Juxtaposition 8.1 by Juxtaposition Global Health Magazine

GLOBAL HEALTH MAGAZINE

JUXTAPOSITION UNIVERSITY OF TORONTO

10 WHEN MATING KILLS: REWIRING NATURE TO KILL MOSQUITOES

14 SOCIAL RESPONSIBILITY IN THE POSTANTIBIOTIC ERA

12 Climate Change:

Our Obligations for Global Health Volume 8 issue 1

ISSN 1918-7653

Table of contents

index

Cover Photo: © Sarah Crawley

Cover Photo: ©James Gathany/CDC

Juxtaposition

21 Sussex Ave. rm 610 Toronto ON, M5S 1J6

04 06

GLOBAL HEALTH SNAPSHOTS

Expectation vs Reality: Student Research in Addis Ababa, Ethiopia

FEATURE: Older Adults Living with HIV/AIDS on the Rise in Canada

10 12 14 16

When Mating Kills: Rewiring Nature to Kill Mosquitoes

Climate Change and Gender Equality: Reflections from OMWHO 2015

20 22

Strides in Trans*Related Health Care in the U.S.

Maternal Health Internship at the World Health Organization

Climate Change: Our Obligations for Global Health Social Responsibility in the Post-Antibiotic Era The Essential Connection Between Peace and Health: A conversation with Dr. Nancy Doubleday

Health Journalism Symposium draws distinguished journalists

sponsors

Executives Editors-in-Chief Gail Robson & Jerico Espinas Managing Editors Antu Hossain & Sabrina Jassemi Associate Editors Marcus Tutert, Charles Lee, Jasper Lim, Sarah Bibby & Nour Qa’aty Production Editor Leigh Cavanaugh Staff Writers Imogen Sirluck-Schroeder, Sudipta Saha, Vladimir Djedovic, Anjum Sultana & Trillium Chang Sponsorship Director Preet Deol Publicity DIrector Nour Bakhache Events Co-Directors Maria Bhersafi & Apirrami Thavalinkham Publicity and Events Associates Jing Bian, Angela Saloman, Navitha Jayakumar, Pooja Kaushal

UTSC ExecutiveS UTSC Co-Directors Rashi Gupta, Aidan McNeill Honorary Mention The coffee machine in the Juxta office

Juxtaposition is proudly sponsored by U of T’s Affinity Partners Printed with:

Content © 2015 by Juxtaposition Global Health Magazine. All rights reserved. Neither this publication nor any part of it may be reproduced or transmitted in any form or by any means, electronic, mechanical, photocopying, recording, or otherwise, without prior written permission of Juxtaposition Global Health Magazine. Juxtaposition Global Health Magazine reserves the right to edit all submissions.

editors’ note

Dear Juxta Readers,

fter over a decade of successful print publications, one of our main goals during our time as Editors-in-Chief was to extend our content into the online world. As such, we expanded the online reach of Juxtaposition by developing our social media network and building regular and engaging website content. Without a doubt, our expansion was enthusiastically received by the University of Toronto and the wider global health community. We fostered discussions around recent global health news on our Facebook page and Twitter feed, creating an online forum for both students and professionals to discuss some of the most pressing issues in health care. We also generated an interdisciplinary interest in global health through our online Theme of the Month prompts. Our themes ranged from Politics in Health to HIV/AIDS to Climate Change. This allowed students with diverse academic backgrounds, from political science to philosophy to environmental science, to examine their studies through a global health framework. In this issue, we wanted to bring the diversity of our online content into print by including pieces from both our social media and our website campaigns. Our Global Health Snapshots were inspired by some of the social media posts we shared this past year, highlighting major global health events in 2014. Additionally, our feature articles were selected from some of the best Theme of the Month submissions during our time as Editors-in-Chief. With article content that includes a WHO internship, a historical look at trans* health care, and a discussion on older adults with HIV/AIDS, we hoped to showcase the multidisciplinary voices in Canada’s global health community. Notably, during our decision-making process, we realized that many of our contributing authors, student staff, and financial sponsors were keenly aware of the impacts that climate change has on our health. Indeed, many of them were involved with global health events that discussed climate change and health, such as Ontario Model World Health Organization 2015, as delegates, directors, or administrative staff. We wanted to showcase the importance of, and the community’s interest in, this topic by making climate change on of the main themes in this issue. Of course, Juxtaposition does not only focus on the written word. This past year, we continued Juxta’s mission to provide students practical opportunities to apply their global health education outside the classroom. We hosted U of T’s Global Health Expo, which officially launched our magazine and gave students a chance to sign up for different global health clubs on campus. We also held the second annual Toronto Thinks: Global Health Case Competition, allowing students the chance to present multidisciplinary solutions to a key global health problem to a team of professionals in the field. Lastly, we collaborated with The Varsity to make the Health Journalism Symposium, bringing together a panel of talented journalists to discuss effective health reporting and knowledge dissemination. Overall, during our time as Editors-in-Chief, we wanted to uphold Juxtaposition’s reputation as the University of Toronto’s premier global health magazine. After listening to all the feedback, whether online or in person, we can confidently say we succeeded in upholding this legacy. However, we could not have done this without our hard-working team, our generous sponsors, and, last but not least, our loyal readers. So thank you all for sharing this great year with us, and we hope you enjoy reading issue 8.1 of Juxtaposition Global Health Magazine. Signing off,

Jerico espinas

Editor-In-Chief, 2014-2015 Editorial Division

gail robson

Editor-In-Chief, 2014-2015 Executive Division

KEEP IN TOUCH: juxtamagazine.org | @juxtamagazine | facebook.com/juxtamagazine

SNAPSHOTS

GLOBAL HEALTH Discovery of the first new antibiotic in 30 years A promising new antibiotic, Teixobactin, was discovered from the topsoil of an unremarkable patch of land in Maine. In a previously unheralded development, researchers from Northeastern University in Boston, Massachusetts revealed their results regarding the new, yet so far clinically untested, compound. The excitement is however not solely in the discovery of a potentially powerful new tool to combat infectious agents; the real buzz surrounds the way in which this compound was identified. Teixobactin was found using a technology that allows for the growth of previously uncultivable bacteria found teeming in soil. The “Ichip” allows for such bacteria –specifically the bacterium eleftheria terrae from which Teixobactin was isolated – to grow, allowing researchers to isolate novel compounds. And the excitement is not merely limited to antibiotic discovery; potentially many undiscovered compounds could be growing in these soil bacteria, representing a previously untapped wealth of novel therapeutics. As the technology advances and continues to be refined, we can hope to literally dig up exciting discoveries. Teixobactin represents an important shift in drug discovery.

Tipping point in AIDS epidemic The AIDS epidemic started over 30 years ago in the 1980s and has caused over 40 million deaths since then. For the first time since the start of the global epidemic, the number of HIV positive people in treatment surpassed the number of newly

infected people. UNAIDS reported that by June 2014, over 13.6 million people had access to HIV drugs worldwide, a significant increase in coverage from the 5 million people in 2010. Reaching this milestone does not mean the fight against AIDS is over, far from it. More than 35 million people are currently living with HIV and 1.5 million people have died of AIDS related illnesses in 2013. More investment and research is needed to focus on improving the effectiveness of current treatments, the creation of a vaccine and improving delivery of treatment and prevention services to harder-to-reach populations such as injection drug users and sex workers, groups who are often stigmatized.

