Juxtaposition 13.1

Volume 13 Issue 1 | 2020

CONTRIBUTORS Zoha Anjum and Ayesha Asaf Both Zoha and Ayesha are graduates of the Master of Public Health program from McMaster University and have received a graduate diploma in Water Without Borders from the United Nations University, Institute of Water, Environment and Health. Currently, Zoha is building a career in public health dentistry to be at the forefront of clinical care, and Ayesha is working towards a career as an epidemiologist.

Juxtaposition Global Health Magazine 21 Sussex Avenue Rm. 610 Toronto, ON M5S 1J6

Archchun Ariyarajah Archchun is a PhD student in Epidemiology at the Dalla Lana School of Public Health at the University of Toronto. His interests include infectious disease epidemiology, vaccine-preventable diseases, and global health.

Vaishnavi Bhamidi Vaishnavi is a first-year student currently studying Medical Sciences at Western University. She adores creative writing, as well as investigative journalism (especially when it pertains to human health and wellbeing), and wishes to continue her pursuit of both well into the future!

Matilda Dipieri Matilda is a second-year Health Studies Specialist and Human Geography minor at the University of Toronto. Within the field of Global Health, she is particularly interested in the effects of social determinants on the health outcomes of the world's most vulnerable communities.

Shafna Kallil Shafna is a third-year undergraduate student with a double major in Public Policy and Statistics at the University of Toronto. Her research interests are focused on the intersection of politics and health.

Ori E. Solomon Ori is a postgraduate with a Master of Global Health from the ISGlobal Institute for Global Health at the University of Barcelona. His interests in Global Health focus on addressing social factors that lead to gaps in health inequality in communicable and non-communicable diseases.

Adam G. Wynne Adam is a recent graduate with an undergraduate specialist in Health Studies and a minor in Diaspora and Transnational Studies at the University of Toronto. He is an associate editor for Peace Magazine, and a research assistant on Project Save the World, which examines the interconnected nature of disasters and global threats, and ways to mitigate these scenarios.

Sarah Crawley Artist for Cover Page and illustrations.

Sophia Srebot Artist of public submission of illustration on page 13

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TEAM Editors-in-Chief: Kimberly Dias Sanaya Rau Editorial Team: Archchun Ariyarajah Vaishnavi Bhamidi Fatima Chohan Matilda Dipieri Shafna Kallil Nammal Khan Celina Liu Communications: Samantha Parker Suha Sagheer

TABLE OF CONTENTS LETTER FROM THE EDITORS

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GUNNING DOWN HEALTH: THE DETERIORATION OF HEALTH DURING CONFLICT

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MEDICAL SECURITY AT THE FACE OF LOOMING NATURAL DISASTERS

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AIR POLLUTION: AN EMERGING THREAT TO HEALTH IN PAKISTAN

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MIRRORED RIVALRIES: BRAZZAVILLE, KINSHASA, AND INTER-CONGO RELATIONS

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BIOLOGICAL MANIFESTATIONS OF SOCIAL MALADIES: LUPUS IN THE UNITED STATES

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A DROUGHT IN HEALTH: THE THREAT OF WATER SCARCITY

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INCUBATING A STATE: THE ROLE OF BORDER SECURITY IN MITIGATING INFECTIOUS DISEASES

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INTERVIEW: DR. JOY FITZGIBBON

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LETTER FROM THE EDITORS We are pleased to present the 13th volume of Juxtaposition, the University of Toronto’s premiere global health magazine. As we write this letter, the ground is shifting beneath our feet. From the health impact of climate change as seen in the devastating Australian wildfires to the opioid crisis ravaging much of the United States to the seemingly intractable spread of COVID-19 - we are truly living in interesting, if worrisome, times. Juxtaposition has always sought to be a timely publication and this year is no different. As uncertainty abounds, it only seemed natural to seek out stories that illustrate both our failings and successes as we seek to adapt to an ever-changing ‘new normal’. It is for this reason that the theme of this volume is “Security”.

Juxtaposition creates a space for multidisciplinary discussion about complex global health issues through various political, social, economic, legal and biomedical lenses. As editors, we feel a particular responsibility to emphasize the health issues that affect marginalized communities. Thus, in this issue, you will find stories of how health security - particularly of those on the margins - is shaped by social determinants, natural disasters, air pollution, conflict, water scarcity and infectious disease outbreaks.

Juxtaposition is unique in that our contributors come from diverse walks of life. With this diversity exists a trove of talent that understands and responds to global health issues in a myriad of ways. This year, we are proud to feature designs by our illustrator Sarah Crawley, and an original artwork by Sophia Srebot. Juxtaposition is proud to provide a space for new and creative ways of conceptualizing health.

This year also brought with it the launch of Juxta Talks – an opportunity to connect and learn from leaders in the global health space. Through intimate conversations with thought leaders, the series aims to highlight the innovative and inspiring work underway to create awareness around and mitigate the challenges of global health inequities. In this volume, we are pleased to share the transcript of an interview with Joy Fitzgibbon, who’s inspiring work highlights our shared humanity as the central pillar of global health efforts and reminds us of our collective responsibility to serve our global community in any way we can.

A sincere thank you to our dedicated editorial and public relations team, our community partners, professional mentors and of course to you, our readers. Your support of this publication and interest in the health narratives of our time is inspiring. We hope you enjoy this year’s print edition.

Kimberly Dias Editor-in-Chief 2019-2020

Sanaya Rau Editor-in-Chief 2019-2020

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

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GUNNING DOWN HEALTH: THE DETERIORATION OF HEALTH DURING CONFLICT ARCHCHUN ARIYARAJAH On the 27th of November 2019, two attacks in the eastern Democratic Republic of the Congo (DRC) resulted in 4 deaths and 5 injuries among workers responding to the Ebola outbreak [1]. Among the dead were a vaccination team member, two drivers, and a police officer. These attacks were the deadliest of a series of attacks on Ebola first responders in the eastern DRC, where the outbreak response has been challenging due to armed conflict in the region. Healthcare workers have been specifically targeted or caught in the crossfire. Although viruses and bacteria are known to cause disease, war and conflict can fuel large outbreaks that become difficult to control.

The Ebola outbreak in the eastern DRC started in August 2018, and was declared a Public Health Emergency of International Concern by the World Health Organization (WHO) in July 2019 [2,3]. To date, 3,428 cases and

2,250 deaths have been reported, making it the largest Ebola outbreak in the DRC, and the second largest in the world after the West African Ebola outbreak in 201316 [2,4]. The armed conflict in the eastern Kivu region is primarily between the military of the Democratic Republic of the Congo (FARDC), the Democratic Forces for the Liberation of Rwanda, the Allied Democratic Forces and other local militias [5]. Attacks on Ebola first responders have impeded prevention and control efforts on the ground. In 2019, there were 390 attacks on health facilities that resulted in 11 deaths and 83 injuries among healthcare workers and patients [6]. Insecurity in the region has made it difficult for responders to treat cases, track contacts of cases, and vaccinate high-risk communities. Violent attacks in February 2019 interfered with response activities, leading to a resurgence of Ebola cases in March-May [4].

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The exacerbation of public health emergencies due to armed conflict and insecurity is not unique to the DRC. In Yemen, poor water, sanitation, and hygiene conditions created by the civil war resulted in the largest cholera outbreak ever recorded, with 2.1 million cases and over 3,800 deaths [7]. Nigeria, Pakistan, and Afghanistan are the last remaining polio-endemic countries, and conflict areas have made it difficult for vaccination teams to reach specific populations to achieve global eradication of polio [8]. In addition to infectious diseases, war and conflict have been noted to, directly and indirectly, increase the risk of malnutrition, mental health problems, noncommunicable diseases, injuries, gender-based violence, and mortality [9]. War and conflict indirectly affect health systems through economic instability, food insecurity, forced migration, and societal breakdown [9].

However, targeted attacks on healthcare facilities and workers have been noted as a military tactic to gain military advantage, create fear in populations, deny healthcare to opponents, and to steal valuable medicine and equipment [10].

To address global health problems, public health professionals must understand the effect of war and conflict on disease incidence and target its root causes [11]. One cannot address the prevention of future Ebola outbreaks in the DRC without addressing the root causes of conflict in the region, which include colonialism, poor governance, control of natural resources, and ethnic tensions. Strong global governance enforcing international humanitarian law is needed to prevent war, and to protect healthcare services during wartime. As such, the First and Fourth Geneva Conventions protect healthcare facilities and workers during conflict [12,13], and in 2016, the United Nations Security Council adopted Resolution 2886 to protect healthcare in conflict settings. However, attacks on healthcare facilities and workers continued to occur due to minimal enforcement, the lack of legal authority that the resolution has, and the lack of a mechanism in place for independent investigations of attacks on healthcare services [14,15]. The American Public Health Association cites that the role of public health professionals includes the prevention of war and conflict [16]. Public health professionals must recognize that health cannot be achieved without peace and that skills in peacebuilding, political negotiation, and examination of the structural causes of war are needed to ensure healthy populations globally [16,17]. The third Sustainable Development Goal (SDG) of ensuring healthy lives and promoting well-being for all, and SDG 16 of promoting just, peaceful, and inclusive societies are inextricably linked [18]. Therefore, public health inherently has an obligation to advocate for and strengthen international humanitarian law to protect healthcare facilities and workers in conflict settings [18].

