The Ampersand Journal, Issue IV

Ampersand

Journal of the Bachelor of Arts and Science Volume iv, 2011

McGill University Montreal, Quebec, Canada www.mcgillbasic.com

Ampersand

Journal of the Bachelor of Arts and Science Volume iv, 2011 Editor-in-Chief Elena Ponte Editorial Board Isabella Liu Jonah Schermbrucker Kartiga Thiyagarajah Art Director Darren Haber Layout Emily Coffey Graphics Anastassia Dokova Theresa Min-Hyung Lee

Ampersand is supported by the Bachelor of Arts and Science Integrative Council, the Science Undergraduate Society, the Arts Undergraduate Society and the Dean of Arts Fund.

The moral rights of the authors have been asserted

Printed on 100% recycled paper

Contents v

About Ampersand

vi

About the Contributors

viii

Introduction

1

Drugs and Dissidence: Making Sense of Thabo Mbeki and AIDS Denialism in South Africa

Gabriel Devlin 8

National, International, Global: Tracing the Origins of the Global Public Health Movementv

Lynsey Grosfield 16

The Medical Scholar: the Italian Renaissance Physician as Portrayed in Commedia dell’Arte

Alexandra Markus

23

Summer Journal

32

Adolescent Smoking Acquisition: A Structural Analysis

42

Harrison Pollock Ian King Tobie Cusson Bryanne Leeming Samantha Allen

Comparative Study of Taiwanese Health Care System

Theresa Min-Hyung Lee

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About Ampersand

A

mpersand is committed to the promotion of interdisciplinary thought, demonstrating how divided fields can be woven together in an insightful way. We take part in a tradition, one that goes back so far and so deep its roots are lost in our collective memory.

A survey of history reveals the progressive impact of interdisciplinary thought. There was no demarcation of anatomy and artistry for da Vinci or of physiology and philosophy for Galen. There were no subject guides for Kant, Hume, Locke, or Descartes. Bridges across paradigms were once common: Newton was at once an alchemist and a physicist, Freud an initiator and a perpetrator of psychology.

Though the tradition today is largely obscured by artificial boundaries and specialized fields, Ampersand highlights domains where integrative discourse takes place. That is, discourse that dares to transcend the gaps of modern thought; discourse that reclaims the value—and the necessity—of integrative study.

For Ampersand, ideas originate in the tension between borders. Consider how unlikely couples—math and literature, empowerment and circumcision, bias and objectivity—provide insight. And, how neuroscience and linguistics, news media and environmental studies open new frontiers alongside previously tread ones: across medieval continents, through potato fields, on meteorite tails, and within Enlightened thought.

We hope to challenge what you think you know—about order, about change, about the relationship of arts and science. For that is progress, in the grand tradition.

The Editors

v

About the Contributors Samantha Allen is an aspiring law student who is currently completing

a major in Honors Sociology and a minor in Psychology. She is actively engaged in many aspects of the McGill community; she is a varsity athlete, Editor-in-Chief of Verstehen, a student representative on several athletic and academic committees and is dedicated to multiple volunteer programs.

Gabriel Devlin is a U3 B.A. & Sc. student majoring in Biology, with mi-

nors in Political Science and Social Studies of Medicine. While volunteering in South Africa the previous summer, he developed a serious and potentially unhealthy crush on the country and its culture, emotions he could only exorcise by writing “Drugs and Dissidence” for his History of AIDS seminar last fall. Apart from his studies, he also enjoys baking empanadas, deliberating in Franglais and giving out awesome high fives.

Lynsey Grosfield is a U2 student, completing an honours degree in Anthropology with a minor in Sexual Diversity Studies. Lynsey currently works as a Research Fellow at the McGill Institute for Health and Social Policy, and is completing a case study on the topic of “disability and equity across the life course.” Additionally, she has worked at Environment Canada, and CoopSol: a fairtrade coffee cooperative. Whether it be in coffee farming, environmental consultations, or public health, her research interests have tended towards integrating the artificially separated fields of arts and science. In her spare time, Lynsey enjoys gardening, landscaping, and learning about biodiversity and sustainability.

Alexandra Markus is a U1 student currently majoring in Physiology and

double-minoring in Drama and Theatre and Social Studies of Medicine. A graduate of Marianopolis CEGEP’s stimulating Arts and Sciences program, she loves integrating the arts and sciences in exciting and creative ways, believing that breaking down the boundaries between disciplines is essential to innovation. She loves to sing, volunteer, and write poetry, prose, and plays.

She wishes to pursue a career in medicine.

Theresa Min-Hyung Lee is a U2 student in Arts and Science pursuing a

dual degree in Biomedical Sciences and International Development Studies. Her essay was written to reflect her experiences with the Comparative Healthcare Systems Program at McGill and her trip to Taiwan and South East Asia. She hopes to pursue a career in public health and law, advocating for policies that bring about social equity and equal opportunities for achieving better health, close at home and abroad.

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Introduction

M

edicine is the science and art of healing. On one hand, a physician uses scientific expertise to diagnose and treat a patient’s disease. On the other hand, a healthcare provider offers patients compassion and attention to better their emotional well-being, while recognizing the ethical and social implications of healthcare. As a B.A. & Sc. student with specific interests in medical science and health economics, I have spent the last three years of my undergraduate career preparing myself for today’s integrative society. I have also learned that to understand and work in the healthcare system requires an interdisciplinary approach. This year, Ampersand has chosen to recognize the application of interdisciplinary studies to a field that dominates our world’s well-being.

In 2008, Canada spent 5,170 CAD per person or 10.7% of its GDP on medical care. Over the past three decades, spending on healthcare has been increasing steadily and is expected to increase further in the coming years. It is no surprise then that healthcare is at the forefront of public policy debates, as politicians, economists, and healthcare providers struggle to find ways to limit spending while improving the quality of Canada’s healthcare system.

The answers, however, require insights from both the arts and sciences.

The healthcare system relies on scientific research and clinical trials to develop novel drugs and medical procedures for improvements in the quality of healthcare. It is also a system that must remain economically efficient so that public funds are not squandered on a sector that is more costly than beneficial to society. While the healing of patients in a healthcare system is rooted in scientific treatments, the system remains a social institution. Hence, it must be fiscally sound and sensitive to societal welfare.

Decisions made in the healthcare system rely on people and ideas from both the arts and sciences. The Canada Health Act of 1984 states that a province must insure all services that are “medically necessary”. The list of insured services is decided upon by medical associations and political authorities. While healthcare providers will evaluate the medical benefit associated with different services, government officials and economists will determine the economic worth of services, by comparing costs and benefits. The integration of their perspectives on medical treatments help to build the healthcare system we benefit from today.