Post 2015: Era of Sustainable Development Goals The Millennium Development Goals (MDGs), a set of 8 globally agreed upon international development goals crafted by the United Nations in 2000, are scheduled to expire later this year. They focused on a wide range of issues from poverty alleviation, gender equality and women’s empowerment, education, child and maternal health, environmental sustainability, reducing rates of HIV/AIDS, Malaria and Tuberculosis and improving global partnerships for development. In the post 2015 period, 17 Sustainable Development Goals (SDGs) are expected to take their place and begin a new focus in international development with an emphasis on sustainability and inclusiveness. Here’s looking forward to where this next era will take us as an international society.

Polio Free in South East Asia In 2014, the 11 states that make up the WHO’s South-East Asia region were declared polio-free by an independent panel of experts. This achievement is the product of decades of work by millions of health workers, governments, NGO’s and wide international collaboration. Regional eradication – rather than simply containment – is particularly important in the fight against polio. This is because only about 1% of poliovirus infections result in the flaccid paralysis that gets reported. Even a few sporadic cases could be the product of a much larger outbreak, with asymptomatic cases being virtually impossible to trace in many regions. With the successful eradication of the disease in Southeast Asia, 80% of the world’s population now lives in regions that are certified polio-free.

Ebola Outbreak in West Africa Far surpassing the number of cases from all past outbreaks combined, the ongoing Ebola outbreak in West Africa has resulted in over 22,000 cases, over 9,000 deaths, and placed an overwhelming burden on health systems in affected countries. Originating in an 18-monthold boy in the Guinean village of Meliandou in December 2013, the outbreak spread to several countries in West Africa, causing full-blown epidemics in Guinea, Sierra Leone and Liberia. The Ebola virus causes an acute hemorrhagic fever with an average mortality rate of 50%, and is transmitted by direct contact with infected bodily fluids. The epidemic has led to widespread questioning of the decision-making processes governing the international response and lack of preparedness for an epidemic on this scale.

SNAPSHOTS

SNAPSHOTS Anti-vaxxer movement at a high

Image Courtesy: © Madiha Naseem

Merely a century ago, diseases such as polio, measles and rubella would affect hundreds of thousands of children per year. However, with the advent of vaccines, rates of these highly curable diseases have declined, if not vanished. Yet today, we are facing the worst measles outbreak in years, despite the disease being completely eliminated from the US in 2000. According to the CDC, December 2014, 84 people had been infected with measles. Why? The anti-vaccine movement is shooting sky high. Despite the inundating scientific evidence backing vaccines, these “anti-vaxxers” have been infectious in spreading misinformation.

Physician-assisted suicide legal in Canada Physician-assisted suicide first appeared in Canadian legislation in 2014 with Quebec’s Bill 52. Sub-titled An Act respecting end-of-life care, the Bill affords certain patients the ability to request medical aid in dying. One of the requirements for requesting treatment states that the patient must be suffering from unbearable physical or psychological pain, emphasizing that the Bill’s purpose is to alleviate the suffering of terminal patients. This requirement has received some criticism from certain physicians and health care advocates, claiming that doctors have an oath to never harm their patients. Despite these criticisms, the bill provided a framework for the Canadian Supreme Court’s Carter decision, which struck down Canada’s ban on physician-assisted suicide in February 2015.

Rising Above Limits A Peruvian mother, who lives in the Andes with her two children, husband and extended family, visits a general practice clinic that runs once a month in the rural mountains of Peru. Her journey to the clinic began at sunrise, and she arrived on foot with her donkey and children six hours later, in time to see the physician where she was diagnosed with a urinary tract infection and severe back pain. Although the infection could be cured by the antibiotics she received, her back pain is more complex. In the rural Andes, she has to walk many miles to access important resources, all while carrying her child on her back. The limitations of living in a resource-poor setting cannot be eradicated by a medicine.

JUXTALIFE

Image Courtesy: © Gail Robson

Maternal Health Internship at the World Health Organization Gail Robson

he World Health Organization (WHO) is a United Nations agency based in Geneva, Switzerland. Founded by the League of Nations in 1948, it is the longest running UN agency charged with ensuring the “attainment by all peoples of the highest possible level of health.” This summer, I had the opportunity to intern for three months at the WHO in the Department of Maternal, Newborn, Child, and Adolescent Health. I began my internship after attending the 67th World Health Assembly as a youth delegate with the International Federation of Medical Students Association (IFMSA). The Assembly is the one week when all 194 member states countries come together to review the proposed agenda for the coming year. The session I attended included the adoption of the Every Newborn Action Plan, which shapes priorities for maternal and newborn health. While improving health for newborns seems like a fairly straight-forward priority, the discussion got very heated when it came to access to reproductive services. At one point, the Director General of the WHO Margaret Chan, had to come in to chastise the delegates for their refusal to compromise. The week after the World Health Assembly, I arrived at the WHO headquarters to get started. I was one of approximately

200 summer interns, and I worked in the Policy, Planning, and Processes section of the department of Maternal, Newborn, Child, and Adolescent Health. My longterm project was to develop a maternal and newborn health policy summary to bring together the various plans for the “Post2015” era. As we approach 2015— the target date for the Millennium Development Goals which have shaped the international agenda for the past 15 years— UN agencies and organizations all over the world are hard at work developing a new set of goals. These include both the “Sustainable Development Goals”, the successors to the MDGs, and more local or targeted action plans. I consolidated WHO and partner action plans into one document for health ministers and policy-makers, by country, to use as a quick reference when creating national plans. This included consulting the Every Newborn Action Plan which, a few weeks earlier, I had witnessed being created during the World Health Assembly. Despite being an incredible learning opportunity, I was extremely disappointed with the demographic of my fellow interns. All the interns worked hard to get there, but we were the lucky ones who could afford to live and work for free in one of the most expensive cities in the world. The support we got from our universities, from our jobs, and from our families gave us a significant advantage that allowed us to take part in this

opportunity. From my own experience, and supported by a survey from last year’s intern board, the vast majority of interns come from high-income countries. In an organization with a mandate of equal representation, where is the geographic and socio-economic representation of interns? This is an issue that urgently needs to be addressed, not only at the WHO, but at most UN agencies that employ this hiring process. There have been movements towards creating scholarships for these placements, and Geneva hosts a yearly “Pay your interns” rally—but there has been little progress up to this point. My time at the WHO gave me a tiny glimpse into the bureaucratic, complicated, and fascinating world of international-level global health work. Leading up to these few months, I pictured the WHO as a monolithic organization, spouting indisputable statistics and guidelines. Obviously, this is not the case. The WHO is a complicated body of thousands of employees run by 194 member states. It produces policy documents, best practice guidelines, and technical research and support. There is dissent within and around it, and communication between the many departments—let alone the many countries—can be a difficult task. I learned so much from this experience and can’t wait to dig deeper into global health, but maybe with a smaller and more local project next time around.

JUXTALIFE

Expectation vs Reality Student Research in Addis Ababa, Ethiopia

Betty Yibrehu

Some nine months before I sit to write this reflection, it is January 2014. The window for planning my summer is closing, and I have finally figured out what I want to do: research in Addis Ababa, Ethiopia. Over the course of the following five months, I framed my research question, wrote a proposal, found a supervisor, and applied for funding. The logistical aspects of this kind of project are often prioritized above emotional considerations. Throughout the journey of planning, executing, and reflecting on my trip, I have learned how impactful it can be to have one’s naivety tempered with reality. Here, I discuss four pre-trip expectations that were adulterated by reality.

Blending in EXPECTATION: As a brown-skinned woman, it is not uncommon to be questioned about my “real” identity when I identify as Canadian. In my mind, being in Ethiopia with people who look like me and speak the same language as me would mean that my identity would be unquestioned. REALITY: I have learned that my foreignness is easily detected. Everyone from street-merchants to a mere passerby could somehow sense my otherness. To say that I was disappointed with their reactions would be an understatement.

