – especially in the Global North – could be called ‘integration plus’: integration with supports so that all students can fully participate in diverse school communities and experiences (e.g. Ferguson, 1995; Pellicano et al., 2018). However, making an environment work well for everyone is not easy, and some autistic young people have articulated the basis of a radically different understanding of inclusion that one might call ‘integration-agnostic’. They suggested that inclusion is about belonging, being supported and feeling valued, regardless of whether one’s peers are neurotypical/non-disabled or neurodivergent/disabled (Goodall, 2020). We argue that a similar integration-agnostic understanding has the potential to transform education systems by increasing meaningful inclusiveness.

RFK Jr's Global Disinformation Virus

 In The Politics of Autism, I analyze the myth that vaccines cause autism. This bogus idea can hurt people by allowing diseases to spread.   

 Examples include measles, COVID, flu, and polio.  A top antivaxxer is HHS Secretary RFK Jr. He is part of the "Disinformation Dozen." He helped cause a deadly 2019 measles outbreak in Samoa.

Hannah Harris Green at The Guardian:

Measles vaccination in the UK has fallen especially dramatically, with only 84% of five-year-olds receiving both recommended doses of the measles, mumps and rubella (MMR) vaccine as of 2024. The UK is also “ground zero”, for vaccine hesitancy, according to Jennifer Nuzzo, director of the Pandemic Center at Brown University. Andrew Wakefield, a former physician, was based in the UK when he linked the MMR vaccine to autism in a 1998 Lancet study that has since been retracted. He subsequently lost his medical credentials. This is the second time the UK has lost its measles elimination status in less than a decade.

Even though it’s been more than 15 years since Wakefield’s study was retracted, the idea that vaccines and autism are linked is gaining new traction around the world, with the help of Robert F Kennedy Jr, the US health secretary.

“The rhetoric that happens in the United States spills over across borders to other countries,” Nuzzo said, “We live in a global ecosystem, so when they hear, well, [the vaccine is] not good enough for the Americans, maybe it’s not good for us either.”

Kennedy is known for his work with the anti-vaccine group Children’s Health Defense, which continues to promote Wakefield’s debunked talking points about vaccines and autism.

Organizations like Children’s Health Defense and influencers who promote their rhetoric often bill themselves as activists, but Nuzzo is quick to point out that there is an industry with a profit motive behind their work. A report from the Center for Countering Digital Hate found that the “Anti-Vaxx industry” brings in at least $36m a year. Before becoming health secretary, in 2024, Kennedy himself received millions of dollars in combined income from Children’s Health Defense and various law firms that go after vaccine manufacturers.

Under Kennedy’s leadership, the US is now also on the brink of losing its measles elimination status. Measles often spreads through international transmission, and the two nations that border the US, Canada and Mexico, have also seen a rise in measles outbreaks. Canada lost its elimination.

Roim Rachok

In The Politics of Autism, I discuss military personnel and military families.  The IDF recruits autistic soldiers.

Policy entrepreneurs and policy change when politicians are absent: The inclusion of autistic individuals in the Israel Defense Forces Ben Kizel & Nissim Cohen The University of Haifa, paper for the International Public Policy Association.

Abstract 

How do policy entrepreneurs achieve policy change in the absence of the direct involvement of politicians? While the public policy literature has examined the conditions under which politicians refrain from direct engagement in policy design, less attention has been paid to the strategies policy entrepreneurs employ when political actors are absent from the policy arena. We address this gap by examining how policy entrepreneurs independently advance policy change. Drawing on 30 in-depth interviews and textual analysis, and using the “Roim Rachok” (“Looking Ahead”) program, which facilitates the inclusion of individuals on the autism spectrum in the Israel Defense Forces as a case study, we have several indications of the strategies of policy entrepreneurs in the absence of political involvement. First, the policy entrepreneurs operated through institutionalized collaborative networks for funding. Second, they leveraged Israel's security challenges as a structured framework to advance change. Third, the policy entrepreneurs created an organizational infrastructure. Fourth, they used trust building as a strategy when collaborating with security organizations.