But why do we value health? Our well-being and ability to function in society rely on our health. Without good health, we would not have the opportunity to achieve what we want in life, irrespective of other factors. It

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follows then that decisions made in the practice of medicine must be based on scientific knowledge and reasoning, but also an understanding of human behaviour, social values, and ethical guidelines. What is beneficial to a patient must be considered from a scientific and humanistic perspective.

A health policy survey in 2007 found that 60% of surveyed Canadians feel that the healthcare system is in need of fundamental change. To deliver this change will require an integrative approach. Researchers and physicians must turn to science to develop new treatments to battle cancer and heart disease, today’s major killers. Policy makers must decide on which social structures to target to improve society’s health status. Healthcare providers must better understand the needs of visible minorities, disabled persons, and new Canadians to provide patient-centeredness care. Policy options are plentiful, but what will determine their success is the level of consideration that is given to their scientific and humanistic implications.

The papers presented in this volume of Ampersand illustrate how disciplines in the arts and sciences interact in the practice of medicine and the functioning of a healthcare system. Whether it be the political implications of disease management or the social change needed to overcome a health problem, the integration of the arts and sciences is crucial for both understanding health issues and striving for national and global health improvements.

- Kartiga Thiyagarajah

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1

“Mbeki resigns before the nation,” proclaimed the Mail & Guardian on September 21st, 2008. This event marked the end of a long and turbulent mandate for Thabo Mbeki, South Africa’s second democratically elected President since the fall of Apartheid in 1990.

When South Africa elected Mbeki as President in 1999, AIDS affected over 15 percent of the population and the state had no plan to handle the disease. There were widespread calls upon the government to take action and to subsidize antiretroviral (ARV) treatment. Yet despite pressure to take action, Mbeki refused to acquiesce. He claimed that ARVs were too costly and toxic. By 2000, he started publicly questioning the science behind AIDS, arguing that poverty, as well as HIV, caused AIDS. He accused his opponents of racism and proclaimed that AIDS was a Western-led conspiracy to discredit African identity.

Why would an otherwise capable and educated leader suddenly espouse such seemingly irrational opinions? The answer lies in the historical context. After a century marked by racism and abuse, South Africa emerged from Apartheid immeasurably divided along racial lines.

In moving forward, Mbeki put forward a vision of an African Renaissance, an ambitious national project that sought to unify his people through equitable economic growth and development. However, the AIDS epidemic undermined the Renaissance’s prospects. After a series of disputes over Mbeki’s AIDS policies within the Renaissance frame-

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work, the President gradually began to accuse his critics – AIDS activists, the scientific establishment, and the West – of opposing the Renaissance project and African identity. Although Mbeki hastily painted his opponents as enemies of Africa, his opponents were equally predisposed to dismiss the President as deluded. They swiftly condemned the ANC’s reluctance to distribute ARVs as ‘genocide’.

Thabo Mbeki’s Views On AIDS Despite the ‘denialist’ label, Mbeki never denied the AIDS epidemic’s existence, nor did he deny that HIV may cause it (BBC World’s Hard Talk, 2001). During the 1990s and 2000s, Mbeki repeatedly stressed the epidemic’s severity, characterizing it as “a health crisis of enormous proportion” (Opening of 13th International AIDS conference, 2000), and “a very, very severe problem that’s likely to decimate the South African population” (BBC World’s Hard Talk, 2001). In a letter to global leaders from 2000, Mbeki outlines his government’s initiatives to “encourage safe sex and the use of condoms,” “provide the necessary medicaments and care to deal with what are described as ‘opportunistic diseases,’” “contribute [to] the development of an AIDS vaccine” and “organize ourselves to ensure that we take care of the children affected and orphaned to AIDS” (Opening of 13th International AIDS conference, 2000).

Yet Mbeki contended that precisely because the AIDS epidemic in Africa is far more severe than the epidemic in the rest of the world, “a simple superimposition of Western experience on African reality would be absurd and illogical” (Letter to World Leaders on AIDS, 2000). He claimed that the answers to the AIDS epidemic must come from Africans themselves, in order to develop “specific and targeted responses to the specifically African incidence of HIVAIDS” (Opening of 13th International AIDS conference, 2000).

Mbeki believed that an essential cofactor of the African AIDS epidemic

is poverty. Quoting the World Health Organization, he argued “Poverty is the main reason why babies are not vaccinated, why clean water and sanitation are not provided, why curative drugs and other treatments are unavailable and why mothers die in childbirth…”

(Opening of 13th International AIDS conference, 2000). As a result, fighting AIDS by concentrating on ARV distribution was said to be ineffective. Rather, the state must engage in a “comprehen-

3 sive treatment response” that fights the “whole variety of things [that] can cause the immune system to collapse” (Time, 2000).

From these opinions, one can identify several themes. First is Mbeki’s skepticism of the Western scientific establishment, namely its view that HIV is the only cause of AIDS. He interprets criticism of his views as a “campaign of intellectual intimidation and terrorism” (Letter to World Leaders on AIDS,

2000). Second is his contention that poverty is an essential component of the AIDS epidemic. This suggests that money would be better spent fighting poverty than simply purchasing ARVs. Immune, but not for long Throughout the 1980s, AIDS slowly spread across the African Continent. At first, South Africa appeared unaffected: in 1990, “whereas between 10 and 20 percent of the adult population of central Africa were (sic) HIV-positive, annual surveys of major South African cities gave figures below 1 percent” (Fassin, 2005).

However, within a decade AIDS spread to over 15 percent of the population (UNAIDS, 2000). William Gumede (2007) argues that “given South Africa’s combustible social mix – a large migrant population, people displaced because of Apartheid, the breakdown of traditional family bonds, a labour system that keeps men away from home for most of the year – it is hardly surprising that AIDS struck with such devastation”.

For most of the 1990s, the state largely ignored the AIDS crisis. In 1994, the ANC founded the National AIDS Committee of South Africa (NACOSA) to develop a state strategy. However, the program only pledged 105 million Rands (US $15 million), and the ANC left most of the funds untouched (Fassin, 2005). Insufficient state commitment to fighting AIDS led to a rise in AIDS activism in 1998, the most notable organization being the Treatment Action Campaign founded in 1998 (Robins, S. and B. von Lieres, 2004).

By the late 1990s, Deputy President Thabo Mbeki, who oversaw health matters in Mandela’s government, and Health Minister Nkosazana DlaminiZuma faced significant electoral pressure to intervene and provide ARVs to the five million South Africans too impoverished to access treatment through private clinics.

The failure of ‘African’ responses Thabo Mbeki attempted to respond to the epidemic within the African Renaissance framework, which emphasized

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‘local’, ‘African’ solutions. However, this led to counter-intuitive responses, the most famous being the Virodene scandal. In July 1996, researchers at the University of Pretoria contacted Health Minister Dlamini-Zuma, claiming they discovered a possible cure for AIDS. In a letter to Zuma, they presented “extremely encouraging results” from “unofficial clinical trials on informed, consenting patients.” In a follow-up letter half a year later, the researchers proclaimed “the results far exceed what we anticipated” (Myburgh, 2007).