Volunteers EXPECTATION: Similar to the way in which you can be approached on a street in Toronto to answer questions, I thought the same could happen in Ethiopia. I imagined that people would have the time to spare. REALITY: In a place with widespread—and at times incomprehensible—poverty, people seek compensation for small tasks out of necessity. While at the time I felt as though people were always asking things of me, I now understand why things work that way.

Government EXPECTATION: Upon receiving ethical clearance from Addis Ababa University, I assumed I would only need to carry my documentation when working to avoid trouble with the police. REALITY: Imagine sitting in a café conducting a focus group, only to be warned mid-sentence that a man, who looked like an official, kept glancing over to our table. Imagine that the response of the group is to relocate to avoid “casting suspicion on ourselves”. The distrust of the government due to corruption is a real problem, the likes of which I never considered.

Community and Support EXPECTATION: The preconceived ideas I held about how I would be received professionally by Ethiopians were negative. As a nineteen year-old, first-time researcher with limited experience, I was ready to be treated as a joke. REALITY: One of the greatest gifts I received from the people of Addis Ababa was their encouragement. From hairdressers to acquaintances to participants, people expressed nothing but kind words and encouragement to me when they found out that my research was aimed at helping Ethiopia. While I do not

Image Courtesy: © Betty Yibrehu

believe one should work to be acknowledged, I can’t deny that their appreciation has motivated me to continue working to let Ethiopia help herself. No amount of research can compare to getting first-hand experience working in a country that you feel connected to. My time in Ethiopia, while challenging and nerve-wracking, has served to improve both my research skills and my knowledge about the complex society of Addis Ababa. Most importantly, however, my trip this summer has shown me that nobody wants Ethiopia to improve more than Ethiopians, both within and beyond the nation’s borders.

HIV/AIDS

Older Adults Living with HIV/AIDS

on the Rise in Canada AIDS Society of Canada The number of older Canadians living with HIV has spiked over the past decade and a half. The reason for this trend is twofold. First, increased access to improved antiretroviral therapy allows those currently living with HIV to live longer lives. Secondly, more and more Canadians are now diagnosed with HIV at later stages of life.1 According to the Public Health Agency of Canada report, HIV/AIDS Among Older Canadians, over one in four newly reported AIDS cases were among older Canadians in 2011. Early diagnosis of HIV is important at any age, but early detection for seniors is critical as the disease progresses quicker in those with weaker immune systems, such as the elderly.1 Illustration Courtesy: ÂŠ Sarah Crawley

HIV/AIDS

he World Health Organization demonstrated in a 2009 study that seniors are less likely to be tested for HIV.2 Additionally, past research on late diagnosis of HIV infection from the American Journal of Medicine showed that older patients were more likely than younger patients to be diagnosed during hospitalization and to receive an AIDS diagnosis at the time HIV was detected.3 “It is more important than ever for our current health care delivery models to address and adapt to the complex issues associated with HIV and aging,” said Monique Doolittle-Romas, the Chief Executive Officer at the Canadian AIDS Society. Health care providers often assume older patients are at a lower risk of acquiring HIV, and typically tend to be less vigilant when it comes to their sexual health. Traditionally, conventional HIV prevention programs have excluded older adults from policy dialogue on HIV/AIDS as they were not considered to be part of the at-risk population. Importantly, changes to policy should include knowledge dissemination alongside medical intervention. According to a 2012 Canadian survey conducted by Ekos Research Associates, seniors are generally misinformed about modes of HIV transmission. In fact, merely 57 percent of survey participants between

the ages of 55 and 64 were aware that HIV transmission could occur through unprotected sex among heterosexual couples, and less than 50 percent of them knew that unprotected sex between two men could serve as a means for HIV infection.4 In addition to facing potential ageism from health care providers, older Canadians living with HIV often confront multiple forms of stigma and intolerance, including HIV-related phobia, sexism, racism and homophobia. Gay men and men who have sex with men (MSM) represent the largest proportion of older Canadians living with HIV today. Often, gay men and MSM may choose to conceal their HIV-positive status within social support settings, such as retirement homes, for fear of encountering homophobic attitudes and HIV-related phobia.1 Other demographics are also impacted by the stigma associated with HIV. Older Canadians living with HIV from Aboriginal and ethnocultural communities may also face HIV-related phobia and homophobia within their own communities. This exacerbates the racism they encounter when they attempt to access a range of care and support outside their cultural circles.1 When it comes to HIV prevention and positive health, it is imperative that older Canadians become part of the HIV/ AIDS discourse. Part of the solution lies in recognizing that older Canadians may be at risk of acquiring HIV, adapting HIV prevention efforts to the specific needs of different populations, and actively engaging older adults living with HIV/AIDS. “We cannot afford to ignore the needs of older Canadians any longer,” said Monique Doolittle-Romas. “The current HIV prevention and support initiatives must include targeted efforts to reach older Canadians who deserve to make informed choices when it comes to their health, and live full and active lives.”

References: 1. 2. 3. 4.

Canadian AIDS Society. (2013). Updated HIV and Aging Fact Sheets. HIV and Aging in Canada: An Introduction. Schmid GP. (2009). The Unexplored Story of HIV and Aging. Bulletin of the World Health Organization. 87(3):162 Mugavero MJ, Castellano C, Edelman D, et al. (2007). Late diagnosis of HIV infection: the role of age and sex. Am J Med. 120(4):370-73. Ekos Research Associates. (2012). HIV/AIDS Attitudinal Tracking Survey. Prepared for Public Health Agency of Canada.

CLIMATE CHANGE

When Mating Kills:

Rewiring Nature to Kill Mosquitoes Sudipta Saha

pray insecticide, wait for the stench to clear, put up a bed net, and then go to sleep. Back in Bangladesh, performing this nightly ritual ensured I wasn’t riddled with itchy mosquito bites. Yet dengue fever, a mosquito-borne viral illness, was a big concern too – I had it once, and my sister twice. We were privileged enough to receive health care, but many people don’t and subsequently die. In 2012, malaria – also carried by mosquitoes – killed approximately 630,000 people worldwide1, while dengue infected over 100 million.2 Traditionally, insecticides, bed nets, and environmental clean-up have been the standard methods for combatting mosquito-borne illnesses. These work, and have saved countless lives, but resistance in mosquitoes, cost, and adherence are challenges. Promising new alternatives have emerged over the last decade, such as genetically engineering mosquitoes or infecting them with bacteria. In September 2014, scientists in Brazil began field trials of Aedes aegypti (the mosquito species that transmits dengue) infected with Wolbachia, a bacterial parasite of the mosquito itself.3 These trials are a follow-up to successful testing completed in Australia by an international scientific collaboration called ‘Eliminate Dengue’. Based at Monash University, Eliminate Dengue has projects in Colombia, China, Indonesia, and Vietnam, and collaborators from other countries as well.4 The British company Oxitec is also working in Brazil after initial trials in the Grand Cayman Islands; but rather than infecting, they are genetically modifying mos-

quitoes.5 They aren’t the only ones bringing the latest in molecular and microbial science to the fight against such historically neglected issues: labs all over the world are designing promising new strategies.6 An attractive aspect of Wolbachia infections is that the bacteria can spread through mosquito populations. The bacteria don’t usually kill the mosquitoes immediately, and can be passed on from generation to generation. This can result in unviable offspring between infected males and uninfected females, giving matings between infected partners the upper hand. The question remains, but how does that stop dengue? Wolbachia can block mosquitoes from carrying dengue, or kill them before they begin to bite for blood. By mixing and matching traits from different bacterial strains and infecting mosquitoes, scientists can release mosquitoes into the

wild that spread the infection – an epidemic in mosquitoes that saves human lives.7 The Australian field trials had hopeful results – even two years after release, most mosquitoes were stably infected in the population.8 Unfortunately, Wolbachia doesn’t easily infect Anopheles, the mosquito that transmits the malaria-causing Plasmodium parasite, and so genetic modification seems a better option.6 So far, most modifications have been tested in Aedes aegypti, but will hopefully be translated to Anopheles as well. Oxitec, for example, has created a population of male Aedes aegypti mosquitoes that carry a “repressive lethal” gene. The males are propagated in lab conditions that repress the gene. Large numbers of males with this ticking time bomb can continually be released into the wild. The males mate, and the bomb goes off in the offspring: the lethal gene turns on Illustration Courtesy: © Sarah Crawley