From the article:

The "Roim Rachok" program was founded in 2012 by two former employees of the Israeli Defense Ministry. It was not a project undertaken by the Israeli government. Its goal is to include those on the autism spectrum in the IDF, specifically in military professions where the distinctive abilities of this population can address personnel shortages. Thus, the program regards integrating individuals on the autism spectrum as an operational imperative for the military rather than a charitable endeavor aimed at supporting a disadvantaged population (Greenbank et al., 2024). 

 

Autism in Russia

  In The Politics of Autism, I discuss international perspectives.

Ayman Eckford at The Moscow Times:

One of the biggest issues in talking about autism in Russia is that it is extremely difficult for adults to be recognized as autistic.

Although Russia officially recognizes the World Health Organization’s norms and uses the ICD-10 medical standardization system (though not the updated ICD-11 codes). Instead, doctors often rely on outdated Soviet-era standards, where autism is equated with childhood schizophrenia, which means that autistic people automatically have their diagnosis changed when they turn 18.

This results in autistic adults not only being denied support and recognition but also facing an increased risk of forced institutionalization. In Russia, there are many jobs you cannot get if you are diagnosed with schizophrenia, and the social stigma is extremely severe.

And this automatic diagnosis change is not just a relic of the Soviet past — it remains alive in medical education. In 2015, I spoke to a medical student at one of Saint Petersburg’s top universities. He told me that, according to his curriculum, distinguishing autism from schizophrenia is extremely difficult.

There is a deeper ideological reason for this.

The stereotype of autism as a form of schizophrenia is not just medical incompetence. It is not a political myth, rooted deeply in Russian history.

During the Soviet era, many political dissidents were forcibly hospitalized and given diagnoses like schizophrenia or sluggish schizophrenia. The latter was a fictional disorder created by Soviet psychiatrists after World War II.

Study: 61.8m Autistic People in the World

In The Politics of Autism, I discuss the uncertainty surrounding estimates of autism prevalence. c

 Elana Gotkine at MedicalXpress:

Damian Santomauro, Ph.D., from the University of Queensland in Archerfield, Australia, and colleagues conducted a systematic literature review to estimate the global prevalence and health burden of autism spectrum disorder.

The researchers found that in 2021, an estimated 61.8 million individuals were on the autism spectrum globally. The global age-standardized prevalence was 788.3 per 100,000 people, which was equivalent to 1,064.7 and 508.1 males and females with autism per 100,000 males and females, respectively.

Globally, autism spectrum disorder accounted for 11.5 million disability-adjusted life-years (DALYs), which was equivalent to 147.6 DALYs per 100,000 people. Age-standardized DALY rates varied from 126.5 to 204.1 per 100,000 people in Southeast Asia, East Asia, and Oceania and in the high-income super region, respectively. Across the lifespan, DALYs were evident, emerging for children younger than 5 years (169.2 DALYs per 100,000 people) and decreasing with age (163.4 and 137.7 DALYs per 100,00 people aged younger than 20 and aged 20 years or older, respectively). For people younger than 20 years, autism spectrum disorder was ranked within the top 10 causes of nonfatal health burden.

From: Damian F Santomauro et al, The global epidemiology and health burden of the autism spectrum: findings from the Global Burden of Disease Study 2021, The Lancet Psychiatry (2024). DOI: 10.1016/S2215-0366(24)00363-8

Prevalence did not vary substantially over time. Studies reporting an increase in the prevalence of the autism spectrum have often relied on registries or administrative records to determine prevalence. Studies using random sampling or consistent active-case finding did not show this trend. This finding aligns with previous work suggesting autistic characteristics in the population have remained stable over time despite a rise in registered diagnoses.32 Nonetheless, the absence of temporal trends in our analysis should be interpreted with caution as we relied on a 15-year time window (reduced from 25 years) to model prevalence data. This time window might have limited our ability to explore temporal trends, but a further reduction was not possible because of data sparsity.