Zuma quickly passed the information to Thabo Mbeki, and asked the researchers to present their findings to the cabinet.

The presentation was a success. Behind this governmental show of support, the researchers moved towards testing Virodene in clinical trials.

Inspiring as it was, South Africa’s other scientists were much less enthusiastic. A year before, the Medical Control Council (MCC) refused to approve clinical trials, citing “ethical concerns” (Myburgh, 2007). A month after the researchers presented their results to the cabinet; the MCC announced that further review revealed that Virodene contains a highly toxic industrial solvent, which may cause irreversible fatal liver damage. Nevertheless, the government insisted that the trials move forward. In 1998, Zuma abolished the MCC. Although the issue slowly disappeared from the public eye, the Virodene scandal led to a significant fallout between the ANC and the scientific establishment. By eliminating the possibility of a homegrown treatment to AIDS, the scientific establishment had positioned itself as an enemy of the African Renaissance in the eyes of Mbeki.

Indeed, the Virodene scandal led Mbeki and the ANC to increasingly view the scientific establishment as opposed to Mbeki’s national project.

The costs of AZT Another controversy that exploded alongside the Virodene scandal further intensified Mbeki’s distaste for the scientific establishment. In 1998, the ANC explored the possibility of securing ARVs from Western pharmaceutical companies. The government was particularly interested in azidothymidine (AZT), an ARV manufactured by Glaxo-Wellcome that was accepted to be effective in preventing mother-tochild transmission. However, negotiations proved fruitless; Glaxo-Wellcome insisted that South Africa pay the same price as industrialized countries (Bond, 1999).

After negotiations with Glaxo-Wellcome fell through, the ANC shifted its focus to importing generic ARVs offered at one fifth of AZT’s price. In 1997, the government passed the “Medicines and Related Substances Control Amendment Act”, which made provision for generic substitution by pharmacists of prescription medicine. However, Western pharmaceutical companies quickly reacted. The Pharmaceutical Manufacturers’ Association tied up the law in courts, citing patent violations. Back home, they pressured the Clinton administration to threaten economic sanctions if South Africa did not repeal the law (Bond, 1999).

These disputes progressively convinced Deputy President Thabo Mbeki that the West was more concerned with profits than with the well-being of Af-

5 ricans. Mbeki theorized that the West was overstating the extent of AIDS in Africa; it was logically in the pharmaceuticals’ interest to do so (Gevisser, 2007). The skirmish over AZT prices increased his skepticism of the West and AIDS activists, and progressively made them arch-enemies of the African Renaissance A progressive racialization of the debate The Virodene scandal and government battles with Glaxo-Wellcome led to the gradual falling out between the ANC and the scientific establishment, AIDS activists, and the West.

Consequently, the debate between the ANC and Western countries became increasingly radicalized. Mbeki accused Virodene’s opponents of “[denying] dying AIDS sufferers the possibility of ‘mercy treatment’ to which they are morally entitled” (Myburgh, 2007).

Mbeki progressively framed the battle in terms of race. Virodene’s opponents were “blinded by racist white rage” (“Mbeki versus Leon”, Sunday Times, 2000). The TAC was “convinced that we are but natural-born, promiscuous carriers of germs” (Address by President Thabo Mbeki at the Inaugural ZK Matthews Memorial, 2001).

To explain the phenomenon, one has to examine the aspects of South African history. The history of racist science and imperial medicine has received significant attention. Throughout the 19th and 20th centuries, whites employed scientific theories to defend their racial superiority and denigrate African identity through ‘objective’, ‘rational’ means. As David Arnold (1988) argues, “beneath the language of medical objectivity and

the talk of ‘sanitary science’, European medical attitudes often remained highly subjective, embodying the social and cultural prejudices of the age.”

South Africa was no exception. As Saul Dubow extensively details in Scientific Racism in South Africa (1998), science played a central role in Apartheid’s construction. South African anthropologists claimed that humanoid remains discovered a few miles out of Johannesburg in 1927 established blacks as the “missing link” between chimpanzees and whites. Psychologists claimed that the “native mind” was primitive and inherently sexually promiscuous. Eugenicists in the 1940s pushed for sterilization campaigns targeting Africans who, if uncontrolled, would overrun society (Dubow, 1998). Public health officials cited African ‘filth’ and ‘susceptibility to disease’ to justify residential segregation (Swanson, 1977).

After the end of Apartheid, South Africans tried to move past the racism that had traditionally defined the nation. However, associations between science and colonialism reared its ugly head during the 1997-98 Truth and Reconciliation hearings. The hearings unearthed various human rights abuses of the past and in the process, revived memories of racist science. Revelations included secret military tests on rural African communities during the 1970s and a government research program that sought to create a race-specific biological weapon in the 1980s (Purkitt and Burgess, 2002). These revelations were made concurrently with the Virodene and AZT battles.

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As the Truth and Reconciliation hearings revived African memories of racist science, Mbeki increasingly drew parallels between his enemies and the racist scientists of yore. The AIDS debate became more radicalized and Mbeki started to remind audiences of Apartheid “medical schools [that] convinced [Africans] of their inferiority by being reminded of their role as germ carriers” and that they were “human beings of a lower order that cannot subject its passions to reason” (Address by President Thabo Mbeki at the Inaugural ZK Matthews Memorial, 2001). He claimed that if South Africa wanted to move forward with “the struggle for our renaissance”, Africans must shed these labels in favor of “the urgent process of reclaiming our identity, our dignity and our pride.” Mbeki progressively viewed his battles as a defense of African identity. AIDS became construed as another ‘tool of empire’, another excuse through which the West could degrade African identity and maintain the global order.

Ultimately, the growing distance between Mbeki and his opponents shifted his attention away from the real enemy, AIDS, and towards the ANC’s old enemy: racism.

From skepticism to dissidence As Mbeki’s disenchantment with Western scientists and AIDS activists grew during the late 1990s, the President came across a document that would bring the controversy to a whole new level. In March 1999, a lawyer named Anthony Brink gave Mbeki a book titled Debating AZT. The document argued that ARVs were in fact toxic, and HIV did not cause AIDS. Rather, AIDS was a collection of diseases caused by malnutrition, poor sanitation, and drugs.

The theory that AIDS was an environmental rather than pathological or behavioral disease proved incredibly attractive to Thabo Mbeki. Arguing that a sexually transmitted virus caused AIDS implied that Africans were promiscuous and that the government should invest in expensive and potentially dangerous treatments. These solutions implied an attack on the African Renaissance’s call for national pride. However, if AIDS was an environmental problem, then curing it required social change and poverty alleviation, which coincided with the African Renaissance’s goals.

The theory was too tempting to ignore.