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In response to the recent attacks in DRC, the WHO and its partners withdrew teams from the specific location of the attacks, but remain present in the region to maintain Ebola response efforts [19]. Although it is difficult to predict the end of the current Ebola outbreak, the root causes of conflict in the region will need to be addressed to maintain outbreak response efforts on the ground.

References [1] World Health Organization. (2019, November 28). Dead and injured following attacks on Ebola responders in the Democratic Republic of the Congo. World Health Organization. Retrieved from https://www.who.int/newsroom/detail/28-11-2019-dead-and-injured-following-attacks-onebola-responders-in-the-democratic-republic-of-the-congo [2] Médecins Sans Frontières (2019, August 2). DRC Ebola outbreak crisis update. MSF. Retrieved from https://www.msf.org/drc-ebola-outbreak-crisis-update [3] World Health Organization. (2019, July 17). Ebola outbreak in the Democratic Republic of the Congo declared a Public Health Emergency of International Concern. World Health Organization. Retrieved from https://www.who.int/newsroom/detail/17-07-2019-ebola-outbreak-in-the-democraticrepublic-of-the-congo-declared-a-public-health-emergency-ofinternational-concern [4] World Health Organization: Regional Office for Africa. Ebola Virus Disease Democratic Republic of Congo: External Situation Report 72. World Health Organization: Regional Office for Africa. Retrieved from https://www.who.int/publicationsdetail/ebola-virus-disease-democratic-republic-of-congoexternal-situation-report-78-2019 [5] Human Rights Watch. (2019, August 14). DR Congo: 1,900 Civilians Killed in Kivus Over 2 Years. Human Rights Watch.

Retrieved from https://www.hrw.org/news/2019/08/14/drcongo-1900-civilians-killed-kivus-over-2-years [6] World Health Organization. (2019, December 1). WHO Director-General praises bravery of health workers during visit to eastern Democratic Republic of Congo following fatal attacks on Ebola responders. World Health Organization.

Retrieved from https://www.who.int/news-room/detail/01-122019-who-director-general-praises-bravery-of-health-workersduring-visit-to-eastern-democratic-republic-of-congo-followingfatal-attacks-on-ebola-responders [7] World Health Organization: Regional Office for the Eastern Mediterranean. (October 2019). Cholera situation in Yemen.

Accessed December 12, 2019, http://applications.emro.who.int/docs/EMRPUB-CSR-240-2019EN.pdf.

[8] Garon, J. R., & Orenstein, W. A. (2015). Overcoming barriers to polio eradication in conflict areas. The Lancet Infectious Diseases, 15(10), 1122–1124. doi: 10.1016/s14733099(15)00008-0 [9] Garry, S., & Checchi, F. (2019). Armed conflict and public health: into the 21st century. Journal of Public Health, 1-12. doi: 10.1093/pubmed/fdz095 [10] Patel, P., Gibson-Fall, F., Sullivan, R., & Irwin, R. (2016).

Documenting attacks on health workers and facilities in armed conflicts. Bulletin of the World Health Organization, 95(1), 79– 81. doi: 10.2471/blt.15.168328 [11] Fisman, D., & Tuite, A. (2019). The DAGs of war.

Proceedings of the National Academy of Sciences, 116(48), 23880–23882. doi: 10.1073/pnas.1916910116.

[12] International Committee of the Red Cross. (n.d.). Treaties,

States Parties, and Commentaries - Geneva Convention (I) on Wounded and Sick in Armed Forces in the Field,1949.

International Committee of the Red Cross. Retrieved from ihl-

databases.icrc.org/applic/ihl/ihl.nsf/Comment.xsp?action=open Document&documentId=84FF993DB70E67D1C1257F7A005A BDAD. [13] International Committee of the Red Cross. (n.d.).

Convention (IV) relative to the protection of civilian persons in time of war. International Committee of the Red Cross.

Accessed December 13, 2019, https://ihldatabases.icrc.org/ihl/INTRO/380.

[14] United Nations Security Council. (2016, May 3). Security

council adopts resolution 2286 (2016), strongly condemning attacks against medical facilities, personnel in conflict situations. United Nations. Accessed December 13, 2019, https://www.un.org/press/en/2016/sc12347.doc.htm

[15] Dayoub, R. (2019, May 2). Getting Serious About Protecting Health Care in Conflict. Chatham House. Retrieved from https://www.chathamhouse.org/expert/comment/gettingserious-about-protecting-health-care-conflict [16] Wiist, W. H., Barker, K., Arya, N., Rohde, J., Donohoe, M., White, S., … Hagopian, A. (2014). The Role of Public Health in the Prevention of War: Rationale and Competencies. American Journal of Public Health, 104(6). doi: 10.2105/ajph.2013.301778 [17] Beardsley, K., Cunningham, D. E., & White, P. B. (2018).

Mediation, Peacekeeping, and the Severity of Civil War. Journal of Conflict Resolution, 63(7), 1682–1709. doi: 10.1177/0022002718817092 [18] Wesley, H., Tittle, V., & Seita, A. (2016). No health without peace: why SDG 16 is essential for health. The Lancet, 388(10058), 2352–2353. doi: 10.1016/s0140-6736(16)32133-x [19] Branswell, H. (2019, December 2). Ebola-Response

Workers Killed in Attacks Force Withdrawal from Critical DRC Region. STAT. Retrieved from https://www.scientificamerican.com/article/ebola-responseworkers-killed-in-attacks-force-withdrawal-from-critical-drcregion/?utm_source=dlvr.it&utm_medium=twitter

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MEDICAL SECURITY AT THE FACE OF LOOMING NATURAL DISASTER MATILDA DIPIERI By now the world is well aware that our obsession with development has resulted in damaging effects on the environment. With imminent threats of “underwater cities,” mass species’ extinctions, and global food shortages, governments and policymakers have responded with recommendations on emissions, and, alternatively, the potential of moving towards a degrowth economy [1]. These reactionary strategies to face the incoming effects of climate change add to the growing field of human security, a logical progression from the security mindset instilled during the Cold War [2]. While the movement towards human security has grown more holistic and aware of the multiplicity of factors endangering a population’s health, it is still important to evaluate just how prepared we are to face the consequences of climate change.

As early as 2002, the World Health Organization (WHO) presented a technical report outlining a series of steps and guidelines for governments, aid agencies, and even communities to respond with in the event of environmental or natural disasters [3]. By highlighting the need for risk assessment, action and recovery responses, the report allows for the realization of the magnitude of this issue, and the harsh toll it could take on humanity. Nevertheless, countless governments, including Canada, started to address this issue internally.

Unsurprisingly, studies have shown that higher-income countries have the most developed disaster management programmes within their public health agencies [4]. Countries like the United States and Australia have systems that cover an entire range of responses needed from public health and other agencies, from preparedness to response to recovery, and incorporate a series of multileveled laws, policies, and even technical procedures [4]. Many of these countries also boast continuous surveillance systems, and consistent epidemiological investigations that only improve the situation that facilitates and accelerates the response and recovery process in any natural disaster [5].

While this infrastructure and apparent preparedness are reflected in higher-income countries, the situation is different for public health agencies in lower- to middleincome countries. With the Asian continent reporting the highest incidences of natural disasters, including earthquakes, cyclones, and tsunamis, rural

communities often find themselves stuck in the recovery phase with insufficient support [6]. In 2019, it was found that some of the most severe and devastating disasters occurring in the region this decade affected rural communities [6]. With much of the research on environmental disaster management coming from highincome countries, or even simply urban regions, this leaves rural populations with few tools and evidencebased programming that would aid them directly [4].

This knowledge gap has been echoed in regions like Latin America and the Caribbean as well, with rural regions disproportionately at risk for the looming health consequences of natural disasters [7]. Nevertheless, engaging literature has come out of this region regarding the development of disaster management programs when resources are limited, leading to important innovations. With a better system of communication and support across this region, a decrease in the loss of lives due to natural disaster was observed in a 5-year range. However, the resources used and depleted in order for this success to occur continued to rise as the region confronted more natural disasters [8]. A clear need for mitigation was found at the centre of the problem, and soon a loss production plan was created involving different sectors of the affected or at-risk public [8]. Here, the frequent movement from research to policy to action was recognized and targeted to better serve the population and their health.

The prioritization of environmental health, and the awareness of the impact of natural disasters helped make this region an important advocate for natural disaster management. A key advance in this region that was soon pread to other public health agencies looking to address the risks of environmental disasters was that of telemedicine [9]. While the concept of telemedicine arose as a response to the need to bring medical attention and services to even the most remote of areas, it serves as an important development in environmental disaster response given its flexibility and application in virtually any setting [10].