CLIMATE CHANGE

Illustration Courtesy: © Sarah Crawley

and the mosquitoes die.9 Another of Oxitec’s products features a female-specific gene. Released males have a gene that only turns on in females. Males go around mating with normal females in the wild. In the female offspring of such matings, the gene turns on and produces faulty flight muscles. While the females are eaten up by predators, the male offspring, still carrying the deadly-but-silent gene, keep on mating. Eventually, the whole population crashes.10 One study has targeted Anopheles gambiae, the main mosquito species responsible for malarial transmission. A team at Imperial College London has developed a fascinating and elegant new technique. It’s based on something called a homing endonuclease – an enzyme that recognizes a specific DNA sequence and chops it up. Scientists took the gene for a homing endonuclease from a mold,

and put it into mosquitoes. The enzyme recognizes sequences in the mosquito’s X-chromosome and attacks it. Where the science gets really neat is in the way the team tweaked the enzyme. They engineered the gene to be expressed only when the males produced sperm, and to make an unstable enzyme that would only be active between the time the sperm was made and the time the male mated. Like humans, male mosquitoes have one X and one Y chromosome, and females have two X. In these genetically engineered mosquitoes, X chromosomes in sperm are chopped up, and only sperms with Y survive. After mating, the only viable offspring that these mosquitoes produce will have inherited a Y chromosome – meaning they will always be male. Moreover, these male offspring will have the engineered gene, so they can, ironically, keep on destroying their own kind by

mating. Within a few generations the team found that populations became almost 100% male and subsequently died off.11 Field trials for this project are hopefully coming soon. Unfortunately, that’s where promising initiatives often go horribly wrong. In the 1970s, the WHO tried to introduce sterile male mosquitoes to bring down mosquito populations in parts of India. However, misinformation and lack of community consultation sparked rumours that the project was a US plot to develop biological weapons and the program was shut down.12 Fast forward to 2011, when Oxitec published results of trials in the Grand Cayman Islands. They worked and there was no local public backlash, but the scientific community faulted their lack of community consultation and transparency.13,14 Subsequent Oxitec trials in Florida are placing much greater emphasis on ensuring that locals know the science and data behind the intervention, but there still has still been significant resistance.15 The mosquitoes are now up for FDA approval.16 Eliminate Dengue worked with local scientists and local groups for months in advance to ensure that the implementation of their projects was a community-based effort.4 The results from field trials and lab experiments have been extremely promising. If things go smoothly, lab-grown mosquitoes might be released into the wild soon. This now promises to be as revolutionary in tackling the likes of malaria and dengue as insecticide and bed nets were when first used.

References: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16.

WHO (2013). World Malaria Report 2013. WHO. Ratnam I, Leder K, Black J & Torresi J. (2013). Dengue Fever and International Travel. J. Travel Med 20:384–393. Brazil releases ‘good’ mosquitoes. (2014). BBC News. Web. Eliminate Dengue. Retrieved from http://www.eliminatedengue.com/program Oxitec. (2015). Aedes aegypti OX513A. Retrieved from http://www.oxitec.com/health/our-products/aedes-agypti-ox513a/ McGraw EA & O’Neill SL. (2013). Beyond insecticides: new thinking on an ancient problem. Nat. Rev. Microbiol 11:181–193. LePage D & Bordenstein SR. (2013). Wolbachia: Can we save lives with a great pandemic? Trends Parasitol 29:385–393. Hoffmann AA, et al. (2014). Stability of the wMel Wolbachia Infection following Invasion into Aedes aegypti Populations. PLoS Negl Trop Dis 8:e3115. Harris AF, et al. (2011). Field performance of engineered male mosquitoes. Nat. Biotechnol 29:1034–1037. Fu G, et al. (2010). Female-specific flightless phenotype for mosquito control. Proc. Natl. Acad. Sci 107:4550–4554. Galizi R, et al. (2014). A synthetic sex ratio distortion system for the control of the human malaria mosquito. Nat. Commun 5. Curtis CF & von Borstel RC. (1978). Allegations against Indian research unit refuted. Nature 273:96–96. Subbaraman N. (2011). Science snipes at Oxitec transgenic-mosquito trial. Nat. Biotechnol 29:9–11. Enserink M. (2010). Science and society. GM mosquito trial alarms opponents, strains ties in Gates-funded project. Science 330:1030–1031. Genetically modified mosquitoes set off uproar in Florida Keys. Al Jazeera America. Web. Alvarez LA. (2015). Mosquito Solution (More Mosquitoes) Raises Heat in Florida Keys. The New York Times.

CLIMATE CHANGE

Climate Change:

Our Obligations for Global Health Jerico Espinas

There is significant and increasing evidence that climate change has serious effects on health that will only exacerbate with time. The spread of vectors, such as mosquitoes and deer ticks, increases the occurrence of vector-borne diseases.1 More frequent extreme weather events cause accidents and injuries that tax our healthcare systems.2 The depletion of arable land raises issues of food and water insecurity.3 Despite our growing understanding of anthropogenic climate change, we are still at an impasse in creating appropriate action.

CLIMATE CHANGE

ne reason for this standstill concerns the scope of our actions. The common belief that our individual changes make a significant difference in slowing the rise of greenhouse gas emissions and the destruction of our ecosystems is misplaced. This might seem counter-intuitive to some, especially because we’re constantly inundated with ads promoting clean, green lifestyles through clean, green products. However, these consumer-based answers cannot adequately tackle the large-scale problems that are actually causing climate change. This notion of changing individual behaviours as the solution to climate change is unique to this particular issue. For many other social issues, we often take a different approach. Consider Canada’s reaction to the federal government’s cuts to refugee health care.4 Due to economic concerns regarding our health care spending, the Canadian government thought it appropriate to decrease the health care coverage of certain refugees. How did we react to these cuts? Our immediate response was not to change our habits. We didn’t advocate for more generic drugs to reduce the cost of pharmaceuticals. We didn’t reduce our use of antibiotics to prevent the spread of resistance. We didn’t even try and improve vaccination rates to minimize outbreaks of vaccine-preventable diseases. Instead of approaching the problem through individual-level action, our immediate response was to lobby for political action. Organizations such as Doctors for Refugee Care were created to legally challenge the government’s decision, and events such as the National Day of Action were organized to add significant political pressure.4 This created the political will