Autism spectrum disorder ranked within the top-ten causes of non-fatal health burden for young people (age <20 years), emphasising the need for early detection and developmental support for autistic people.3,4,33 Most epidemiological investigations into the autism spectrum have been predominantly centred on children and adolescents, leaving a gap in our understanding of the autism spectrum in adults. The prevalence and health burden of autism spectrum disorder persisted across the lifespan, beginning to decline from age 60 years. DisMod MR 2.1 estimated prevalence while also taking into consideration data available from other epidemiological parameters. In this case, with most of our raw prevalence data limited to younger cohorts, the age pattern in prevalence was informed by excess mortality data modelled by DisMod-MR 2.1 because of limited available prevalence data in adulthood. Because of limited data availability, all mortality data sourced from the systematic review relied on passive case finding (eg, from administrative records). This method might overestimate excess mortality for all autistic people, leading to an underestimation of prevalence in adulthood.

32. Lundström, S ∙ Reichenberg, A ∙ Anckarsäter, H ∙ et al.
Autism phenotype versus registered diagnosis in Swedish children: prevalence trends over 10 years in general population samplesBMJ. 2015; 350, h1961 Crossref Scopus (126)  PubMed Google Scholar
33. Peters-Scheffer, N ∙ Didden, R ∙ Korzilius, H ∙ et al. A meta-analytic study on the effectiveness of comprehensive ABA-based early intervention programs for children with autism spectrum disordersRes Autism Spect Disorder. 2011; 5:60-6  Crossref Scopus (0) Google Scholar 

 

Autism in France

  In The Politics of Autism, I discuss international perspectives.

In the past, France was a laggard in autism services, in part as a result of the malign influence of psychoanalysis.

There are signs of progress.

 The Connexion:

Earlier this year the French government launched an autism awareness campaign on TV and in cinemas to help people “better understand” the condition.

It featured celebrities who have been directly affected by autism, whether as the parents of autistic children, such as comedian Élie Semoun, actor Francis Perrin and screenwriter Minh Tran Huy, those who have siblings with it, or those who have been diagnosed themselves.

"There are 700,000 autistic people in France," said Fadila Khattabi, Secretary of State in charge of People with Disabilities and who introduced the campaign in April.

"We want to help society better understand how these people evolve, and how their exclusion is unjustified. Disabled people are fellow citizens in their own right... and not apart."

The short clips focused especially on the communication difficulties of autistic people and their sensory hypersensitivity.

Read more: 'Being neurodivergent is challenging in Paris'

Autism Therapy in the US and Israel

In The Politics of Autism, I note that we need more study of how autistic people fare in other countries.

Arkady Bukh at The Times of Israel

In the U.S., ABA therapy is heavily supported by both the government and insurance companies. Many states require insurance to cover ABA, making it more accessible for families. This support has helped the ABA market grow significantly, with projections indicating it could reach $4 billion by 2032.

In Israel, ABA therapy is also widely used for treating autism and is incorporated into public and private healthcare systems, schools, and specialized centers. Attitudes towards ABA therapy in Israel are varied. Many parents and professionals appreciate ABA for its structured methods and positive outcomes. However, similar to the U.S., the autistic community and some professionals are growing critical of ABA’s ethics and intense behavior modification focus. The Israeli government and health insurance providers strongly support ABA therapy.

...

Parents and professionals in both countries value ABA’s structured, evidence-based approach. Both have integrated ABA into their healthcare and educational systems.

Nevertheless, cultural differences greatly influence the implementation and perception of ABA therapy, which in turn shape societal attitudes towards it. The focus on individualism in the USA aligns with ABA’s goals of increasing independence and specific skills. American parents and professionals often prioritize interventions that help children gain autonomy, explaining ABA’s wide acceptance.