This sort of knowledge translation is pivotal in addressing the high risks of natural disasters, particularly when addressing the recovery of an affected or potentially affected region. As previously mentioned, planning for recovery is often one of the largest obstacles in environmental emergency preparedness, since there is often the potential for the destruction of

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medical infrastructure, and a great loss of resources [6].

Yet, this area of focus often receives the least funding in disaster management programs since it is difficult to truly weigh the costs of an unforeseen event [4].

Nevertheless, it is key to successful disaster management, and has the potential for promoting sustainable development and healthier environments.

Using disaster management as an opportunity to foster important relationships between grassroots organizations, philanthropic foundations, and private entities is one way of creating community resilience to prepare and recover from a disaster [11]. This approach has been emphasized greatly by the Science and Environmental Health Network, a non-governmental organization looking to address the cumulative effects that climate change will have both on the natural world and our built environment [11]. This sentiment has been echoed by the United Nations and national agencies like the National Institute of Environmental Health Sciences in the United States [12,13]. As such, there seems to be a general need for an approach to disaster management that involves communities, and promotes sustainable development throughout its programming.

It takes cooperation and the coordination of knowledge, research, and practice to prepare for this level of environmental health emergency. While preparedness is traditionally reflected by a country’s income level and resource allocation towards these kinds of initiatives, lower- to middle-income countries have often shown great innovation in the face of disaster. In order to more effectively respond instead of reacting to disaster, the prioritization of human health, the transfer of knowledge, and cooperation should be at the centre.

References [1] Ghazali, D., Guericolas, M., Thys, F., Sarasin, F., Arcos González, P., & Casalino, E. (2018). Climate change impacts on disaster and emergency medicine focusing on mitigation disruptive effects: An international perspective. International Journal of Environmental Research and Public Health, 15(7), 1379. https://doi.org/10.3390/ijerph15071379.

[2] Futamura, M., Hobson, C., & Turner, N. (2011, April 29).

Natural disasters and human security. United Nations University. https://unu.edu/publications/articles/naturaldisasters-and-human-security.html.

[3] Wisner, B., Adams, J., & World Health Organization (Eds.).

(2002). Environmental health in emergencies and disasters: A practical guide. World Health Organization. https://apps.who.int/iris/handle/10665/42561 [4] Généreux, M., Lafontaine, M., & Eykelbosh, A. (2019). From science to policy and practice: A critical assessment of knowledge management before, during, and after environmental public health disasters. International Journal of Environmental Research and Public Health, 16(4), 587. https://doi.org/10.3390/ijerph16040587.

[5] Toner, E. (2017). Healthcare preparedness: Saving lives.

Health Security, 15(1), 8–11. https://doi.org/10.1089/hs.2016.0090.

[6] Chan, E. Y. Y., Man, A. Y. T., & Lam, H. C. Y. (2019).

Scientific evidence on natural disasters and health emergency and disaster risk management in Asian rural-based area.

British Medical Bulletin, 129(1), 91–105. https://doi.org/10.1093/bmb/ldz002.

[7] Charvériat, C. (October 2000). Natural disasters in Latin America and the Caribbean: An Overview of Risk. IDB Working Paper No.364. https://doi.org/10.2139/ssrn.1817233.

[8] Collymore, J. (2011). Disaster management in the Caribbean: Perspectives on institutional capacity reform and development. Environmental Hazards, 10(1), 6–22. https://doi.org/10.3763/ehaz.2011.0002.

[9] Adler, E., Ali, Z., Bartels, U., Bick, C., Bird-Compton, J… Blanchette, V. (2015). Bridging the distance in the Caribbean: Telemedicine as a means to build capacity for care in paediatric cancer and blood disorders. Studies in Health Technology and Informatics, 209, 1–8. DOI: 10.3233/978-161499-505-0-1 [10] Pourhosseini, S. S., Ardalan, A. H., & Mehrolhassani, M. (2015). Key aspects of providing healthcare services in disaster response stage. Iranian Journal of Public Health, 44, 111–118.

[11] Cornell, K. Activist tips for changemakers: Planning and disaster preparedness. Science & Environmental Health Network. https://static1.squarespace.com/static/5ad8bb3336099bd6ed7 b022a/t/5c931d319b747a74ce75fcf5/1553145137758/Activist+ Tips+Volume+Two.pdf.

[12] Global environmental health and sustainable development.

(2018). National Institute of Environmental Health Sciences.

Retrieved February 14, 2020, from https://www.niehs.nih.gov/health/topics/population/global/index .cfm.

[13] Prüss-Üstün, A., & Corvalán, C. (2006). Preventing disease through healthy environments: Towards an estimate of the environmental burden of disease. World Health Organization. https://apps.who.int/iris/handle/10665/4345.

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AIR POLLUTION: AN EMERGING THREAT TO HEALTH IN PAKISTAN ZOHA ANJUM, AYESHA ASAF Introduction Health security refers to mitigating the impact of public health events on a population living in a geographical area [1]. Outdoor air pollution is an environmental risk factor that affects the health of millions of individuals worldwide, with 4.2 million attributable deaths [2]. One of the countries where air pollution is of critical concern is Pakistan. In 2018, Pakistan was ranked as the secondmost polluted country in the world in terms of high particulate matter present in the air [3]. Although air pollution is a concern throughout the year, it is worst from October to February, and this period is also known as the smog season [3].

Causes of air pollution Ninety-eight percent of the energy produced in Pakistan is composed of fossil fuels; therefore, it is no surprise that air pollution is a major problem across the country [4].

Moreover, in the last few decades, there has been an exponential increase in the use of automobiles, urbanization and unregulated deforestation, further contributing to the current state of pollution [5]. For example, between 1990 and 2010, the number of motor vehicles grew from 0.8 million to nearly 5 million at an average growth rate of 14% [6]. Mass-transit systems in urban areas were also identified as major contributors to the deterioration of air quality due to the use of old and poorly maintained equipment [6]. In addition, Pakistan’s economy is highly dependent on the growth of largescale manufacturing industries that use technologies which are detrimental to the environment, and further exacerbate the problem of air pollution [4].

Particulate matter is one of the main pollutants that deteriorates air quality. There are two types of particulate matter which differ in their size: PM2.5 and PM10 [7].

PM2.5, smaller than PM10, can easily be ingested by the body [7]. PM2.5 is composed of various particles such as crusted material (e.g., aluminum, calcium), sea spray (e.g., salt), fossil fuel combustion particles (i.e., nickel, sulfur), industrial emissions (e.g., arsenic, lead), black carbon, ammonium and nitrate [7]. However, the major contributor to PM2.5 seems to be organic carbon, comprising 17-40% of PM2.5 [7].

Figure 1: PM2.5 levels in a few major cities of Pakistan categorized based on their impact on human health [3].

Impact on health security A recent study based in Pakistan, India, and Bangladesh demonstrated that exposure to PM2.5 was associated with cardiovascular disease and stroke, with the latter accounting for 40% of the premature deaths in these countries [8]. Moreover, PM2.5 exposure also has a serious impact on the cardiovascular health of children living in Pakistan, and has been associated with higher diastolic and systolic blood pressure among children of age 8-12 years. These striking results were significant when differences in gender, height, weight, socioeconomic status, and passive smoking were included in the analysis [9].

Another health impact of air pollution is increased levels of inflammatory mediators caused by high oxidative stress in the body, which can be positively correlated with ischemic heart disease and hypertension [10]. As well, air pollution affects the nervous and reproductive systems. PM2.5 exposure has been linked with a high risk of ‘silent’ miscarriages, bipolar disorder, suicide, anxiety and depression in a few studies [11,12].

Next steps In order to combat air pollution in Pakistan, changes in government policy must take place. Firstly, priority should be given to establishing a reliable and sustainable air quality monitoring system [13]. Without relevant data, evidence-based management plans cannot be developed. This system should include an inventory of mobile and stationary sources of pollutants, as well as large-scale industrial pollutants [13]. The stringent requirements for this system would require financial, technical and personnel support [13].

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References [1] World Health Organization. WHO | Health security.

World Health Organization. http://www.who.int/healthsecurity/en/.

[2] World Health Organization. (2018). Ambient (outdoor) air pollution. World Health Organization. https://www.who.int/news-room/factsheets/detail/ambient-(outdoor)-air-quality-and-health.

[3] AQI Air Visual. Lahore Air Quality Index (AQI) and Pakistan Air Pollution | AirVisual. https://www.airvisual.com/pakistan/punjab/lahore.

[4] Khan, I., Khan, N., Yaqub, A., & Sabir, M. (2019).

An empirical investigation of the determinants of CO2 emissions: Evidence from Pakistan. Environmental Science and Pollution Research, 26(9), 9099–9112. https://doi.org/10.1007/s11356-019-04342-8

Furthermore, greater coordination between sectors and provincial and federal governments is required to allow for the above recommendation to be carried out [13].