In July 2001, Mbeki opened the 13th International AIDS conference in Durban by arguing, “we could not blame everything on a single virus” (Opening of 13th International AIDS conference, 2000). In a TIME interview on September 11th, 2001, he claimed that, “the notion that immune deficiency is only acquired from a single virus cannot be sustained.” Mbeki’s insistence that poverty, not HIV, causes AIDS can be explained by his overarching political and ideological imperative to engage in radical social change free of Western colonialist tones. Such social change was called upon by the African Renaissance.

After the government’s refusal to offer Nevirapine, the TAC took the government to court. On December 14th, 2001, the South African High Court ordered that Nevirapine be made available to all HIV-positive pregnant women (Gevisser, 2007). The government swiftly appealed the decision, only to have the Constitutional Court return the same decision six months later. Defeated, the ANC announced “near universal rollout” of state-subsidized ARV treatment programs, and Thabo Mbeki publicly

7 withdrew from the AIDS debate. After years of disputes, the AIDS controversy had come to a close.

The controversy certainly tarnished Mbeki’s reputation. Commentators have come to portray Mbeki as “aloof ” (Nolen, 2007), “stubborn” (“The World: AIDS in South Africa; A President Misapprehends a Killer,” The New York Times, 2000), “thin-skinned” (WikiLeaks cables, The Guardian, 2010), “idiosyncratic” (The Economist, 2010), and “an emperor without clothes” (Ryklief, 2002). To an extent, Mbeki merits these labels. For whatever personal reasons, his unquestionable loyalty to the ideological framework of the African Renaissance, and his absolute distrust of those who questioned it, blinded him to the realities on the ground: that an increasing number of South Africans were dying of AIDS. REFERENCES Arnold, D. (1988). Imperial Medicine and Indigenous Societies. Manchester: Manchester University Press.

Baldwin, P. (2005). Disease and Democracy: The Industrialized World Faces AIDS. Berkeley: University of California Press.

Bond, P. (1999). Globalization, Pharmaceutical Pricing, and South African Health Policy: Managing Confrontation with U.S. Firms and Politicians. The International Journal of Health Services, 29, 765–792.

Bongmba, E. K. (2002). Reflection on Thabo Mbeki’s African Renaissance. Journal of Southern African Studies, 30, 291-316.

Campbell, C. (2003). Letting Them Die: Why HIV/AIDS Prevention Programmes Fail.

Bloomington: Indiana University Press.

Darracq, V. (2008). Being a ‘Movement of the People’ and a Governing Party: Study of the African National Congress Mass Character.

Journal of Southern African Studies, 34, 429-449.

Dubow, S. (1995). Scientific Racism in South Africa.

Cambridge: Cambridge University Press.

Farmer, P. (1992). AIDS and Accusation: Haiti and the Geography of Blame. Berkeley: University of California Press.

Fassin, D. (2005). When Bodies Remember.

Berkeley: University of California Press.

Gevisser, M. (2007). Thabo Mbeki: The Dream Deferred. Jeppestown: Jonathan Ball Publishers.

Gumede, W. M. (2007). Thabo Mbeki and the Battle for the Soul of the ANC. New York: Zed Books.

Hays, J. N. (1998). The Burdens of Disease: Epidemics and Human Response in Western History. New Brunswick: Rutgers University Press.

Jacobs, S. and Calland R. (2002). Thabo Mbeki’s World. Pietermaritzburg: University of Natal Press.

Lodge, T. (2003). Politics in South Africa: From Mandela to Mbeki. Bloomington: University of Indiana Press.

Maynard, S. W. (1977). The Sanitation Syndrome: Bubonic Plague and Urban Native Policy in the Cape Colony, 1900-1909. The Journal of African History, 18, 387-410.

Myburgh, J. (2007). The Virodene Affair. Retrieved Feb 7, 2011, from www.tac.org.za/community/ printpdf/2134 Nolen, S. (2007). 28 Stories of AIDS in Africa.

Toronto: Knopf.

Purkitt, H. and Burgess S. (2002). South Africa’s Chemical and Biological Warfare Programme: A Historical and International Perspective. The Journal of Southern African Studies, 28, 229-253.

Robins, S. and Von Lieres B. (2004). Remaking Citizenship, Unmaking Marginalization: The Treatment Action Campaign in PostApartheid South Africa. Canadian Journal of African Studies, 38, 575-586.

Ryklief, S. (2002). Does the emperor really have no clothes? Thabo Mbeki and ideology. Sean Jacobs and Richard Calland (Eds.). Thabo Mbeki’s World. Pietermaritzburg: University of Natal Press.

Sherer, G. (2000). Intergroup Economic Inequality in South Africa: The PostApartheid Era. The American Economic Review, 90, 317-321.

UNAIDS. (2000). 2000 report on the global AIDS epidemic. Retrieved Feb 7, 2011, from unaids. org. The Official Web: http://www.unaids.org White, Reynolds S., Whyte M., Meinert L. and Kyaddondo B. (2006). Treating AIDS: Dilemmas of Unequal Access in Uganda. In Petryna, Ariana (Ed.), Global Pharmaceuticals.

Durham: Duke University Press.

World Health Organization. (2004). Antiretroviral drugs and the prevention of Mother-to-Child Transmission of HIV Infection in Resourceconstrained Settings. Retrieved Feb 7, 2011, from who.org. The Official Web: http://www.who. org

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ince the inception of several Global Public Health Organizations in the 1990s and 2000s - including the Bill and Melinda Gates Foundation, The Girl Effect, and The Global Fund - the definition of “Public Health” has undergone a rapid transformation. In fact, the definition of Public Health has been implicated since the 1800s with evolving modifiers: National-, International-, and Global- being the three most prevalent. From an anthropological perspective, tracing the origins of these various trends in Public Health is a multi-faceted question, due to key aspects and terms of the discourse, such as “humanity,” “life itself,” and “the social,” have had diverse and changing definitions throughout different historical moments. Certainly each incarnation has been contingent upon the idea of “health for all,” but who is

included in that “all” and how “health” is defined are quintessential questions of anthropological inquiry.

In understanding the discourse about Public Health, it is first useful to trace the trajectory of certain key concepts, the first being “humanity.” The notion of an essentialized humanness that was shared by all - humanity - emerged around 1800, largely as a response to increase European contact with other peoples (Rees, 2010). Implicit in this notion is the paternalistic conceit that Europeans had “achieved” humanity, whereas in others, true humanity was a latent possibility, reliant upon Colonial rule to blossom into its truest form: in this conception, humanity was either a fact, hidden under obstacles such as ill health, or a project, which required Colonial investment. In either sense, hu-

9 manity was an endeavor, and an integral execution part of this endeavor was the heady task of providing “health for all.”

Anthropology emerged in this climate as an academic and Colonial discipline, a means of making sense of those whom the Europeans believed to be “peoples without history” (Wolf, 1982).