Conversely, Israel’s collectivist culture promotes a holistic view of therapy, considering the family unit and community alongside individual progress. Israeli families and professionals emphasize communal well-being and cohesion, adapting interventions to include family dynamics and collective goals.

The Need for Research Beyond the West

In The Politics of Autism, I discuss international perspectives. I also discuss evaluation, diagnosis, and the uncertainty of prevalence estimates.

Petrus de Vries at The Transmitter:

Almost everything we know about autism comes from a handful of WEIRD (Western, educated, industrialized, rich and democratic) countries in the so-called “global north,” yet most autistic people live in low- and middle-income countries (LMICs) around the globe that are quite different from these predominantly English-speaking nations. In a review conducted in 2017, my colleagues and I discovered that less than 1 percent of all autism research to date was performed in Africa, a continent that is predicted by UNICEF to be the home of more than 40 percent of the world’s children by 2050. At the service level, the majority of people in LMICs receive no diagnoses or supports, and in the few—typically urban—areas that can offer services, families often have to pay out of their own pocket. Finding strategies to meet the needs of autistic people and their families in LMICs is therefore fast approaching critical levels.

Scientists have made some progress toward diversifying autism research in high-income countries, by setting up initiatives to increase the diversity, equity and inclusion of the researchers, organizations and communities involved. My colleagues and I acknowledge those efforts. But unless autism research becomes diverse and global at the same time, we will retain the “knowledge gap” between the high-income/English-speaking nations and the rest of the world.

The International Society for Autism Research (INSAR) annual meeting begins tomorrow in Melbourne, Australia. Having this meeting in Australia, rather than in the U.S. or Europe as has previously been the case, is a values-based action intended to make it easier for researchers, clinicians and advocates from the Western Pacific Region to participate. The program deliberately includes panels and special-interest groups on the perspectives and needs of Indigenous, minority and other marginalized groups across the Western Pacific Region. Discussions are also slated to include the research priorities of diverse communities across the globe.

Autistic Welsh Pol

In The Politics of Autism, I discuss international perspectives. I write:  "Support from the general public will be an important political asset for autistic people. Another will be their sheer numbers, since a larger population of identified autistic adults will mean more autistic voters and activists." Previous posts have discussed autistic elected officials in the United States.  Autistic people hold office in other countries as well.

Ashleigh Crowter at BBC Wales Live:

You won't find many more sharply dressed people in Welsh politics.

The natty suit, feathered trilby hat and engraved tie-pin reflect just how seriously 26-year-old Kyle Jamie Eldridge takes his job as a town councillor in Abergavenny.

He believes he has been elected to do an important job and so he should look the part.

And Kyle said it is his autism that makes him care about every detail.

"Having autism gives me critical thinking skills, and skills that I think are excellent for public servants," he said.

Since his election last year to represent the town's Park ward, Kyle is the only councillor to have completed all the non-mandatory training that is available.

He is also meticulous in his preparation for council work, renowned for arriving at every meeting, having read and digested all the relevant documents.

Sandra Rosser, the clerk and principal officer for Abergavenny Town Council, said: "He's made it a point to understand fully the importance of good governance, knowing the rights and wrongs of what we can and can't do as town councillors.

French Autistic Adults

  In The Politics of Autism, I discuss international perspectives.

Raven Bureau and Céline Clément have an article at Autism titled “`Survival classes for a neurotypical world': What French autistic adults want and need after receiving an autism diagnosis." Lay abstract:

Adults receiving an autism diagnosis might not react the same depending on their countries or cultures. We also know that autistic people are rarely asked what they think would be best for them following this diagnosis. In this study, we asked 12 French autistic adults about their experiences of receiving an autism diagnosis as well as what they thought might be useful afterwards. Overall, we found that some experiences were similar to experiences related by English or American participants, but some were specific to the French culture, suggesting that such research should expand into new territories and cultures, especially non-European ones. Our participants also had quite a few ideas as to what would be useful for people in the same situation. Some of the suggestions can be put into action by peers and professionals alike, while others are wishes relating to how our participants would like society to behave toward them and people like them, for example. This article allows for a better comprehension of how cultural differences can impact the experience of receiving an autism diagnosis as an adult and provides some insight into what these adults want and desire following such a diagnosis.