Collaboration with industrial and environmental sectors will ensure that those with the necessary expertise are recruited for implementation of an air quality management plan, while government oversight will allow for enforcement of policies for effective air quality improvement and minimum risks to health security [13].

Lastly, the dissemination of information to communities will be essential when implementing an air quality management plan [5,13]. Communities should be involved in the decision-making process and information should be shared in a way that is accessible to empower communities and to hold the stakeholders accountable [13]. Public interest is a powerful tool that can be used to advocate for improvements in the environment [5,13].

Conclusion Based on previous studies, it is evident that air pollution is a growing concern in Pakistan, and it has a serious impact on human health security in the country.

Exposure to air pollution not only impacts respiratory function, but it also has implications for reproductive, cardiovascular and mental health. A critical way to tackle this issue of air pollution is through policy development and enforcement, accurate monitoring, intersectoral collaboration on the government level, and dissemination and empowerment on the community level. Only once such changes have been implemented can the impact of air pollution on human health security in Pakistan be minimized.

[5] Riaz, R., & Hamid, K. (2018). Existing smog in Lahore, Pakistan: An alarming public health concern. Cureus, 10(1), e2111. https://doi.org/10.7759/cureus.2111 [6] Colbeck, I., Nasir, Z. A., & Ali, Z. (2010). The state of ambient air quality in Pakistan—A review. Environmental Science and Pollution Research, 17(1), 49–63. https://doi.org/10.1007/s11356-009-0217-2 [7] Lu, Y., Lin, S., Fatmi, Z., Malashock, D., Hussain, M. M., Siddique, A., … Khwaja, H. A. (2019). Assessing the association between fine particulate matter (PM2.5) constituents and cardiovascular diseases in a mega-city of Pakistan. Environmental Pollution, 252, 1412–1422. https://doi.org/10.1016/j.envpol.2019.06.078 [8] Shi, Y., Zhao, A., Matsunaga, T., Yamaguchi, Y., Zang, S., Li, Z., Yu, T., & Gu, X. (2018). Underlying causes of PM2.5induced premature mortality and potential health benefits of air pollution control in South and Southeast Asia from 1999 to 2014. Environment International, 121, 814–823. https://doi.org/10.1016/j.envint.2018.10.019 [9] Sughis, M., Nawrot, T. S., Ihsan-ul-Haque, S., Amjad, A., & Nemery, B. (2012). Blood pressure and particulate air pollution in schoolchildren of Lahore, Pakistan. BMC Public Health, 12(1), 378. https://doi.org/10.1186/1471-2458-12-378 [10] Yamamoto, S. S., Phalkey, R., & Malik, A. A. (2014). A systematic review of air pollution as a risk factor for cardiovascular disease in South Asia: Limited evidence from India and Pakistan. International Journal of Hygiene and Environmental Health, 217(2–3), 133–144. https://doi.org/10.1016/j.ijheh.2013.08.003 [11] Braithwaite, I., Zhang, S., Kirkbride, J. B., Osborn, D. P. J., & Hayes, J. F. (2019). Air pollution (Particulate matter) exposure and associations with depression, anxiety, bipolar, psychosis and suicide risk: A systematic review and metaanalysis. Environmental Health Perspectives, 127(12), pp.126002. https://doi.org/10.1289/EHP4595 [12] Zhang, L., Liu, W., Hou, K., Lin, J., Zhou, C., Tong, X., …

Zhu, P. (2019). Air pollution-induced missed abortion risk for pregnancies. Nature Sustainability, 2(11), 1011–1017. https://doi.org/10.1038/s41893-019-0387-y [13] Sánchez Triana, E., Enriquez, S., Afzal, J., Nakagawa, A. & Shuja Khan, A. (2014). Cleaning Pakistan’s air: Policy options to address the cost of outdoor air pollution. The World Bank.

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MIRRORED RIVALRIES: BRAZZAVILLE, KINSHASA, AND INTER-CONGO RELATIONS ADAM G. WYNNE The Congo River is one of the longest rivers in the world, flowing over 4700 kilometres across the heart of Africa.

Historically, this river has held importance as a trading and transportation corridor, connecting the interior of the continent with coastal ports, and has been considered a place “bursting with nature and culture” since time immemorial [1]. While much of the Congo River traverses rural regions of the continent, the rival metropolises of Brazzaville in the Republic of the Congo and Kinshasa in the Democratic Republic of the Congo, with a combined population of over 15 million, are situated on opposing banks of this great river and have been a hotspot of regional instability and conflict since their establishment in the nineteenth century [2, 3]. These cities are situated less than two kilometres apart from each other, yet have less intercity traffic than East and West Berlin did while they were separated by the Berlin Wall [2]. The development of tangible intercity and transnational links, the creation and maintenance of functional regional infrastructure, and economic partnerships are essential in creating and promoting strong inter-Congo relations.

Lasting impacts from historic eras of colonization combined with major conflicts in the years immediately following independence have contributed to the problems still faced within the daily lives of Congolese citizens on both sides of the river.

The location of Brazzaville and Kinshasa was historically within the territory of the BaKongo people, an ethnic group who had migrated into the Lower Congo Basin during the Bantu Expansion. Whereas the Congo River had traditionally flowed through this territory without the demarcations of international borders, the scramble for Africa in the late nineteenth and early twentieth centuries created strictly defined boundaries that divided the BaKongo lands [4]. The Congo River was transformed into part of the border between the French Congo (present day Republic of the Congo) and the Congo Free State/Belgian Congo (present day Democratic Republic of the Congo), leading to rivalries between the two countries due to differing colonial policies [6]. The French administration turned Brazzaville into the de facto capital of their equatorial possessions, despite practicing a policy still heavily focused on the extraction and exploitation of resources within their colonies.

Furthermore, the French administration allowed the formation of a class of African, political elites who “operate[d] under rules different from those applied to Frenchmen or those immediately associated with them (the native population),” strengthening relationships 14

between the two cultures [5, 6]. In comparison, the Belgian Congo was initially a private enterprise owned

by King Léopold II, whose administration “bled unmercifully [with] disregard of the laws of humanity” the resident native populations when it came to resource extraction, and who financed the construction of European style, grand “villa-type houses [and] gardencity enclaves” for colonial agents [7, 8]. This drastically inhibited the education and advancement of Africans under Belgian colonial rule, and led to enmity between citizens of the two Congos, laying the framework for issues still present in modern times.

The decolonization process for the Congos was rapid, with both countries gaining independence in 1960 [9].

However, this was a period marked by significant political turmoil [9]. The Belgian colonial regime collapsed after over a century of tyrannical hegemony, with its dissolution being initiated by a series of riots in major cities across the country beginning in 1959 [10].

The resulting power vacuum allowed a coalition of internal and external forces to form, each with their own unique and often incompatible agendas, resulting in widespread political instability across the country [10].

Between 1960 and 1966, urban society in Léopoldville (present day Kinshasa) was dominated by the Congo Crisis, which was a period of intense, racialized, and anticolonial politics, ultimately resulting in conflicts, politically motivated killings, and over 100,000 estimated deaths [10, 11, 12]. The Congo Crisis’ legacy contributed to the multitude of civil and transnational wars in this region throughout the twentieth century by allowing the establishment of politically unstable parties and regimes, as well as the abandonment of colonial infrastructure, which has contributed to isolationism and transportation issues in the present day Congos.

The two Congos have some of the worst transportation infrastructure in the world, with large areas of the countries isolated and virtually cut-off from other regions.

However, during colonial times, a vast network of rail and road transit systems were constructed in order to transport exportable resources from the interior and to aid with the migration of European settlers and labour forces [13]. Within the Republic of the Congo, the Congo Ocean Railway was built in 1934, but has received virtually no maintenance since its initial construction due to a lack of funding, harsh terrain, and indifference from local politicians [14]. Recently, the discovery of oil within the Republic of Congo’s interior region has renewed interest

in redeveloping the rail system and several multinational corporations, such as General Electric, have proposed plans to finance and reinstate service [14]. Furthermore, the rail system is vital for oceanic trade and transport, as the Congo River becomes unnavigable to large ships downstream from the Stanley Pool near Brazzaville and Kinshasa. If there is no rail system, the only alternative for international trade is a road link to neighbouring Cameroon, which is subject to high tariffs, effectively making small scale trade impossible [15].

Air transportation in the Congos is primarily limited to government and military applications, however, there are a few localized cargo and passenger carriers based out of decaying Cold War era airports [16]. Only the MayaMaya International Airport in Brazzaville and the N’djili International Airport in Kinshasa offer connections to Europe and the rest of the world, as virtually all Congolese airlines are blacklisted from European airspace due to safety regulations [16]. Currently, there is extremely limited water-based transportation within this urban region, with the only option being privatized and expensive ferries, as there is no physical bridge connecting the two cities [2]. If adjusted and compared to North American economic standards, the average cost of a return ferry crossing is roughly $2,000 USD [2].