The idea of Public Health also hinges upon a population conceiving of itself in biological terms, having a widespread definition of what constitutes “life itself,” and creating an episteme based on the intrinsic value of biological human life.

Marx and Engels are the first “biopoliticians”, in this sense they wrote about citizens as a biological fact, of “historical materialism”, that is, history as a series of class struggles over access to the means to fulfill material needs, rather than a Hegelian series of epochs (Rees, 2010) . In this conception of history, each and every mode of production also implies a social structure - and nearly every social structure is predicated on the existence of the “haves” and the “have nots.” For Marx and Engels, only in eradicating the difference between the two by moving beyond material wealth could the project of humanity be achieved. in The Human Condition (1958), Hannah Arendt, analyzes this notion by drawing a distinction between labour and work. Labour being the effort to provide for one’s basic material needs whereas work being craftsmanship. To Arendt, Marxism would reduce every person to a labourer or slave, and therefore, extinguish the light of the essential “humanness” in work and intellectual pursuit.

Foucault (1990) further complicates this picture; he wrote of “biopower” - the interest of the state in the vital characteristics of its populace - as a means of social

control in the nation-state (as opposed to the punitive power of the Monarch).

In the nation-state, state power is Since the inception of several Global Public Health Organizations in the 1990s and 2000s - including the Bill and Melinda Gates Foundation, The Girl Effect, and The Global Fund - the definition of “Public Health” has undergone a rapid transformation. In fact, the definition of Public Health has been implicated since the 1800s with evolving modifiers: National-, International-, and Global- being the three most prevalent. From an anthropological perspective, tracing the origins of these various trends in Public Health is a multi-faceted question, due to key aspects and terms of the discourse, such as “humanity,” “life itself,” and “the social,” have had diverse and changing definitions throughout different historical moments. Certainly each incarnation has been contingent upon the idea of “health for all,” but who is included in that “all” and how “health” is defined are quintessential questions of anthropological inquiry.

In understanding the discourse about Public Health, it is first useful to trace the trajectory of certain key concepts, the first being “humanity.” The notion of an essentialized humanness that was shared by all - humanity - emerged around 1800, largely as a response to increase European contact with other peoples (Rees, 2010). Implicit in this notion is the paternalistic conceit that Europeans had “achieved” humanity, whereas in others, true humanity was a latent possibility, reliant upon Colonial rule to blossom into its truest form: in this conception, humanity was either a fact, hidden under obstacles such as ill health, or a project, which required Colonial investment. In either sense, hu-

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manity was an endeavor, and an integral execution part of this endeavor was the heady task of providing “health for all.”

Anthropology emerged in this climate as an academic and Colonial discipline, a means of making sense of those whom the Europeans believed to be “peoples without history” (Wolf, 1982).

The idea of Public Health also hinges upon a population conceiving of itself in biological terms, having a widespread definition of what constitutes “life itself,” and creating an episteme based on the intrinsic value of biological human life.

Marx and Engels are the first “biopoliticians”, in this sense they wrote about citizens as a biological fact, of “historical materialism”, that is, history as a series of class struggles over access to the means to fulfill material needs, rather than a Hegelian series of epochs (Rees, 2010) . In this conception of history, each and every mode of production also implies a social structure - and nearly every social structure is predicated on the existence of the “haves” and the “have nots.”

For Marx and Engels, only in eradicating the difference between the two by moving beyond material wealth could the project of humanity be achieved. in The Human Condition (1958), Hannah Arendt, analyzes this notion by drawing a distinction between labour and work. Labour being the effort to provide for one’s basic material needs whereas work being craftsmanship. To Arendt, Marxism would reduce every person to a labourer or slave, and therefore, extinguish the light of the essential “humanness” in work and intellectual pursuit.

Foucault (1990) further complicates this picture; he wrote of “biopower” the interest of the state in the vital characteristics of its populace - as a means of

social control in the nation-state (as opposed to the punitive power of the Monarch). In the nation-state, state power is subjected to the health and wellness of the populace, as the populace is responsible for going to war, and economic as well as population growth. In Foucault’s conception, national projects were and are necessarily racist projects, as the investment in ones’ own society over another is by its nature exclusionary; even before pseudo-scientific understandings of race were born, the idea of the nation as a race existed, making possible atrocities such as genocide that are fuelled by an idea of preserving one’s own nation or race. In this schema, the history is a series of social as opposed to class conflicts; Foucault also pins the emergence of the “life itself ” idea at the junction of Monarch to nation-state where the vital statistics on the populace were at this time coded as social.

All of these changes wrought in the discourse surrounding human life were fuelled by the emerging social questions and challenges of industrialisation, namely a working-class of urban poor (Victor Hugo’s Les Miserables) who lived in circumstances that readily incubated disease and facilitated its rapid spread (Flin, 1965). Social science, predicated at the time on the idea of death as a “social disease” (Horne, 2002), emerged as a response to these conditions, and also as a ready arm of state “biopower” in the form of systematic sanitary surveillance.

The epidemic of historical consequence in this context was cholera, which spurred the first real Public Health Act in Britain in 1848 (Flin, 1965). This act and its associated measures aimed to systematically eradicate the disease from the British populace by instilling stricter port regulations, quarantines, and vari-

11 ous attempts at hygiene improvement for vulnerable populations. Futhermore, the act was steadily and continuously adapted to seasonal conditions and epidemiological discoveries (Hardy, 1993).

Additionally, continental cholera epidemics led to an unprecedented level of international cooperation in sharing resources and data about the disease and national Public Health measures. The international cooperation is exemplified in the first International Sanitary Conference at Paris in 1851, and the following events in 1865, 1875, and 1885 in Constantinople, Vienna, and Rome respectively. Along with the implications for the fight against cholera, each of these conferences was also the site of nation-state forming discourse regarding social control: a hardening of borders, more stringent trade and immigration rules, definitions of social outcasts (such as gypsies and pilgrims), and increased surveillance (Huber, 2006).

During this time, Britain laid down a series of publications and acts which solidified the role of the state in healthcare, such as the Quarantine Act on 1825, the New Poor Law of 19334, The Chadwick Report in 1842 (Flin, 1965), and the additional Public Health Acts of 1866 and 1875 (Hardy, 1993). Additionally, the Office International d’Hygiène Publique (OIHP) was established in France as an international regulator and monitor of the spread of cholera in 1907 (Rees, 2010).