What I am advocating, then, is for individuals to realize that they must uphold multiple ethical obligations if they want to be serious about combating climate change. necessary for the Supreme Court to rule the cuts unconstitutional.5 What was significant about our reaction was that we recognized the appropriate scope to create meaningful change. We realized that solving this issue was not a job for the individual, but rather a job for the government and their broader regulations. Don’t get me wrong. It would be great if everyone accessed generic drugs, used fewer antibiotics, and vaccinated their children. However, for an immediate impact, we had to confront the government. It might seem unreasonable to compare this health care issue with climate change, but individual actions in both cases are equally ineffective. So, the same political approach must be used for climate change. Quite simply, governments have the power and resources necessary to reduce greenhouse gas emissions on a large scale. They can create environmental policies for industries, capping carbon emissions for manufacturers and oil-producers; create legislation that tax our carbon emissions, forcing individuals to pay for their ecolog-

ical footprint; and interact with other governments to create a sense of liability and obligation.6,7 This is not, of course, to say that we haven’t been pressuring our governments at all. Similar to our reaction to the refugee health care cuts, we’ve created organizations like 350.org to foster grassroots movements, and we’ve organized events such as the climate march to advocate for legislative change.6,7 Many are doing their part to ensure that governments act, but more needs to be done. What is concerning is the number of individuals who feel satisfied with their actions on an individual level.6,7 They eat less meat, they drive electric cars, and they buy “green” products believing that living this low-carbon lifestyle alone is enough. While it would be great if more people took responsibility for their actions, we cannot become complacent just because of these meager reductions. Individuals need to consider their role more broadly as political agents. What I am advocating, then, is for individuals to realize that they must uphold multiple ethical obligations if they want to be serious about combating climate change. One obligation concerns the individual as a consumer, ensuring that they don’t directly contribute to the problem through wasteful choices. Another obligation concerns the individual as a political agent, impacting government policy by applying political pressure. While most individuals acknowledge at least one of these through their low-carbon purchases or their activist involvement, few truly internalize both by acting conscientiously and politically. However, we must try to achieve both as best as we can if we want to mitigate the effects of a warming climate.

References: 1. 2. 3. 4. 5. 6. 7.

Seguin, J. (2008). Human Health in Climate Change: A Canadian Assessment of Vulnerabilities and Adaptive Capacity. Canada: Her Majesty the Queen in Right of Canada. Richardson, G. (2010). Adapting to Climate Change: An Introduction for Canadian Municipalities. Canada: Her Majesty the Queen in Right of Canada. Warren, F.J., & Lemmen, D.S. (2014). Canada in a Changing Climate: Sector Perspectives on Impacts and Adaptation. Canada: Her Majesty the Queen in Right of Canada. Canadian Doctors for Refugee Care. (2012). “The Issue.” Canadian Doctors for Refugee Care. Web. Canadian Doctors for Refugee Care. (2012). “In the news.” Canadian Doctors for Refugee Care. Web. Sinnott-Armstrong, W. (2005). “It’s Not My Fault: Global Warming and Individual Moral Obligations.” Sinnott-armstrong.com. Web. Broome, J. (2012). Climate Matters: Ethics in a Warming World. United States of America: W. W. Norton & Company, Inc.

ACCESS TO MEDICINE

Social Responsibility in the Post-Antibiotic Era “Keep a watch on the faults of the patients, which often make them lie about the taking of things prescribed. For through not taking disagreeable drinks, purgative or other, they sometimes die.”1 -Hippocrates

Vladimir Djedovic

e are facing a future where it is entirely possible that infections may once again become the leading cause of mortality worldwide.1-3 Though antibiotic resistance is a natural phenomenon, its development has been accelerated by the misuse, misapplication, and overuse of medications.1-3 A contributing factor in this process is a lack of health literacy. This leads to medication non-adherence, exacerbating health problems and increasing mortality.4,5 With information accessible at our fingertips, it is no longer sufficient to look to health care professionals and decision-makers as the sole caretakers of our health. More than ever, there is a personal and social responsibility to correctly use prescribed medication and to implement healthy lifestyle adjustments.3 Our response to antibiotic resistance must involve educating patients to promote reliable medication usage and to instil this sense of responsibility.

Medication Adherence and Selection of Resistant Bacteria Antibiotic resistance is a naturally acquired resilience to common treatments that is accelerated by the misuse of medications, such as failing to complete a full treatment course.1-4 Many factors

contribute to improper usage of medication. Some factors are economic, such as insufficient insurance coverage or income; some are institutional, such as improper patient counseling; and others are personal, such as scientific illiteracy. The complex interplay of these elements contributes to staggering economic losses, prolonged human suffering, and an increase in mortality due to multiple-drug-resistant organisms.4,5 As a result, increasing compliance with prescriptions is a central issue in health care management. Of all the issues surrounding patient compliance, health literacy may be the easiest to remedy, as medication adherence is in part determined by an understanding of how antibiotic resistance is acquired. Medication adherence, according to the World Health Organization is “the extent to which a person’s behavior – taking medication, following a diet, or making healthy lifestyle changes – corresponds to agreed-upon recommendations from a health care provider.”4 For antibiotics, adherence is taking the required dose for the required duration. Between 2030% of patients do not complete the full prescribed course and 50% do not get a prescribed refill.4 Non-adherence to medication promotes selection for antibiotic resistance in bacteria.2,3,5 This occurs mainly by conferring a competitive advantage to bacteria that have elements in their genes allowing them to survive an incomplete – or sometimes complete - course of antibiotics.4 These genes are passed to the next generation and some-

times to to nearby bacteria in the same generation.5 Ultimately, the survival and propagation of resistant bacteria can lead to widespread resistance to common treatments.5 As a result of widespread use and misuse of drugs, the selection of drug-resistance bacteria has led to an increase in the use of second and third-line antibiotic treatments.5 In fact, the use of second-line medications has been increasing steadily since 2000.2,3 Further misuse may ultimately lead to complete drug resistance, as is the case for several common infections. 5-7 Infection with multi-drug-resistant bacteria leads to increased mortality – up to a 64% increase for several infectious agents.2,7 Moreover, completely drug-resistant microbes, such as certain strains of those that cause tuberculosis, gonorrhea and E.coli-related diseases, have been reported in several regions with overused second- and third-line medications.1 “Treatment failures due to resistance to treatments of last resort for [an increasing number of infections] have now been reported from 10 countries. [Ex.] Gonorrhea may soon become untreatable as no vaccines or new drugs are in development.”2 In fact, some bacteria have become completely immune to treatment and have the potential to emerge as severe health burdens in upcoming years. Increased mortality rates can be attributed to prolonged illness, increased severity of symptoms, more toxic treatment regimens, and increased incidence of comorbidity.2,3 Proper use of antibiotics, while

ACCESS TO MEDICINE they are still effective, is a pragmatic method of inhibiting the spread of complete resistance. This must coincide with patient education, compliance and understanding.

Economic impact The economics of health care governs treatments, policies and health care discoveries. Stringent budgeting, cost cutting, and funding are all integral parts of the health care system. Therefore, it is important to understand the impact of antibiotic-resistant microbes on health care costs. Consistently, and across various diseases, antibiotic resistance leads to increased hospital fees and prolonged hospital time. These factors amount to a 1.5 to 5-fold increase in total treatment costs.3,8 In the United States alone, medication non-adherence is estimated to cost 100 to 289 billion dollars annually, of which antibiotic related non-adherence makes up a considerable portion.3.4 As resistant microbes tend to appear at higher rates in less-developed countries, the cumulative increase in cost may further deprive already strained or failing health care budgets. Depleted funding results in overloaded staff, less medication, and perpetuation of fundamental inadequacies in overwrought systems.3

So what? “WHO’s 2014 report on global surveillance of antimicrobial resistance reveals that antibiotic resistance is no longer a prediction for the future; it is happening right now, across the world, and is put-

ting at risk the ability to treat common infections in the community and hospitals. Without urgent, coordinated action, the world is heading towards a post-antibiotic era, in which common infections and minor injuries, which have been treatable for decades, can once again kill.”1 Urgent and coordinated action is required to manage the spread of antibiotic resistance, to prolong the use of current treatment options, and to preserve the health of the global community.2,3 Alongside the policy, practice, and innovative changes that are required for management of future health care crises education is of paramount importance.2,3 It is key to therefore relay basic knowledge of mechanisms of antibiotic action, how to complete full treatment courses, and when (or when not) to take medication. Ultimately, it is the responsibility of both the individual and the system to make a concerted effort to disseminate essential material throughout the populace.