Within Congolese urban regions, transportation is hindered by a lack of civil engineering and planning in the rapid post-independence era growth. This has led to a vast network of shantytowns, slums, and refugee camps being built on both shores of the Congo River, and over previous decades, these chaotic zones have been growing larger due to an influx of displaced Congolese citizens, who are migrating to the city in order to escape war, civil unrest, and poorer economic conditions in other regions [17, 18].

The economic conditions of Brazzaville and Kinshasa are one of the most important factors that shape everyday life in the Congos, on personal, business, and national levels.

For many years, Kinshasa was a city that relied on “few entities to manage its relationship with the rest of the world,” as most of its economic relations were strictly interregional or as a direct product of foreign aid [19]. The city has been compared to a “forsaken black hole characterized by calamity, chaos [and] confusion” which engulfs everyday life [20]. Likewise, Brazzaville is a city infamous for “periodically run[ning] short of essentials” that are necessary for survival [14]. Together these cities create a bleak image of economic underdevelopment and provide serious doubt of a potential for positive growth in upcoming decades. Furthermore, inter-Congo economic partnerships and development are hindered by pre-existing trade protocols. The vast majority of both Congo’s official economy is directly related to the states’ oil and mineral extraction industries, and often subjects individual citizens with the duty of arranging the import of

personal goods [15]. These individuals are confronted with extremely high tariffs, often at rates greater than 20% [15]. This has led to the formation of an unofficial, yet widely used, underground economy based around a vast smuggling network [15]. This network spans across international borders and each individual who utilizes this underground economy “uses the border to cope with different country-specific risks and uncertainties in their everyday life” through a variety of activities, including small-scale trade, smuggling, and commuting [21, 22].

Additional complications such as congested trade and transit routes, electrical blackouts, and the seizing of merchandise by Congolese ‘officials’ further compound the marketplace debacle [2, 15, 19]. The combination of these factors illustrates the necessity of economic development, and the requirement that each municipal government ought to address the unique needs of its citizens.

In recent years, the construction of a physical road and rail link between the cities of Brazzaville and Kinshasa has been proposed, as this link would be vital for the future stability and growth of this region. As of 2020, there are only two bridges crossing the Congo River and both are located hundreds of kilometres away from the metropolitan region. It is estimated that by 2025, this region will become the largest urban centre in Africa [2].

The Brazzaville-Kinshasa Road and Rail Project would contain a border post, a rail line connecting Central and Southern Africa, as well as provide a road terminus to promote primarily economic growth and development in the cities [23]. There has been controversy since the two Congos have been “facing difficulties harmonizing and rationalizing their immigration and customs procedures” [23]. There are fears that opening a bridge would directly expose Brazzaville and the Republic of the Congo to civil unrest and war present in the Democratic Republic of the Congo due to mass migration from Kinshasa to Brazzaville [23]. Whether this bridge would ultimately benefit the region is yet to be seen, as this process is only in the planning stages with many roadblocks still to overcome, including the specific details of construction, distribution of funding, and the examination of both short and long term impacts that would arise from linking these two cities.

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References [1] Antweiler, C., Forster, L. Groschwitz, H., Gunsenheimer, A., & Noack, K. (2013). Congo River: 4700 Km Bursting with Nature and Culture. African Arts, 46(1), 85-88. DOI: 10.1162/AFAR_r_00048 [2] Brülhart, M., & Hoppe, M. (2011). Economic Integration in the Lower Congo Region: Opening the Kinshasa-Brazzaville Bottleneck. Policy Research Working Paper; no. WPS 5909.

Washington, DC: The World Bank. Retrieved from http://documents.worldbank.org/curated/en/6553314680257661 74/Economic-integration-in-the-lower-Congo-region-openingthe-Kinshasa-Brazzaville-bottleneck [3] Deibert, M. (2008). Congo: Between Hope and Despair.

World Policy Journal, 25(2), 63-68. https://doi.org/10.1162/wopj.2008.25.2.63

[14] Roads and Railways: Congo. (2007). Africa Research Bulletin: Economic, Financial and Technical Series, 44(3), 17338A-17339C. https://doi.org/10.1111/j.14676346.2007.00878.x [15] Oliva, M. A. (2008). Trade Restrictiveness in the CEMAC Region: The Case of Congo. IMF Working Paper; no. WP/08/15 Washington DC: International Monetary Fund. Retrieved from https://www.imf.org/external/pubs/ft/wp/2008/wp0815.pdf [16] Air Synapsis. 2009. Domestic Air Transport in Democratic Republic of Congo: Feasibility & Market Overview. Marketing Report, Dubai: Air Synapsis.

[17] Jan Van Eyck Academie. (2006). Brakin: BrazzavilleKinshasa: Visualizing the Visible. Maastricht: Lars Müller Publishers.

[4] Lewis, T. (1902). The Ancient Kingdom of Kongo: Its Present Position and Possibilities. The Royal Geographical Journal, 19(5), 541-558. Retrieved from https://www.jstor.org/stable/1775621

[18] Corker, J. (2013). Internal migration to Kinshasa 1970-2007: Investigating migrant characteristics in times of insecurity and economic crises. IUSSP Conference t 2013. Busan: University of Pennsylvania. Retrieved from https://iussp.org/sites/default/files/event_call_for_papers/Corker _IUSSP2013_Session006.pdf

[5] Le Vine, V. T. (1968). Political Elite Recruitment and Political Structure in French-Speaking Africa. Cahiers d'Études Africaines, 8(31), 369-389. DOI: https://doi.org/10.3406/cea.1968.3133

[19] AbdouMaliq, S. (2011). Deals with imaginaries and perspectives: reworking urban economies in Kinshasa. Social Dynamics, 37(1), 111-124. https://doi.org/10.1080/02533952.2011.569999

[6] (October 31, 1992). Two Cities: Brazzaville and KinshasaThat Crucial French Connection. The Economist, 325(7783), 46.

[20] Trefon, T. (2004). "Reinventing Order: Kinois and the State."

In Reinventing order in the Congo: How People Respond to State Failure in Kinshasa by Theodore Trefon (ed.), 1-19.

Kampala: Fountain Publishers.

[7] Morel, E. D. (1904). King Leopold's Rule in Africa. London: William Heinemann.

[8] Lagae, J. (2009). Rewriting Congo’s Colonial Past: History, Memory, and Colonial Built Heritage in Lubumbashi. Paris: Institut national d'histoire de l'art. DOI: 10.4000/books.inha.499 [9] Zolberg, A. R. (1966). A View from the Congo. World Politics, 19(1): 137-149. DOI: https://doi.org/10.2307/2009847 [10] Legum, C. (1961). Congo Disaster. Harmondsworth: Penguin Books Ltd. [11] La Fontaine, J. S. (1970). City Politics: A Study of Léopoldville, 1962-1963. Cambridge: Cambridge University Press [12] Tullberg, A. (2012). 'We are in the Congo now:' Sweden and the Trinity of Peacekeeping during the Congo Crisis, 19601964. Lund: Lund University.

[13] The Congo Railway. (1894). British Architect: A Journal of Architecture and Its Accessory Arts, 42, 211-212.

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[21] Doevenspeck, M., & Mwanabiningo, N.M. (2012).

"Navigating uncertainty: Observations from the Congo-Rwanda border." In Subverting borders: doing research on smuggling and small-scale trade by Bettina Bruns and Judith Miggelbrink (eds.), 85-106. Wiesbaden: VS Verlag.

[22] Bilakila, A.N. (2004). "The Kinshasa Bargain." In Reinventing Order in the Congo: How People Respond to State Failure in Kinshasa by Theodore Trefon (ed.), 20-32. Kampala: Fountain Publishers.

[23] African Development Bank Group. (2013). Multinational: Democratic Republic of Congo - Republic of Congo: Proposal for a Grant of UA5 Million to Finance the Study on the Road-Rail Bridge between Kinshasa and Brazzaville and the KinshasaIlebo Railroad. Proposal, Abidjan: African Development Bank Group.

BIOLOGICAL MANIFESTATIONS OF SOCIAL MALADIES: LUPUS IN THE UNITED STATES ORI E. SOLOMON From ancient times to the 21st century, the determinants of health have shifted along with our understanding of disease etiology – from Hippocratic principles and miasmatic forces, to germ theory and hereditary factors.

However, in modern medicine and public health, we have come to incorporate both ancient and modern paradigms.

Hippocrates posited that health is affected by unique internal and external factors which can work together to balance the body in health, and can work against each other, causing an imbalance manifesting in disease [1].

With time, we have come to identify what he referred to as ‘individual internal factors’ to be hereditary factors and microorganisms, which play major parts in disease, prognosis, and death. Nevertheless, in the late 20th century and early 21st century, a greater emphasis has been placed on external factors, such as the environment and culture, in affecting perceptions of health, and causing disease. Many diseases are influenced by the interplay of internal and external factors that, due to an imbalance, tip the body into a disease state.