Amidst the domestic turmoil with seasonal cholera pandemics, European nations with colonial projects were continually encountering new diseases in more tropical climes. Tropical diseases became a manner in which colonialists could conceptualise the colonies’ spatial

“otherness,” an epidemiologically based imperialism, which was focused on making the tropics healthier for Europeans, and tempering the “inconveniences” of dealing with an unhealthy colonised workforce. Malaria, known as “bad air” as per miasmic disease theory, before it was examined under germ theory (Cohen, 1983), was literally thought to be caused by the air of a place. The developing biomedical discourse surrounding this disease became an additional vector for the justification of continued colonial occupation, as it was assumed that the Europeans were “bringing” Public Health to the indigenous population to combat the climactic challenges of the place (Cohen, 1983).

Following the major cholera epidemics of the mid- to late-1800s was the domestic development of the welfare state and various forms of social security in the late-1800s. Otto von Bismarck introduced a range of social security measures in the 1880s that began to form a German Social Safety net, such as the Health Insurance Law of 1883 (Porter, 1999). By 1920, following the First World War, nations such as Britain and Sweden had also established a similar system of social security and Public Health statutes. In essence, the growing European trend towards the welfare state was the widespread ideological transition to the “national social,” and the “rule of experts.”

Following the First World War, the United States’ Rockefeller Foundation (est. 1913) became a leader in the field of international health (Birn, 2000). Its goals were based on the idea of achievable projects, such as the eradication of diseases such as hookworm and yellow fever in the developing world. Its dual

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purposes were to protect American borders from the diseases of “others,” and to ensure American political interests were protected. There was an idea that healthy nations and citizens do not turn to communism - or other similarly “antiAmerican” ideologies - as well as that the American national interests could be served by attempting to aid other national populations with health projects. The Rockefeller foundation was also heavily involved with the League of Nations Health Office, which was comparably a much more administrative and research-oriented institution (Dubin, 1995).

However, in this climate of addressing International Public Health needs, there was also the widespread and growing post-first World War trend of eugenics, a pseudo-scientific theory that saw “racial degradation” as the source of social ills, and prioritised certain lives over those that were believed to be more base. Eugenics was informed by history and social factors, but was coded as biological.

When the League of Nations collapsed during the Second World War, so too did its health arm; and it was not effectively replaced until the creation of the World Health Organisation (WHO) in 1948, which incorporated the epidemiological service of the Office International d’Hygiène Publique (Chrisholm, 1950).

Also, during the 1940s, initiatives, such as the Beveridge Report of 1941 in Britain, solidified the idea of the Welfare State and the creation of National Public Health services (Porter, 1999). Parallel to these developments were the creations of the World Bank and the International Monetary Fund at the Bretton Woods conference in 1944, which led to a fur-

ther standardization of commerce and exchange. Amidst all of these new institutions, the World Health Organisation was largely created to address the gaping health care needs following the devastation of the war. The organization was also incepted in a climate of Cold War, decolonization, and the rise of new nations-states, and was integral in defining how, exactly, the international arena would be re-constructed after the war.

The World Health Organization was different and more efficacious than the League of Nations Health Office. The WHO had universal membership, which allowed it to deliver projects much easily, and it operated within the framework of existing state Public Health systems (Brown, Cueto et al., 2006). Like the British cholera eradication projects of the 1800s, the WHO initially focused on the preventive management of disease as well as the standardisation of biomedical health discourses through education and “expert committees” (Chrisholm, 1950). However, the WHO soon became a more educated body in the midst of several changes to the climate of International Health (Brown, Cueto et al., 2006). The WHO definition of primary health care was defined as a state’s “compete physical, mental, and social well-being,” which depended less on mere biology (Chrisholm, 1950).

Additionally, it depended on existing National Public Health Care services as the means to achieve International Public Health. Implicit in the early goals of the WHO is the idea that science, technology, and research were essentially apolitical domains, governed solely by biological realities as determined by experts, which was an essential component of the idea of the national social as well.

(Rees, 2010)

13 In the 1960s, however, there was a growing politicization of health in the larger movements towards social change that characterised the decade, such as the civil rights movement. It became apparent in these movements that science and technology, particularly medical technology, were not apolitical. Malaria eradication became a theme in terms of developing countries, in which health organizations shifted their focus from the areas of consequence to trade, such as ports and major cities, to the rural.

This can be seen as a generational rift, a part of a larger worldwide trend that was characterised by a rejection of the “rule of experts” by the post-Second World War generation. Health, no longer just a technical nor scientific project, but a socio-economic one as well, was pursued through a growing number of community-based projects. A decidedly more “bottom-up” as opposed to “top-down” model of policy-making and knowledge production was sought as an ideal (Rees, 2010). This idea was furthered with the declaration of Alma Ata in 1978, which stated that, “The people have the right and duty to participate individually and collectively in the planning and implementation of their health care.” Alma Ata was also a critique of the militaristic attempts to eradicate malaria in the developing world between 1955-1978, which had largely been comprised of pesticide spraying and short-term operations in which the social context of diseases such as malaria was ignored in favour of the pathogen. Instead, the declaration advocated for horizontal (as opposed to vertical) healthcare approaches: . . .primary health care is essential health care based on practical, scientifically sound and socially acceptable methods and technol-

ogy made universally accessible to individuals and families in the community through their full participation and at a cost that the community and country can afford to maintain at every stage of their development in the spirit of selfreliance and self-determination (Declaration of Alma Ata, 1978).

However, these proclamations were too vague for some, and lacked measurable, quantifiable, and achievable goals.

Counter to the sentiments of Alma Ata was an alternative movement for Selective Primary Health Care (SPHC), an “intermediary” step towards “health for all by the year 2000” (Walt, 1993) that asserted that vertical programs; if implemented properly, could be an effective way to fight disease in a costeffective manner. Proponents of Selective Primary Health Care believed that the Primary Health Care approach was too idealistic and unachievable from an economic perspective, inexorably tying together the politics of Public Health with the economy.

The lofty ideals of Alma Ata were thus short-lived; as in the 1980s, the World Bank and the International Monetary Fund entered the field of health. This was during the rise of neoliberalism, in which the efficacy of the “national social” was questioned in an ethos that favoured market forces. The World Bank released a report in 1987 about “financing health,” in which it clearly advocated for a user-funded health services in developing countries. The ideas and rhetoric from Alma Ata were essentially appropriated in the neoliberal discourse; whereas under Alma Ata, the right to participate in defining the parameters of one’s care was determined by one’s input;

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in the World Bank ideal, the right to participate is determined by one’s dollar - both can be seen as “bottom-up” in some sense; however, the neoliberal discourse prioritizes the mass-market as the determinant of health needs and services as opposed to the mass-participation of citizens in social programs. In addition, throughout the late 1980s and early 1990s, the procedures and efficacy of the WHO were questioned in an attempt to understand where an institution created in the 1940s exactly fit in to the new climate of Public Health as an economic question (Walt, 1993). Some of the key terms of the Public Health discourse were also called into question, including Disability Adjusted Life Years (DALYs) (Sudhier & Hanson, 1997). Vital health, under neoliberalism, became the responsibility of the individual and not the state. This created a vacuum of accountability for health that Non-Governmental Organizations soon began to fill.