From the article:

 Some experiences related by our participants reflected the way autism is understood and conceptualized in France which, while the presence of stigma is similar to what autistic people can experience in other countries (Cage et al., 2019), seems to have a particular flavor due to psychoanalysis and its wide-reaching influence (Bishop & Swendsen, 2021; Briggs, 2020). As this approach is stillvery present in the public discourse, it seems unavoidable that it influences the social representations of autism inFrance. Research on the subject is scarce, and more research on representations of autism in France is needed. Indeed, these representations can have an impact on the mental health of adults receiving an autism diagnosis, as identified by our participants and supported by research using the minority-stress model and how it applies to autism (Botha & Frost, 2020).

Transition in Norway

  In The Politics of Autism, I discuss international perspectives.

From Eric Benninghoff:

For the past year I have traveled throughout Norway, exploring the transition to adulthood for a variety of often-marginalized groups, including people with intellectual disabilities or learning challenges. Along the way, I have met several organizations aiming to improve the situation for this population, including a largely government-funded but privately run group called Helt Med.

Helt Med has developed a work inclusion model across Norway to help employ individuals with intellectual disabilities in the mainstream workforce. More recently, they have also been trying to expand a smaller pilot program called Ung Jobb, which aims to create a smooth school-to-career pipeline for some of these students.

As of spring 2023, only about 40 high school students have gone through the Ung Jobb program, which is primarily in Agder County in southern Norway. But Agder government announced it will be tripling its current investment in the program starting in the 2023-2024 school year. This comes as Helt Med aims to expand the Ung Jobb project to other parts of the country.

This video report takes an in-depth look at Helt Med’s school-to-career program in Agder County, exploring its potential as one solution to better support students with intellectual disabilities in their transition from school to working life in Norway.

 

Dearth of Autism Research in Low-Income Countries

In The Politics of Autism, I discuss international perspectives.

Sayyed Ali Samadi has an article at Brain Sciences titled "Overview of Services for Autism Spectrum Disorders (ASD) in Low- and Middle-Income Countries (LMICs) and among Immigrants and Minority Groups in High-Income Countries (HICs)"

Autism spectrum disorder (ASD) prevalence is rising [1] at different paces. The reported prevalence currently lies between 0.9% and 1.5% [2]. In affluent and high-income countries, a higher speed is reported compared to a slower pace in developing countries [3]. A recent worldwide ASD prevalence estimate of 0.6% falls far below estimates for Western developed societies. This reported difference probably reflects an inability to diagnose due to the shortage of available diagnostic services rather than a natural worldwide variation in the incidence of ASD in its different forms [4]. There are various contributing factors to the reported difference. It reflects inequality in broadening the diagnosis services and different levels of awareness among countries and multiple degrees of endeavor for identification among children primarily. Hence, the increasing international wealth of information on ASD is based mainly on numerous studies conducted in developed, affluent countries [5]. As de Leeuw et al. [6] indicated, “Autism research is heavily skewed towards western high-income countries”.