Autoimmune diseases are a great illustrative representation of this interplay. Systemic Lupus Erythematosus (SLE, commonly known as lupus) is a disease characterized by systemic inflammation throughout the body due to antibodies mistaking the hosts’ tissue as “foreign” targets [2]. This results in symptoms that commonly include a signature butterfly rash across the cheeks and nose, joint pain and swelling, and anemia. Furthermore, the disease can lead to reduced quality of life, disability, death, and less commonly kidney damage (in lupus nephritis) [3]. Although lupus has been shown to have some hereditary genetic etiology (Human Leukocyte Antigen types, which are inherited immune system regulatory genes, are shown to greatly increase the risk of developing lupus if present), this is not enough to predict disease onset [4]. This indicates that some external non-hereditary factors also play a role in triggering the disease.

However, the effects of environmental and social factors are not limited to disease onset. For example, in the United States, disparities in lupus mortality and outcomes have predominantly manifested in young women of non-white descent [2]. This is thought to be

due to associated socioeconomic status (SES), specifically factors such as education, unemployment, household income, and poverty. In patients suffering from autoimmune diseases, race/ethnicity and SES factors have been shown to be associated with reduced access to quality and affordable healthcare, poverty, reduced understanding of disease and the medical system, and competing work and home demands that form barriers to effective disease management [5].

Psychosocial factors also play a crucial role in disease management. These factors include self-efficacy, social support, and compliance. In a cohort study of lupus patients, a significant difference in adherence to therapies was observed between black patients and white patients [6]. This difference in non-adherence may contribute to a difference in renal diseases caused by lupus complications differing between either race [6,7]. Shortcomings in education, mistrust in medical institutions due to discrimination, personal beliefs of the cause and nature of the illness, poor social support, depression, and low self-confidence in the ability to control disease are associated with poor adherence to therapies [8].

The most difficult aspect of addressing non-adherence is the issue of identifying and diagnosing it, with nonadherence falling in the broad range of 3-76% [9].

Improving communication between physicians, and patients at risk of non-compliance may lead to better patient understanding and increased trust in the patient-physician dynamic. Furthermore, it may result in reduced incidence of intentional non-adherence, and in general, increased efficacy of treatment and disease control. Programs focusing on self-efficacy theory and education are crucial for improving the management and control of diseases. This is because they provide patients with increased confidence in the ability to selfadvocate effectively in patient-doctor interactions, and increase overall medical understanding within patients to create a balanced patient-physician interaction [8].

Another important contributor to lupus disparities in low SES populations is attributed to health policies. Access to public health insurance plays a significant role in lupus treatment in the US, with only 1 in 4 individuals treated for lupus being covered by governmentsponsored health programs (i.e. Medicare/Medicaid)

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[10]. Preserving aspects of policies, such as the Affordable Care Act, to ensure coverage for chronic diseases, such as lupus, is crucial, especially within vulnerable populations [11]. Policies introduced to address shortcomings in other autoimmune and chronic diseases may be applied to lupus. For example, introducing ethnic-directed interventions to target high-risk minority groups may prove effective in better educating these patients in a culturally relevant manner about the consequences of diseases, the importance of treatment adherence, and disease management. Furthermore, a recent survey found that although diseases such as lupus have wide recognition, the knowledge of the disease in the general population is not substantial [10]. Therefore, campaigns to educate the public, especially in highrisk populations, can help to improve social structures, and provide better social support for those most affected by the disease.

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Three targets for improving management of NonCommunicable Diseases (NCDs), like lupus and other autoimmune diseases, include: improving psychosocial factors (self-efficacy, social support, and non-adherence), supporting physicians and patients in fostering a medical culture that perpetuates better communication, and empowering advocacy groups that aim to protect policies that help those with preexisting conditions [12].

This paradigm shift in treating disease as biological manifestations of social maladies has become the cornerstone in public health philosophy. However, it is important to point out that these social effects not only create disparities in who becomes ill, but also how sick these patients get, and the ultimate burdens these diseases bring to the patients, their loved ones, and the community as a whole. As such, these social disparities create more avenues that perpetuate inequality, and thus ought to be addressed in order to control the economic and health burdens of NCDs, such as lupus.

References [1] David Wootton (2006). Bad Medicine: Doctors doing harm since Hippocrates. New York: Oxford University Press.

[2] Lupus Foundation of America. What is Lupus? Lupus.org.

2020 [cited February 18, 2020]. Available from: https://www.lupus.org/resources/what-is-lupus [3] Lupus Foundation of America. Common symptoms of Lupus. Lupus.org. 2020 [cited February 10, 2020]. Available from https://www.lupus.org/resources/common-symptoms-oflupus [4] Cruz-Tapias, P., Castiblanco, J., & Anaya, J. M. (2013).

HLA association with autoimmune diseases. In Autoimmunity: From Bench to Bedside. Bogota: El Rosario University Press.

[5]Jacobi, C. E., Mol, G. D., Boshuizen, H. C., Rupp, I., Dinant, H. J., & Van den Bos, G. A. (2003). Impact of socioeconomic status on the course of rheumatoid arthritis and on related use of health care services. Arthritis Care & Research, 49(4), 567573. https://doi.org/10.1002/art.11200 [6] Sule, S., & Petri, M. (2006). Socioeconomic status in systemic lupus erythematosus. Lupus, 15(11), 720-3. doi: 10.1177/0961203306070008 [7] Lau, C.S., Yin, G., & Mok, M.Y. (2006). Ethnic and geographical differences in systemic lupus erythematosus: an overview. Lupus, 15(11), 715-719. doi: 10.1177/0961203306072311 [8] Demas, K.L., & Costenbader, K.H. (2009). Disparities in lupus care and outcomes. Current Opinion in Rheumatology, 21(2), 102-109. doi: 10.1097/BOR.0b013e328323daad [9] Costedoat-Chalumeau, N., Tamirou, F., & Piette, J.C. (2018). Treatment adherence in systemic lupus erythematosus and rheumatoid arthritis: Time to focus on this important issue: Treatment adherence in SLE and RA. Rheumatology (Oxford), 57(9), 1507–1509. doi: 10.1093/rheumatology/kex337 [10] GfK Roper Public Affairs & Corporate Communications.

Executive Summary Lupus Awareness Survey. Washington, D.C.: Executive Summary Lupus Awareness Survey; 2012.

Retrieved from: https://b.3cdn.net/lupus/2489f6ca2bcbde1818_ggm6i6gzi.pdf [11] Yelin, E., Yazdany, J., & Trupin, L. (2018). Relationship Between Poverty and Mortality in Systemic Lupus Erythematosus. Arthritis Care & Research, 70(7, 1101-1106. doi: 10.1002/acr.23428 [12] Lupus Foundation of America. Update on Lupus Funding and Health Care Reform. (2018). Lupus.org. [cited 12 October 2018]. Available from https://www.lupus.org/generalnews/entry/breaking-news-update-on-lupus-funding-andhealth-care-reform

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A DROUGHT IN HEALTH: THE THREAT OF WATER SCARCITY VAISHNAVI BHAMIDI Water - to simply claim that this resource is important would be a gross understatement. The hydrosphere’s reach of influence stretches into climate, agriculture, human health, economic systems, and societal organization as a whole. Therefore, it is not a surprise that the most resilient ancient civilizations have invariably emerged around massive bodies of freshwater, reiterating that in many ways, the presence of clean, drinkable water and well-managed water systems is a reliable indicator of productive and innovative human life.

For millennia, water has been considered a fundamental and indispensable component of nature. Much of the efforts of our ancestors have been focused on controlling this medium for the purpose of energy production, irrigation, or waste treatment with a high level of confidence regarding its abundance. Over the past three decades, however, there has been a gradual unravelling of the hydrosphere’s delicate state. Slowly, our self-assurance in the constancy of copious freshwater sources is beginning to show cracks.

Governments and organizations around the world are now realizing that they can no longer allow environmental irresponsibility - not when the safety, health, and security of millions are at stake.

Currently, approximately 1.6 billion people face water scarcity [1]. By 2025, it is predicted that two-thirds of the world’s population may face water shortages [1]. The most acutely affected regions will be poor, agrarian countries, which exhibit both physical and economic scarcity. They will lack the adequate volume of water necessary to meet the needs of their populations, and will continue to have poor water-management infrastructure [1]. As well, the economic and developmental inadequacies of these countries will be further exacerbated by the additional pressures that accompany water scarcity – food scarcity, mass migration, threats to public health, political instability, violence, and civil unrest. However, the selectivity of these problems does not absolve higher-income states from danger or responsibility. It is important to note that the social qualms of water scarcity are impossible to quarantine in our interconnected world.