In 2000, Gro Harlem Bruntland, ten Director-General of the World Health Organization, commissioned the Sachs report: Macroeconomics and Health: Investing in Health for Economic Development. This report solidified the new position of the WHO, which was previously in somewhat of a crisis, as a leader in Global development via the improvement of Global Health, instead of being a leader in Primary Health Care, expertise, and education.

Thus, the Global Health movement was born as a response to the failings of neoliberalism. The movement addressed the comprehensive health needs of vulnerable populations outside of the context of development. Global Health, unlike International Public Health, is

supra-national - it does not depend on previously established National Public Health services to function, but rather on “creative capitalism” (Gates, 2005) and market-driven initiatives to provide such basic medical needs as vaccines for curable diseases, and also to create artificial markets for medical research and development. Global Public Health is a technical and accomplishable goal, and a seemingly necessary one at that. “It’s no big deal, just the future of humanity” (The Girl Effect, 2010), as stated in The Girl Effect video, implies that “humanity is at stake in the field of health” (Rees, 2010). As a fiscal and technical project, the modern arena of Global Health is dominated by Bill Gates’ idea in which, “Given the right approach, it is possible to save thousands of lives in a short period of time” (Gates, 2005).

Life - each and every biological being saved - is measures the success of Global Health endeavors. Thus what is unique about this moment in history is that, theoretically, each one of these lives is deemed to have equal value, and that there is something intrinsically valuable about “life itself ” in the Global arena.

REFERENCES Arendt, H. (1958). Labor & Life as the Highest Good. The Human Condition. Chicago: University of Chicago Press, 1958.

Birn, A. E. (2000). Wa(i)ves of Influence: Rockefeller Public Health in Mexico, 1920–50.

Studies in History and Philosophy of Science, 31, 3 (2000), 381-95.

Brown, T., Cueto M., & Fee E. (2006). The World Health Organization and the transition from ‘international’ to ‘global’ public health.

American Journal of Public Health, 1, 62-72.

Chrisholm, B. (1950). The World Health Organization. British Medical Journal, 1021-7.

Cohen, W. (1983). Malaria and French Imperialism. Journal of African History, 24, 23-36.

15 Declaration of Alma-Ata (1978, September 12) International Conference on Primary Health Care, Alma Ata, USSR. Dubin, M. (1995). The League of Nations Health Organisation. International Health Organisations and Movements. Cambridge (UK): Cambridge University Press.

Flinn, M. (1965). Report on the Sanitary Condition of the Labouring Population of Great Britain Edinburgh: Edinburgh University Press.

Foucault, M. (1990). Right of Death and Power over Life. History of Sexuality I: An Introduction. New York: Vintage Books.

Gates, B. (2005). Remarks of Mister Bill Gates, Co-founder of the Bill and Melinda Gates Foundation, at the World Health Assembly.

Geneva, Switzerland.

Hardy, A. (1993). Cholera, Quarantine, and the English Preventive System, 1850-1895.

Medical History, 37, 250-69.

Horne, J. (2002). The Modern Sphinx: Debating the Social Question in 19th Century France.

A Social Laboratory for France. Durham: Duke University Press.

Huber, V. (2006). The Unification of the Globe

by Disease? The International Sanitary Conferences on Cholera, 1851-1894. The Historical Journal, 49, 453-76.

Marx, K., & Friedrich E. (1998). The German Ideology. New York: Prometheus Books.

Porter, Dorothy. (1999). Health and the Rise of the Classic Welfare State. Health, Civilization, and the State: A History of Public Health from Ancient to Modern Times. New York: Routledge.

Rees T. Lecture (2010, March 2) First Hour: Global Health Emerges as an Informed Response. McGill University, Montreal, Canada.

Sachs J.D. (2001). Macroeconomics and Health: Investing in Health for Economic Development. Geneva; World Health Organization.

Sudhier A. & Hanson K. (1997). Disability Adjusted Life Years: A Critical Review.

Journal of Health Economics, 16, 685-702.

The Girl Effect, Online Video, Retrieved March 10. 2010, from girleffect.org, The Official Web: http://www. girleffect.org Walt, G. (1993). WHO Under Stress: Implications for Health Policy. Health Policy, 24, 125-144.

Wolf, E. (1982). Europe and the People without History. 4. Berkely: University of California Press.

World Bank Policy Study. (1987). Financing Health Services in Developing Countries: An Agenda for Reform. Washington DC: The World Bank.

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17

“Quand le docteur parle, l’on doute Si c’est latin ou bas-breton Et souvent celui qui l’écoute L’interrompt à coup de bâton” Towards the beginning of the sixteenth century, a new form of theatre called Commedia dell’Arte emerged in Italy and remained popular throughout the Renaissance. The improvised sketches that composed the Commedia dell’Arte repertoire were meant to mimic, in an exaggerated fashion, daily life in Renaissance Italy using a variety of “stock characters” who depicted ostensibly “archetypal” Italian citizens.

One such stock character, referred to as Il Dottore—Italian for “The Doctor” was meant to represent the stereotypical Italian physician: a gluttonous, pedantic know-it-all who donned black academic robes and spewed nonsensical babble.

Today, it can be understood that this portrayal reflected society’s response to the growth of the scholarly medical paradigm during the Renaissance, which, coinciding with the genesis of so-called “scientific” medicine, contributed to the increased knowledge gap between the university-educated physicians and the often illiterate laypeople.

This paper will analyze two scenarios from Commedia dell’Arte to illustrate how the physician was portrayed within a historical context in the midst of the Scientific Revolution during the Renaissance.

Il Dottore was from Bologna, the birthplace of the world’s first university and, by extension, the birthplace of the Physician-Scholar. Prior to the preeminence of the University, which began

as a kind of academic guild, medicine was regarded as a craft; “healers” were considered on par with barbers, stonecutters, and goldsmiths. The advent of the Physician-Scholar as a result of the foundation of the University of Bologna Faculty of Medicine in 1260 gave rise to a more exclusive form of medical care, conferring a particular subset of the medical profession a great deal of prestige (Pilcher, 1906). Thus, doctors advanced in rank above bonesetters, apothecaries, barbers, surgeons, and charlatans, many of whom attempted— if not executed—similar work. Indeed, from its inception, the Bolognese Faculty of Medicine received the majority of University’s funding, a testament to its comparative prestige. It was typical of a university graduate who received his degree in Arts and Medicine to teach logic for two to three years, pass on to natural philosophy, and, as soon as possible, move on to medicine, which was viewed as the pinnacle of academic achievement. However, during the Renaissance, the importance of “natural philosophy”, which we now know as science, increased as scholars discovered its immense potential following discoveries

by Bologna’s own Nicolaus Copernicus and Pisa’s Galileo Galilei. As a result, natural philosophy, much of which involved the study of ancient texts, formed an increasingly integral part of the Renaissance physician’s background (Lines, 2004). According to the medical historian Mary Lindemann, an increasing

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number of academics “were busily engaged in the revival of classical learning that, at that point, consisted of the rediscovery of ancient Greek texts [by philosopher-scientists such as Aristotle, Hippocrates, and Galen] and their publication or translation into Latin” (Lindemann, 1999). This renewed interest in ancient treatises gave rise to a widening perceived knowledge gap between physicians and laypeople, contributing to the caricaturization of the PhysicianScholar as a “an eternal gas-bag who cannot open his mouth without spitting out a Latin phrase or quotation” (Duchartre, 1966); in other words, the arid, pompous, and pedantic know-it-all immortalized as “Il Dottore.”