More attention should be considered to the presence of similarities and differences in the representation and the influence of ASD in different world regions and between different cultures and minority groups. Still, the available wealth of data remains limited in low-and-middle-income countries (LMICs) and among immigrants and minority groups in high-income countries (HICs). In many ways, there is considerable overlap between the situation for individuals with ASD in LMICs and HICs [5]. There are similar challenges for this group of individuals and their family members and caregivers in both country groups. Hence, there are additional cultural, political, and economic challenges pertaining to LMICs [4]. There are different aspects of ASD that have been understudied, and investigating their impacts on particular groups of individuals is missed in LMICs and HICs. It seems that healthcare policymakers were not entirely convinced to consider these research aspects and allocate strategies and resources for them. There are various reasons for this neglect; still, factors such as lack of suitable instruments for detection and diagnosis, lower levels of awareness and practiced stigma affecting demand for ASD caregiving and the dominance of specialist models for diagnosis and treatment, and finally, the high cost of researching ASD contributed to this imbalance in LMICs [6]. There are understudied groups in the ASD population, such as groups with ASD and other developmental disabilities [7], and aspects of the life of individuals with ASD, such as their sexual development [8] in HICs.

Autism and Inequality: International Perspectives

In The Politics of Autism, I discuss international perspectives.

Rosa A. Hoekstra has an editorial at Autism titled "Serving the underserved: How can we reach autism families who systemically miss out on support?"

Key factors that may make a family vulnerable and at risk of missing out on support include poverty, limited access to education, poor literacy, being subject to structural racism and other forms of discrimination and stigma. Families caring for a child with autism are more likely to be affected by poverty because the child’s needs may prevent the caregiver from generating an income (Minhas et al., 2015; Tilahun et al., 2016). In countries where (mental) healthcare is paid for out-of-pocket, seeking help may result in catastrophic payments, meaning that the costs comprise a very high portion of household income (de Leeuw et al., 2020; Gona et al., 2016). Families from lower-income households report poorer access to care (Bishop-Fitzpatrick & Kind, 2017) and poorer quality (Magaña et al., 2015) of care for their child with autism. Even when children are diagnosed and families are offered intervention, barriers linked to poverty (e.g. transportation costs) may prevent them from attending the intervention (Koerting et al., 2013) or having the time and capacity to actively engage with the intervention (Szlamka et al., 2021; Tekola, Girma, et al., 2020).

Low literacy is common in low-income countries but also affects vulnerable groups in high-income countries. Caregiver-reported screening instruments developed and tested in primarily highly educated families may not work as well in groups with limited literacy (Khowaja et al., 2015). Similarly, interventions developed and tested with highly educated caregivers may require adaptation when applied to families with low literacy and limited prior education.

Families with a cultural minority status in the country of residence may be less likely to access services and report lower satisfaction when accessing such services (Magaña et al., 2015). This is likely due to systemic factors. For example, clinicians may be less likely to recognise autism in ethnic minority children than in children from the cultural majority (Begeer et al., 2009) and in some contexts autism identification rates in ethnic or racial minority children (Begeer et al., 2009; Maenner et al., 2021) or children from Indigenous backgrounds (Bailey & Arciuli, 2020) lag behind identification in White children. Access barriers linked to racism may also be intertwined with language diversity. Latino parents living in the United States with low English language proficiency reported receiving poorer primary healthcare services than those with good English language proficiency (Pippins et al., 2007).

Stigma towards autistic people and their families occurs globally and across different cultures (de Leeuw et al., 2020; Han et al., 2022). In low-resource contexts where awareness of autism is low, stigma may be particularly strong (Tekola, Kinfe, et al., 2020). Stigma may affect how families interpret the signs and symptoms of their child, when and where they seek help (de Leeuw et al., 2020) and how they engage with intervention services (Guler et al., 2018; Koerting et al., 2013).

Worldwide Prevalence

In The Politics of Autism, I discuss evaluation, diagnosis, and the uncertainty of prevalence estimates.

 At Autism Research, Jinan Zeidan,Eric Fombonne and colleagues have an article titled "Global prevalence of autism: A systematic review update." Lay abstract:

We reviewed studies of the prevalence of autism worldwide, considering the impact of geographic, ethnic, and socioeconomic factors on prevalence estimates. Approximately 1/100 children are diagnosed with autism spectrum disorder around the world. Prevalence estimates increased over time and varied greatly within and across sociodemographic groups. These findings reflect changes in the definition of autism and differences in the methodology and contexts of prevalence studies.