The causes of water scarcity are vast and varied. But one resonant principle underlies all of them: anthropogenic intervention. The grand success of human survival has been facilitated via sacrifice of the environment. Our burgeoning population has, over the centuries, required increasingly more resources – more food, more land, more water. In our tunnel-visioned aim

to collectively survive, we have intervened in the flow of rivers, in underground aquifers, and in natural landscaping. In the case of water security, this has led to three troubling issues: diminished water supply and quality, increased water demand, and drastic flooding events. These three issues have resulted from complex causative pathways, several of which are detailed below: • Reduced water usability due to pollution - Weak environmental policies, and a lack of enforcement allows unrestricted pollution of the waterways. Over the long term, previously usable water becomes unsafe. In São Paulo, Brazil a reservoir was considered too polluted for public use at a time when the constituency was undergoing a large drought. If it was not corrected in time, it would have left 20 million people without a reliable water source [2].

• Saltwater intrusion in aquifers - Excessive groundwater pumping is contributing to saline contamination of freshwater aquifers. Water bodies which were once thought to be indispensable are now facing numerous risks due to excessive salinization. Increased salinization of the water raises the energy cost of purification, and increases the total cost of desalination [3].

• Drought contributing to state failure - Large-scale droughts cripple agricultural efforts. If countries lack the economic viability to import food, they will face famine. This troubling event occurred in Somalia, where 260,000 people died due to a famine from 2010-2012 [2].

• Increase in global food prices - Apart from directly impacting those in the locality of a drought, agricultural failures in growing cash crops such as rice, tea, cotton, and wheat may lead to international spikes in food prices. This occurred when droughts in Russia, Ukraine, China, and Argentina led to international food price spikes from 2010-2011 [2].

• Landscape degradation - Deforestation leads to the loss of topsoil, and causes the land to lose its ability to retain rainwater. However, with the appropriate preventative and interventionist methods, the vitality of the land can be safeguarded. An example of this concept is the Tigray region of Ethiopia, which had become barren and infertile due to extensive deforestation. However, after twenty years of restorative efforts, it has once again retained its initial vigor [2].

• Chronically stressed irrigated areas - Unsustainable agricultural policies may reap short-term bursts in food production, but may eventually over-exploit environmental resources and lead to catastrophic long-term outcomes.

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• Chronically stressed urban areas - Megacities with insufficient and poorly managed water infrastructure are ticking time bombs. If and when water runs out, millions of people will be simultaneously affected.

These factors have contributed to a plethora of secondary problems which have far-reaching global implications. One of the most serious security concerns involves civil unrest and increasing militarization of at-risk regions. As water scarcity becomes more widespread, there is the possibility that it will be exploited by non-state or insurgent groups to destabilize a region. There have been more than twenty water-related violent exchanges between the Middle East and North Africa since 2012 [1]. Military strategy is also evolving to include purposeful damage to water infrastructure. A prominent example of such behaviour can be observed in Syria, where water has been used as a war tool; air force bombing left five million residents in Damascus without water for a month [1].

A less extreme, but equally worrying notion is the diplomatic and legal challenges that could arise from water scarcity. Neighboring cities and states will become increasingly divided over how water is rationed, leading to up-stream/down-stream conflict. As a result, it will become continually harder for neighbors sharing river basins to find mutually acceptable diplomatic solutions. For example, Ethiopia currently controls eighty-five percent of the Nile’s waters, and has plans to use it for its own economic prosperity [3]. Egypt, a downstream nation, cannot diplomatically assert itself due to its geographical disadvantage. As a result, Egypt perceives Ethiopia’s actions as a threat to its sovereignty, and has threatened to deploy its military in response [3].

Another frightening prospect to consider is food scarcity. The demand for food is projected to increase by 50% by 2050, and agriculture accounts for 90% of water consumption [1]. With water being increasingly scarce, a threat to water is akin to a threat to food. Less water for irrigation purposes results in a reduction in agricultural output, and as such leaves fewer farmers with available work. Fewer farmers means more people living without a secure livelihood, which further endangers prospects for nutrition. Increasing water scarcity, food insecurity and loss of employment can encourage more migration and land abandonment.

Migrations tend to favor urbanized areas, and mass shifts from rural to urban lifestyles places insurmountable strain on government and employment services [1].

Moreover, there has also been some research that economic instability, when coupled with inadvertent political instability, may push people towards criminal activity due to desperation [4].

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On a national and international level, these regional trends result in stagnating economic development.

Countries with newly developing economies are often dependent on the export of agricultural and natural resources, and as such require an abundant supply of water to sustain their rapid development. Without such abundant sources, there may be a rise in competition for agricultural production, domestic consumption, industry, and energy creation.

There are no easy solutions to water-related problems.

Reducing water usage and preventing inefficient water wastage by industries requires a thorough examination into environmental legislation, and rigorous modifications of loopholes. Reducing pollution and protecting groundwater wells requires hardline policing and enforcement. Innovative solutions are also required, especially in expanding uses for greywater, and creating more contemporary hydroponic farming practices. Moreover, international discourse and proactive cooperation is essential for ongoing research and development. National membership in water conservation groups, such as the Autonomous Water Authority (Bolivia and Peru) and the Water Neighbors Project (Israel, Jordan, Palestine), is crucial for continuous communication [5].

We cannot afford a delayed response nor can we be ignorant of the issue and sit on our hands. Water scarcity in one region is an ominous forbearer of water scarcity everywhere, and when the dominoes fall, water scarcity will become the catalyst for a multitude of other health issues.

References [1] Li, F. (2018, October 5). Five Reasons Why Water Security Matters to Global Security. Global Communities: Partners for Good. Retrieved from https://www.globalcommunities.org/node/38571 [2] Gleick, P. & Iceland, C. (2019, August 1). Water, Security and Conflict. World Resources Institute. Retrieved from https://www.wri.org/publication/water-security-and-conflict tento, A.L. (2018, May 18). Water Scarcity: The Most Understated Global Security Risk. Harvard Law School National Security Journal. Retrieved from https://harvardnsj.org/2018/05/water-scarcity-the-mostunderstated-global-security-risk/ [4] CNA. (2017). The Role of Water Stress in Instability and Conflict. CRM-2017-U-016532. Retrieved from https://www.cna.org/CNA_files/pdf/CRM-2017-U-016532Final.pdf [5] Levy, B. S., & Sidel, V. W. (2011). Water Rights and Water Fights: Preventing and Resolving Conflicts Before They Boil Over. American Journal of Public Health, 101(5), 778–780. doi: 10.2105/ajph.2010.194

INCUBATING A STATE: THE ROLE OF BORDER SECURITY IN MITIGATING INFECTIOUS DISEASES SHAFNA KALLIL The 21st century has been plagued with several unexpected infectious disease outbreaks such as Severe Acute Respiratory Syndrome (SARS), Ebola, Zika, Middle East Respiratory Syndrome (MERS) and now the novel coronavirus. As of February 29, 2020, the Coronavirus disease (COVID-19) has resulted in over 2900 deaths and 85,000 confirmed cases in 28 countries [1]. As the virus spreads, the importance of border security is becoming more relevant due to the virus’ effect on human life and national security. Countries such as the United States and Australia, have already imposed travel restrictions on Chinese nationals or recent travellers returning from China. If contracted, and in lieu of a pending vaccine, citizens are required to place themselves in “selfisolation” so as to limit the spread of the virus [1].

This article will analyze the impact of border security in mitigating issues of health and infectious disease, and how the current approach is limited.

The emergence of infectious diseases has presented a threat to public health, which is increasingly tied to the growing global economy, travel, and urbanization [5]. Transportation and accessibility have made it easier to travel across the world, presenting a large health security risk, with the potential of travellers and migrants importing infectious diseases to states and their spread due to urbanization and close living quarters. As such, several mechanisms have been developed to strengthen health security, such as the International Health Regulations developed by the World Health Organization (WHO), the Joint External Evaluation tool, and the Global Health Security Agenda [2].

Many states approach border security with a systematic approach of surveying, screening, and examining all items and individuals entering the state [4]. In terms of border security, the procedures change based on the type of disease and the population affected. In the European Union, countries such as France and Germany, and newly separated Britain, screen migrants for tuberculosis but very rarely test for HIV [4]. It seems that with regards to viral infectious epidemics, border screenings have mostly been ineffective.

For instance, during the H1N1 pandemic of 2009,

many cases of infectious individuals were not detected before isolation, primarily due to an asymptomatic incubation period of the virus and fever not being a reliable measure of illness. This meant that the virus could have been easily transmitted to the general population [3]. Even with the utilization of thermal scanners, many cases of viral infections will go undetected due to the asymptomatic incubation period, during which the individual is infective. A similar result was seen during the SARS Pandemic in 2003, where five suspected patients arrived in Canada during the screening period, but their symptoms did not develop until only after their arrival. Thus, all five cases were missed during border screening [3].