Education Initiatives The Centres for Disease Control and Prevention (CDC) recommends patient education, collaborative teambased care and telecommunication systems for monitoring and counseling.3 On the topic of adherence, the US Surgeon General stated that “nurses, doctors, pharmacists and other health care professionals can help prevent many serious health complications by initiating conversations with their patients about taking medication as directed.”3 The three pillars of this plan aim to dispel common myths about medication through education on

proper usage, providing a sense of community, and reinforcing responsibility through team-based communications and check-ins. Patient education involves in-depth conversations between patients and health care providers on correct medication usage. Further reinforcement comes from monitoring and counseling systems that remind patients to take medication and reconcile difficulties encountered with that goal.3 Patients must also assume the mantle of responsibility as limited health care resources, including time, money, and staffing, all act to limit effectiveness of the above interventions. 2,3

Overall Although antibiotic resistance has been under the radar for nearly a decade, it is now being put under the microscope. The determinants of antibiotic adherence and efficacy are numerous. However, the most easily controlled factors reside within the policy and decision-making sphere. Social and personal accountability for education and proper adherence to prescriptions are steps in the right direction towards curbing the spread of antibiotic resistant microbes. To spare overwhelming costs, prevent loss of life, and preserve the integrity of medical practice as we know it, education will be an essential component of the toolbox of international medical organizations. As Hippocrates acknowledged in ancient times, “through not taking disagreeable drinks, [patients] sometimes die.”1 It is now the role of science and education to reduce further preventable loss of life.

References: 1. 2. 3. 4. 5. 6. 7. 8. 9.

Page E, Capps E, Rouse WHD, Post A & Warmington EH. (1959). Hippocrates. Boston, Massachusetts: Harvard University Press World Health Organization (2014). Antimicrobial Resistance Global report on surveillance. Centre for Disease Control (2013). Drug Resistant Threat Report 2013. Centre for Disease Control (2013). Medication Adherence. National Community Pharmacists Association. (2013). Medication Adherence in America: A National Report Card. Davies J. (2010). Origins and Evolution of Antibiotic Resistance. Microbiology and Molecular Biology Reviews. 74(3). Aminov R, Mackie R. (2007). Evolution and Ecology of Antibiotic Resistance Genes. Microbiology Letters. (271)147-161. Applebaum PC. (2007). Microbiology of Antibiotic Resistance in Staphylococcus Aureus. Clinical Infectious Disease. 45(3) 165-170 Supplemental. Cox M, Pacala JT, Vercelloti GM & Shea JA. (2004). Healthcare Economics, Financing, Organization and Delivery. Family Medicine. Supplement 4.

CLIMATE CHANGE

The Essential Connection Between Peace and Health:

A conversation with Dr. Nancy Doubleday Imogen Sirluck-Schroeder

r. Nancy Doubleday, a lawyer and biologist who holds the Hope Chair of Peace and Health at McMaster University, is extensively involved with policy development and human rights claims in the Arctic. Over more than three decades, she has worked on conservation and environmental impact assessment, land claims, and even Canadian constitutional amendments. She has also been involved with numerous groups that coordinate Inuit interests with larger environmental policy changes.1 Dr. Doubleday met with Juxtaposition for an interview after the Polanyi Conference on Science and Social Responsibility at the University of Toronto, where she described the militarization of the Arctic during the Cold War and its enduring effects on the Inuit people. She connected this history to the need for human rights initiatives based on an understanding of the causal relationships between all people and communities. She discussed how complex interconnections exist between the most

traditionally powerful and the most marginalized groups on the planet, showing that marginalization creates a long-range trajectory of injustice and instability that resonates on a global level. This analysis is incredibly important for debates within any sphere of policy. It emphasises how a refusal to compromise human rights can be pragmatic within wider political contexts. During the interview, she went into further detail about the ties between justice, resilience, and community empowerment through the lens of her long relationship with Inuvialuit communities in the Western Arctic. She got involved with the Inuvialuit land claims process in 1980 when she participated in a critical meeting of the Inuit Circumpolar Council – an international NGO that supports Inuit representation and drives political changes that protect the Inuit and the Arctic.3 Very early on in the ICC’s history, a resolution was passed to establish the Arctic as a zone free from nuclear weapons, nuclear testing, nuclear dumping, and the mining of nuclear materials.2 The ICC’s resolution reflects the often-ignored capacity of

marginalized peoples like the Inuvialuit to hold informed, politically enlightened views on global politics and to be able to interact with global politics in a meaningful way, when they have the resources to do so. “It’s my chance to do whatever I can to make opportunities for others - to have the potential for engagement, to understand that they have the capacity for engagement, and hopefully to put some tools in their hands so that they can be effective in the engagement,” she says. In line with this aim, Dr. Doubleday has helped link Inuit interests to many ecological monitoring and research initiatives. Her work includes the development of the Northern Contaminants Program, a government-funded, multidisciplinary initiative established in 1991 to address the worrying accumulation of hazardous contaminants in wildlife species that are staple foods for much of Canada’s Inuit population. The approach taken by this program uses a multivalent strategy of community protection: performing research and environmental monitoring in order to identify

CLIMATE CHANGE contamination, working with Inuit communities and providing dietary advice to reduce their immediate exposure risk, and applying their work to influence policy development toward reducing contamination in the long term.4 One enduring contamination problem in northern Canada, which has drawn particular attention in the area surrounding Baker Lake in Nunavut, is mining. In this uranium-rich region, mining for either uranium or other materials can lead to widespread contamination. Dr. Doubleday gave an example of this, and of the health effects that it could have: “The mining that’s happening for gold around Baker Lake is of concern to local people because it’s exposing the underlying strata, which is uranium-rich,” she said. “When you take off the overburden, which is in some cases glacial gravels and things like that, you expose a dust that has a lot of radioactivity, and it’s disseminated through the environment and there’s a selective uptake by lichens and by caribou […]. The caribou are a main food for people in that region, and so people’s exposure levels are going to increase as a result of that kind of disturbance.” Beyond its current effects on food security, uranium mining has a long and problematic legacy with the Inuvialuit. Although it is seldom recognized in most of Canada, the Inuvialuit people have been deeply embroiled within the nuclear issues of the past century, often without their consent. “It was so interesting to hear the last speaker talk about […] the shift of the mine on Great Bear Lake from gold mining, which didn’t work, to uranium mining,”

Dr. Doubleday mentioned. “Uranium from one of the mines in that vicinity in the Northwest Territories was mined by hand, carried by mainly Indians in burlap sacks to canoes and paddled out. And some of that uranium was processed into the fissionable materials that were used to bomb Japan. The people involved in that have been dying of cancers, and they [now] know about the history, so there have been attempts for reconciliation to take place among the survivors of the bombings at Hiroshima-Nagasaki and the people from this area, because the guilt is incredible. The sense of being an accomplice to mass murder is really strong.” She expressed the degree to which individual causes can create ripple effects throughout communities that gradually impact many aspects of life and livelihood, tying this in with her earlier discussion on staple food contamination. “The environment becomes disturbed, then the health of the people is potentially adversely impacted, and then the state of mind is disturbed because of the lack of reliability and certainty about the food and about the environment. […] There are many, many, many youth suicides in the north. This is one of the great tragedies, and it’s partly, I think, because it’s difficult for youth to see a future for themselves. When you think your environment is at risk and you don't see a place for yourself in any sensible economy, you feel like you don’t have a future.” She said that issues like these, which lie at the interface between health, environment and culture, are too complicated to explain concisely. However, the problems desperately need to be addressed. “We have to find ways of lis-

tening and understanding and reconciling across differences. If we don’t, we run the risk of further injuring those who are already marginalized.” “We need to understand that interconnectedness is the rule,” she concludes. “The earth is a commons. The Arctic is a commons. We cannot have a common future unless we understand that bottom line. And we need to start behaving as if we were neighbours instead of enemies. I think that’s pretty simple.”