From the article:

In response to the need for an up-to-date global estimate of ASD prevalence, our review revealed a median prevalence of 65/10,000 as opposed to 62/10,000 in the previous review. In line with previous evidence, recent studies continue to report an increase in measured prevalence over time either at a country level and/or for specific subgroups, for example, the United States (Christensen et al., 2019; Jariwala-Parikh et al., 2019), South Korea (Hong et al., 2020), and Taiwan (Lai et al., 2012). Similarly, an increase in measured prevalence has been reported in later birth cohorts in France (van Bakel et al., 2015) and Australia (May et al., 2020; May et al., 2017; Randall et al., 2016).

Our findings also confirm that the substantial variability observed in the estimates can be, in part, accounted for by methodological and contextual differences among studies. First, surveillance systems, national registries, and other administrative databases offer larger and more representative samples relative to other study designs, but they are usually associated with lower sensitivity for case finding (Dodds et al., 2009), especially in areas with limited availability and/or access to service. In contrast, active case-finding procedures in cohort studies or population-based epidemiological surveys may result in more rigorous estimates, but their results are often confounded by multiple factors related to diverging strategies for case finding, evaluation, and confirmation used across studies. Second, methodological factors also interact with the broader community context where the level of awareness and capacity in health and education systems significantly impact autism identification, evaluation, and therefore prevalence estimates. Third, the evolving nature of the clinical definition of autism and its differentiation from overlapping conditions has continued to influence prevalence estimates.

 

US Vaccination in Comparative Perspective

 In The Politics of Autism, I analyze the discredited notion that vaccines cause autism. This bogus idea can hurt people by allowing diseases to spread.   And among those diseases could be COVID-19.

Antivaxxers are sometimes violent, often abusive, and always wrong.

From Morning Consult:

Lancet Commission on Care and Research

In The Politics of Autism, I discuss evaluation and diagnosis. I also discuss international perspectives. Comparative public policy on autism services and research needs far more study.

Recommendations from  the Lancet Commission on the future of care and clinical research in autism

Although autism affects at least 78 million people worldwide, formal documentation of their existence is limited to a subset of countries. Formal documentation through governmental health-care, education, and social care systems for people with autism would be a first step in determining the needs and addressing the potential inequalities faced by these individuals.

Autism is a complex but common neurodevelopmental disorder that requires personalised assessments and intervention strategies. A stepped care and personalised health model to assess and direct interventions can increase the effectiveness of approaches. Governments and health-care systems must recognise the need for integration across systems to support the needs of autistic individuals and their families across development.

Autism is a neurodevelopmental disorder that changes with and affects development; a single assessment or a single treatment is never sufficient. Follow-up assessments and personalised treatment plans that focus on individual strengths, difficulties, and changes in contexts and expectations across the life span are needed.

Interventions for autism and for co-occurring conditions should begin as soon as signs are noticed and then monitored with more comprehensive assessment once begun. No one should wait for months or years to start treatment because they are unable to find an appropriate assessment. However, within a reasonable period of time (depending on age and context), assessments do need to be supported and undertaken to identify personalised needs.

Focused research strategies at the government or institutional level should be prioritised with an emphasis on clinical practice that can increase the understanding of what interventions work, for whom, when, how, with what general outcomes, and at what cost. National and international infrastructures should be developed to help such projects to move beyond single investigator-led (albeit multisite) studies to more integrated attempts that take into account individual differences within autism. Infrastructures should also support studies that build on each other and provide evidence for broader community implementation and effectiveness, rather than simply showing that an intervention is better than a waiting list or treatment as usual.

Governments and services should monitor access to provision to ensure that underserved groups, including those who are minimally verbal, girls and women, minority ethnic groups, from socially disadvantaged backgrounds, or with severe co-occurring conditions, have equitable access to appropriate services.