A potentially more reliable approach to screen passengers for infectious diseases may be one of communication and self-reporting. By increasing the awareness of an illness, through media, in-flight announcements, and health notices, people are more likely to self-report if they feel unwell [3]. As well, the implementation of a questionnaire specific to the infectious disease may lead to more accurate results as travellers would be more prone to obtaining a medical examination if they recognize their condition is a symptom of a serious illness.

When questionnaires are utilized alongside the routine screening process for all travellers, authorities will have a broader image of the health, and interactions of the traveller. This could have positive implications in cases of large pandemics, such as COVID-19, in which passengers are more likely to self-report or know to place themselves in self-isolation, to minimize the spread of illness.

In conclusion, border security has been primarily ineffective in cases of infectious disease. This can be attributed to the asymptomatic incubation period of a virus and its infectivity levels. As such, the first response in border screening protocol should be increasing awareness of illnesses to travellers and urging them to self-report. As a secondary measure, a questionnaire specific to the illness should be distributed and collected by border security personnel, and any passengers who respond with a ‘yes’ ought to be subsequently evaluated. There is no guarantee that individuals will answer truthfully, but the questionnaire may

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entice them to take precautionary methods if they have recently come into contact with an infected individual. In addition, the typical thermal screening process should still be utilized as a means of complementing the questionnaire process, and as an added layer of security. By taking these steps, there is an extra layer of caution that travellers can take during the asymptomatic incubation period that will ultimately prevent the spread of infectious diseases across borders.

References [1] Coronavirus 2019-nCoV. (n.d.). Retrieved February 29, 2020, from ArcGIS StoryMaps Retrieved from https://www.arcgis.com/apps/opsdashboard/index.html#/bda7 594740fd40299423467b48e9ecf6.

[2] Hospedales, C. J., & Tarantino, L. (2018). Fighting health security threats requires a cross-border approach. Health Systems & Reform, 4(2), 72–76. https://doi.org/10.1080/23288604.2018.1446698 [3] Selvey, L. A., Antão, C., & Hall, R. (2015). Entry screening for infectious diseases in humans. Emerging infectious diseases, 21(2), 197–201. https://doi.org/10.3201/eid2102.131610 [4] Taylor, R. C. R. (2013). The politics of securing borders and the identities of disease. Sociology of Health & Illness, 35, 241254. https://doi.org/10.1111/1467-9566.12009.

[5] Vignier, N., & Bouchaud, O. (2018). Travel, Migration and Emerging Infectious Diseases. EJIFCC, 29(3), 175–179.

Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6247124/

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INTERVIEW: DR. JOY FITZGIBBON SANAYA RAU, SAMANTHA PARKER, SUHA SAGHEER

Joy Fitzgibbon is Assistant Professor and Associate Director of the Margaret MacMillan Trinity One Program at Trinity College in the University of Toronto and a Fellow of College. Joy’s research focuses on the ways in which we can respond more effectively and compassionately to human suffering in the areas of global health policy and violence against women. She is exploring new modalities of pedagogy that enable us to learn, live and serve our communities in integrated and sustainable ways. She lectured as faculty in the International Paediatric Emergency Medicine Elective and in the Canadian Disaster and Humanitarian Response Training Program and submitted policy reports the Canadian Centre for Arms Control and Disarmament and the Canadian International Development Agency (with Janice Stein). She was honoured to join a number of her colleagues in receiving the inaugural Chancellor William C. Graham Award for service to the Trinity College community.

1. What area of global health do you work in? Why are you passionate about this area?

I focus on the health needs of our most vulnerable communities. I am particularly interested in the needs of those who are excluded from the social and economic benefits of our communities—the poor and disenfranchised, women, homeless communities, Indigenous Peoples. My research in my doctorate explored access to gold standard medical care for those suffering from drug resistant tuberculosis—exploring the impact of Harvard’s Partners in Health on WHO’s TB control policy. I am beginning a research project now on sexual violence against women in conflict zones. To know is to serve and it is a privilege to learn from these communities and those who walk directly with them.

They teach me so much about strength, integrity and my own areas of brokenness. They inspire me by their capacity to accomplish things that many say is impossible.

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2. Who were your mentors and how did they support you in your academic journey?

There are a wide range of people who have been most encouraging to me on my journey. I will start with those who influenced me in my doctorate and then move to my current professional life. My dissertation supervisor, Professor Janice Stein, taught me so many things including how to produce policy relevant research that is academically sound and that identifies the most important needs of our communities and how to animate ideas within and throughout institutions. Professor David Cameron also taught me a great deal about policy relevant research, engaging with government, the ethos of the civil service and a what compassion and integrity in mentorship and leadership looks like.

Professor Ron Manzer inspired me with his encouragement at critical points in my research, honouring my voice and vision for global health policy and teaching me the value of engaging in conversations between public policy and administration and international relations literatures—two subsections of political science that do not always collaborate with each other.

Professor Lou Pauly was immensely supportive in encouraging my research on international institutions during my doctorate and has continued to support and encourage me in leadership and research at Trinity. Professor Franklyn Griffiths consistently encouraged me to conduct inductive and angular, creative research—helping me to develop my own voice in my journey. Professor Sylvia Bashevkin also taught me how to approach my teaching and research in a way that honours my own voice and well-being at critical points in my degree. Dr. James Orbinski was a terrific encouragement on all matters global health as he was doing graduate work at U of T at the same time I was beginning my doctorate. He introduced me to our colleagues, Dr. Jim Kim and Dr. Paul Farmer, at Harvard’s Partners in Health who subsequently featured prominently in my PhD research. All of these people played an important part in my intellectual journey.

In my current professional life, I have a life coach who has his doctorate and has significant experience outside the academy. He gives me strong, sound advice on how I allocate my time, how I develop my leadership skills and how I honour my own voice in research, writing, leadership and life. I speak and meet regularly with him. I learn much from my colleagues at Trinity—I will not even begin to list them, but they include gifted individuals across the senior leadership team in the College. They are wonderfully vibrant people from whom I learn so much about research, teaching and transformational leadership. A dear colleague, with whom I served on the Board of a humanitarian aid agency and who is a lawyer, professor and a former senior civil servant in Ottawa—has also given me tremendous advice as I seek to apply my scholarly work into counsel for

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policy communities and particularly not-for-profit organizations. He has shown me how to do so with honour, vitality and integrity. Finally, my parents— Bob and Hope Fitzgibbon. They are not mentors, of course, in the formal sense but the work of mentors would not have had the impact they did without the foundation my parents laid in my life. My late Mom, who was a nurse and a deeply compassionate person, and my Dad who served for years with World Vision and is the kindest and best of men, both instilled in me the commitment to stand with those who are vulnerable and to see the possibilities for goodness and transformation in this world and in people. They taught me to be faithful.

As you can see, this is quite a list and it is an abbreviated version!

3. What is your advice for young people seeking mentorship?

Allow your mentorship relationships to develop organically. There are formal mentorship programs that work too—so give that a try. But look for people that you connect with professionally AND personally. Ask if you can meet with them—-to ask their advice on your own professional or personal journey. Let it be natural. Develop the relationship in an ongoing step by step way. Be faithful to who you are and look for opportunities to connect with people who respect that. You will change and grow—that is the point—but be wise and strategic about who you allow to influence you in that process. Operate out of a sense of expectation and opportunity, understanding that people are often brought into your life for grand purposes. Seize those opportunities. Be respectful of their time and well-organized but don’t hesitate to ask them for counsel. They may be life-long relationships, or a short term. Either can be life transforming for you.

(And them!)

4. How can students get involved with global health initiatives and research at UofT and in the broader community?

We have so much you can be involved with at U of T! It is like drinking from a firehose. Whether it is participating in student groups like The University of Toronto International Health Program, Students for Partners in Health and many others, or research opportunities with professors through Research Opportunity Programs, Independent studies or posted work study programs, or work with NGOs and other global health organizations, be strategic regarding your decisions. It’s not quantity, it is quality.

5. What do the next 5 to 10 years in your research field look like?

Political scientists are notorious for failing to accurately predict the future, so I will not try! The world is changing so fast that no one can, with credibility, predict precisely what policy relevant research with look like in global health or any area of international relations in the next 5-10 years.

There are a few areas to watch however—questions of health equity and effectiveness expressed through different policy expressions of universal health care, the tension between human rights and neo-liberal economic models of growth and how that impacts health including sustainability and health—i.e. environmental impacts on health. On the security side—we should pay continued attention to the way in which the collapse of societies, increased violence from counterinsurgency and terror groups and interstate conflicts of various forms may impact health.

The way in which power is shifting in the international system, away from the west and some if its institutions, towards other centres of power, is impacting the ideas and structures that drive global policy—including in the areas of national and international security, health, human rights, the environment and economics.

6. What are the three things someone working in the global health space needs in their toolbox?

1. Authentic compassion and intellectual humility 2. The ability and disposition to learn from those who are on the front lines of care or at the receiving end of it—i.e. patients, their families and local health care providers.

3. The ability to conduct trans-disciplinary research.

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