References: 1. 2. 3. 4.

McMaster University. (n.d.) Nancy Doubleday Ph.D. (Queen’s University); Professor, Department of Philosophy; Hope Chair in Peace and Health. Inuit Circumpolar Council. (1983). Inuit Circumpolar Conference on a Nuclear Free Zone in the Arctic. Inuit Circumpolar Council Canada. (2014). About ICC. Government of Canada. (2013). Northern Contaminants Program. “Northern Contaminants Program – Background.” Government of Canada: Science.

CLIMATE CHANGE

Climate Change and Gender Equality: Adrina Zhong

Reflections from OMWHO 2015

t this year’s Ontario Model World Health Organization (OMWHO) conference, my fellow delegates and I focused on addressing emergency preparedness to mitigate the disastrous outcomes of extreme weather events linked to climate change. We debated how food and water security will be impacted by climate change. Before long, we arrived at the topic of gender equality, wondering whether men and women are impacted to the same degree in time of natural disaster. Overwhelmingly, women are more vulnerable to the impacts of climate change and will suffer disproportionately in comparison to men in low-income countries. Following the 2004 Indian Ocean tsunami, 75% of the fatalities in 8 Indonesian villages were female, and in the second most affected district, Cuddalore, India, 90% of the fatalities were female.1 Climate change poses a threat to food and water security, as the agricultural industry is heavily dependent on natural resources and weather patterns. In the low-income countries, women living in rural areas are responsible, on average, for 70-80% of household food

production and water collection.2 Extreme weather events, such as floods, droughts and hurricanes, will destroy natural resources essential to agriculture, cooking, and heating. Considering this reality, the discussion at OMWHO explored how the societal roles of women depend on natural resources more than those of men in low-resource communities, and how this disparity in gender roles is amplified when natural resources are destroyed. The disruption of agricultural production affects the livelihoods of women and impedes their ability to support their families. As resources become increasingly scarce, water and fuel will become less accessible and collecting them will become more time-consuming. This will impact other aspects of everyday life, such as a girl’s ability to attend school. Climate change is not merely an environmental issue. It is a challenge to sustainable development that will strongly impact upon various social determinants of health. Socioeconomic conditions strongly predict the chances of survival during climate change. Women make up a disproportionately large part or populations living be-

low the poverty line. Not only are women more vulnerable to climate change because of their societal dependence on natural resources, but they are also at a disadvantage socioeconomically. At OMWHO, we drafted resolutions focusing on ensuring women’s rights in the agricultural sector. In many low-income countries, women do not have equal land ownership rights, although they are typically the heads of their households, providing sustenance and fuel. A recent study shows that, while 60-80% of food crops in low-income countries are the result of women’s labour, women own only 10% of agricultural land and 2% of land rights.3 Traditional divisions of labour, in

CLIMATE CHANGE

which women hold primary responsibility for labour-intensive tasks such as subsistence farming and gathering water, have resulted in a large percentage of women working informally. Male-dominated patterns of inheritance and land-ownership bar women from receiving benefits associated property ownership. Reducing the gender disparity in land ownership rights would not only minimize women’s risk of impoverishment, but also lead to sustainable developments to strengthen food security within at-risk communities. Although women are likely to be disproportionately affected by climate change, they remain underrepresented in decision-making bodies concerned with climate change preparedness. At OMWHO, we urged for the involvement of women’s expertise and knowledge when developing sustainable climate change policies. However, a resolution of this kind macro-categorizes all women, solely based on gender. Simply involving women in decision-making processes does not ensure the concerns of all women, who self-identify in ways other than gender, such as religion, ethnicity, and socioeconomic class, are equally rep-

resented. Gender inequality affects both genders. While this resolution does bring us one step closer to empowering vulnerable women in developing communities, it is not comprehensive and does not address certain problems faced by men in at-risk communities. In reality, while the women of a household typically do farm work, many men are actually unemployed. Educating communities on how women and men can support each other will alleviate some of the burden women face with food and water security. This promotes more equitable gender roles and establishes a more sustainable agricultural future. Most of the resolutions drafted at OMWHO regarding gender equality and climate change pertained to communities in the “developing world,” but what about so-called “developed” countries? Climate change will undoubtedly impact all countries, and one cannot assume that all communities in a high-income country will have equal access to resources. Many populations in high-income countries, especially indigenous communities, rely on natural resources for food, water and fuel. Hunting patterns and practices

will be greatly affected as climate change destroys the natural habitats of hunted animals. In northern communities, gender roles play an important part in the distribution of labour with regard to hunting and food production. Gender equality as it relates to climate change in these communities may not be adequately addressed by blanket resolutions on gender inequality aimed at low-income countries. Our failure to address this issue at OMWHO demonstrates how a country’s reputation of having a strong and developed economy often masks the issues faced by marginalized communities suffering from social inequities. Climate change issues only become pushed to the forefront of policy debates after large-scale events such as natural disasters have already taken place, and many solutions are developed retrospectively. However, this will never produce a sustainable resolution. As global citizens, we must recognize the injustice in the fact that those least responsible for climate change will often experience its most severe impacts, and start facing climate change as an ethical issue.

References: 1. 2. 3. 4.

Horgan P. (2009). In the wake of the tsunami: An evaluation of Oxfam International’s response to the 2004 Indian Ocean Tsunami. Oxfam International. Parikh J. (2007). Gender and climate change framework for analysis, policy & action. UNDP India. Gupta GR. (2009). Guest column: when women farm, crops and economies grow. Truth about trade and technology. Samy K. (2011). Women and climate change: An opportunity to address gender inequality. Yale Journal of International Affairs.

HUMAN RIGHTS

Strides in Trans Related Health Care in the United States *

Editorial Note: The author uses the term trans* as an inclusive terminology to refer to the diverse identities of trans* people within the gender identity spectrum.

Shayan Shakeri

ecent strides in the trans* rights movement have led to positive shifts in how trans* people access necessary health care. In May 2014, the United States Department of Health and Human Services lifted the generalized ban on trans*related health care coverage for Medicare recipients. On a state level, many governments have banned insurance companies from blanket discrimination against trans* people. Overall, these policies have received widespread support from the American Medical Association. The importance of these changes cannot be overemphasized. Trans* people make up a marginalized group within the already stigmatized LGBTQ community, and have some of the highest rates of mental illness and suicide. As such, addressing trans* people’s inadequate access to healthcare resources is critical and failing to do so is potentially deadly. Gender variance first entered the medical sphere in the third edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM- III) as “Gender Identity Disorder”.1 There has since been a debate regarding its legitimacy, and whether insurance policies should cover primary care for trans* people. In 2012, the task force entrusted with producing the fifth edition of

the DSM controversially chose to rename the diagnostic for transgender persons to “Gender Dysphoria.” This recharacterization shifted the focus of the diagnosis from cross-gender identification to gender incongruence.2 This was a major step in the process of de-pathologizing gender variance.

“In May 2014, the U.S. ... removed its 33-year generalized ban on transgender related health services.” In May 2014, the U.S. Department of Health and Human Services (HHS) removed its 33-year generalized ban on transgender related health services, such as hormone therapies and gender confirmation surgeries, for Medicare recipients.3 These services are now considered medically necessary in the treatment of Gender Dysphoria by important regulatory bodies. Part of the platform for the 1981 moratorium was that, when it was instated, trans*related health services were still considered to be experimental, and a risk of serious complications

could be cited against them.3 Following the HHS ruling, the American Civil Liberties Union, the Gay and Lesbian Advocates and Defenders, and the National Center for Lesbian Rights gave a joint comment from the LGBT community: “This decision removes a threshold barrier to coverage for medical care for transgender people under Medicare. It is consistent with the consensus of the medical and scientific community that access to gender transition-related care is medically necessary for many people with gender dysphoria. The removal of the exclusion of coverage for surgical care for Medicare recipients means that individuals will not automatically have claims of coverage for gender transition-related surgeries denied. They should either get coverage or, at a minimum, receive an individualized review of the medical need for the specific procedure they seek, just like anyone seeking coverage for any other medical treatment.”4 Earlier, in 2012, the U.S. Equal Employment Opportunity Commission (EEOC) ruled that transgender discrimination is sexual discrimination under the Civil Rights Act of 1964.5 In line with the EEOC’s ruling and federal nondiscrimination laws, Tom Perez, secretary of the Labor Department, announced protections for their transgender employees in June 2014.6 Furthermore, President Obama has announced plans to sign an executive order forbidding compa-

HUMAN RIGHTS nies affiliated with the federal government from discriminating against employees due to gender identity or sexual orientation.7 The most striking development was a bulletin issued by the District of Columbia’s Department of Insurance, Securities, and Banking on March 15th, 2013. This document prohibited gender identity-based discrimination by insurance companies under the District’s Unfair Insurance Trade Practices Act.8 In 2012, the Office of Civil Rights agreed that “section 1557’s sex discrimination prohibition [of the Affordable Care Act] extends to claims of discrimination based on gender identity or failure to conform to stereotypical notions of masculinity or fem-

ininity and will accept such complaints for investigation.”9 In June 2008, the AMA added a general policy regarding LGBTQ issues, opposing the “denial of health insurance based on sexual orientation/gender identity.”11 The AMA House of Delegates voted in June 2014, that proof of genital reconstruction surgery is not a requisite for changing one’s gender designation on their birth certificate.12 It was argued that a birth certificate is rarely, if ever, used by practitioners when determining the appropriate course of treatment for an individual’s care, regardless of them being cis- or transgender.12 Further, it was stated

that “sex determination on an individual’s birth certificate must not hinder access to medically appropriate preventive care.”13 These recent developments in both medical and political spheres shed a hopeful light on trans* rights, health practices, and equal coverage for the near future. With the amount of media attention on trans* issues as the next civil rights movement, one can only expect to see a stronger push for equal rights. Even with policies in place for trans* peoples protection and equal treatment, an uphill battle lies ahead: the battle for acceptance, normalization and de-pathologization in the social conscience.

References: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13.

Ford Z. (2012). APA Revises Manual: Being Transgender Is No Longer A Mental Disorder. Think Progress. Web. Moran M. (2013). New Gender Dysphoria Criteria Replace GID. Psychiatry Online. Web. Heffernan D. (2014). HHS: Medicare can no longer ban transgender healthcare coverage. GLAAD. Web. American Civil Liberties Union. (2014). ACLU Statement on Final Ruling Invalidating Medicare Ban on Healthcare for Transgender Patients. Web. McGovern AE. (2012). Macy v. Holder: Title VII and Workplace Justice for Transgender Employees. JLPP. Web. Perez T. (2014). Justice and Identity. US Department of Labour Blog. Web. Parsons C, Memoli MA. (2014). Obama to sign executive order curbing discrimination against gays. LA Times. Web. Department of Insurance, Securities, and Banking. (2013). Department of Insurance, Securities and Banking and the Office of GLBT Affairs Announce Prohibition on Discrimination in Health Insurance on the Basis of Gender Identity or Expression. Web. Department Of Health & Human Services, Office For Civil Rights. (2012). OCR Transaction Number: 12-000800. Kriedler M. (2014). Letter to Health Insurance Carriers in Washington State Transgender health issues and discrimination. Washington State Office of the Insurance Commissioner. American Medical Association. (n.d.). AMA Policies on LGBT Issues. Jaspen B. (2014). AMA Says Transgender Patients Don’t Need Surgery To Change Birth Certificate. Forbes.com. Web. American Medical Association. (2014). AMA Calls for Modernizing Birth Certificate Policies. Web.

EVENTS

Health Journalism Symposium draws distinguished journalists Jasper Lim/ The Varsity

Reporters talk about the writing process and the role of health reporting in society

n Friday, March 6, three prominent health journalists from Vox, The Globe and Mail, and The Healthy Debate discussed the current challenges in health reporting faced by both journalists and the wider public at the Health Journalism Symposium co-hosted by The Varsity and Juxtaposition Global Health Magazine at the Dalla Lana School of Public Health. With an eager audience of more than 100 students, scientists and journalists, the Health Journalism Symposium was trending on Twitter as #healthjournalismTO within a matter of minutes. Jeffrey Dvorkin, director of the journalism program at UTSC, moderated the panel and opened the discussion by highlighting the importance of the internet in today’s world specifically in terms of determining “what constitutes authoritative and reliable information.” Dvorkin also emphasized that the media often generates “moral panic”

around the issues it reports, and that the role of a journalist is to enable the public to make better decisions by keeping them informed, while minimizing such panic. Recalling his experiences of interacting with his students, he noted that journalism is more than simply the craft of writing. Each panellist was asked to briefly discuss their writing process. Julia Belluz, an award-winning health reporter from Vox, explained that the use of multi-media can be embedded as early as in the idea-generating phase of the reporting process. “Follow your curiosity,” she told the audience and then, “pick up the phone and meet a lot of people.” Belluz explained that talking to key stakeholders such as health practitioners can help avoid missing important stories. Andre Picard, health reporter and columnist at the The Globe and Mail, concurred and added that the role of health journalism is to help the public understand the key context around current issues in health. Journal-

ists should answer common questions that the public wants answered, like the high cost of certain drugs and why or why not patients should invest in them. The panellists then examined how various vested groups, like the anti-vaccine movement seek to circumvent the mainstream media via the Internet. Picard said that this is “easy to do in the Internet age,” adding that these groups usually tend to speak to the demographic that already subscribe to

EVENTS

the specific ideology in question “It does not seem to swing people,” Picard said. Belluz gave a surprising — if not shocking — example of a popular children’s health book on Amazon, The Vaccine Book, that preaches the ‘harms’ of vaccinations, a view that has been widely disregarded in the scientific community. In addition, the panellists discussed in great detail what was being missed in health journalism and what the public should be focusing its attention on. Dr. Jeremy Petch, managing editor of The Healthy Debate, highlighted that the heaviest users of the health system are people in poverty. “The number one health issue is poverty,” he said. The two other panellists concurred that the topic of social determinants of health remains the most important in understanding structural health problems in society at large. Petch added that, according to research or the wording of the term, “social determinants of health” remains an unpopular concept in communities with conservative political views, and makes a broader discussion about health difficult. The panellists also agreed that Aboriginal health is an issue that’s not covered enough, citing the difficulties and costs of reporting on Aboriginal issues. Above all, the panellists agreed that the manner in which journalists frame issues is vital. Dvorkin summed up the discussion well, saying, “The challenge is: how do you make the interesting important and the important interesting?”

GLOBAL HEALTH MAGAZINE

JUXTAPOSITION UNIVERSITY OF TORONTO

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