According to John Rudlin in his critically acclaimed guide for Commedia actors, Il Dottore originated as a “gross Carnival figure, who also appears in folk plays such as the English Mummers’ plays, which invariably contain a section, usually called the cure, consisting of the mock Doctor’s boast in which he brags of his travels and his powers, followed by a haggle over fees, the administration of the cure, and the resurrection of the fallen hero” (Rudlin, 1994). This “heroic healer” archetype was modified for a contemporary audience to fit the stereotype of the bumbling black-robed academic physician of the Renaissance, who, as far as his often illiterate clientele were concerned, constantly spewed unintelligible streams of nonsensical Latinate babble, addressing everything except the patient’s malady (Duchartre, 1966). In addition to his scholarly black robes, the Doctor wore a mask consisting merely of a bulbous nose and a short, pointed beard not covering the actor’s cheeks, which were saturated in rouge.

According to historian Pierre-Louis

Duchartre, this conveyed an impression of “foolish self-sufficiency mingled with a gravity which bordered on severity... the contrast of which was comic to the extreme” (Duchartre, 1966). His love of eating and drinking is evidenced by his protruding stomach, which, at the time, was a sign of the wealth he gained from the prestige of his profession. This portrayal of Il Dottore in Italian Commedia dell’Arte reflects the growing uncertainty, confusion, and resulting cynicism of the common laypeople with regards to the emergence of the “academic” healer who, from his years of intense, isolated study of antiquated texts, appeared to be almost of a different species, possessing a vastly different body of knowledge from his patrons. Moreover, the common cynicism toward academia at the time becomes apparent in the blatantly exaggerated hypocrisy of Il Dottore, exemplified by Duchartre’s joke that “it scarcely seems fair to maltreat so excellent a savant when he has spent his whole life learning everything without understanding anything” (Duchartre, 1966). Such hypocrisy is highlighted in the numerous scenarios compiled in 1611 by the dramatist Flaminio Scala, some of which are used by Duchartre and Rudlin to provide the necessary evidence to support their claims about Il Dottore’s depiction.

The first scenario, provided by Duchartre, exhibits the Physician’s pedantry, lack of interpersonal skills and inability to pick up social cues. In this scenario, the Doctor (“Doctor” here used in a professorial, rather than medical, context) and the Physician become embroiled in a war of words; this time, the Physician outdoes the Doctor in his pedantry and social ineptitude. It begins with the Physician boasting about

19 his heroism, which brings us back to his Mummers’ Play origins: “I am not only an avalanche of medicine, but the bane of all maladies whatsoever. I exterminate all forms of fever, chills, itch, gravel, measles, the plague, ringworm, gout, apoplexy...” He proceeds to punctiliously list a whole slew of maladies he miraculously cures, culminating in a self-parody that exemplified the more cynical lay attitudes towards physicians: “In short, I wage such a cruel and relentless warfare against all forms of illness that when I see a disorder becoming ineradicable in a patient I even go so far as to kill the patient in order to relieve him of the disorder.” When the Doctor politely remarks that such action “is an excellent cure” the Physician continues his military act by replying that he “[has] no other” (Duchartre, 1966). Later in the scenario, the Physician proves his point when the Doctor remarks that a patient’s spleen is about to burst. The Physician becomes so enthralled in his pedantic recitation of anatomical jargon that he does nothing to aid the situation: “The spleen, you say? Ho, we shall require an anatomical chart for that. The spleen lies in the left hypochondria beneath the diaphragm between the ribs and the ventricles near the kidneys. On that side it is attached to the ventricle, the peritoneum, and the omentum” (Duchartre, 1966). By the end of the scene, the Doctor becomes so annoyed by the Physician that he threatens harm to many of his body parts: “I wish you’d burst open, with all my heart...he’s making my ears buzz....I’d like to bash his nose...I’d like to snatch out all his hair and leave him bald-headed....if I had a club I’d break every rib in your body...go to the devil, my head is splitting.” After each mention of a body part, the Physician, in his oblivious social ineptitude

and inability to pick up social cues, goes on a long-winded and pedantic anatomical and physiological dissertation of the body part. The Doctor quietly escapes offstage, leaving the Physician alone, incognizant of his lack of a conversation partner, figuratively drowning in his own anatomical babble about the occipital bone. The scenario as a whole provides a window into how physicians were perceived during the Renaissance in Italy, highlighting the emphasis on anatomy in the medical curriculum, which, as historian Lewis S. Pilcher (1906) points out, was “the glory of the [Bolognese] School of Medicine”. Since anatomical dissections were rare due to a dearth of available cadavers, much of what physicians knew was by meticulous rote memorization from textbooks, a practice which promoted the pedantic mindset. In addition, both cadavers and medical textbooks were almost exclusively available to the academic elite, creating a large knowledge gap between the Physician-Scholar and the uneducated masses. This knowledge gap elicited cynicism among the general public (and even, in this case, non-medical academics), to whom the physicians’ terminology and anatomical explanations were little more than gibberish.

The second scenario, provided by Rudlin (1994), in addition to highlighting Il Dottore’s social ineptitude and pedantry as in the previous scenario, is a direct jab at the Physician-Scholar’s hypocrisy.

A more typical Commedia scenario, this second example involves the witty banter between Il Dottore, another vecchi or “old man” stock character called Pantalone, and a Zanni, or commoner, about their perceptions of Hell. The scenario begins with Il Dottore exhibiting his social ineptitude by constantly

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interrupting the Zanni, demanding to be at the center of attention at all times by frequently asking, “Why does [the Zanni] do all the talking?” The actors employ evident dramatic irony as it is obvious that Il Dottore is monopolizing the discourse. Il Dottore, in his usual fashion, bores his audience with dry and pointless monologues, which Pantalone claims sound like “how a donkey eats straw”. Following the Zanni’s vision of Hell, in which hypocritical individuals abound, Il Dottore offers his perception. First, he describes a Hell in which there lived “an ignorant pedant naked on all fours like a horse,” where “fifty times a day they tanned his hide with a red-hot poker and a hundred times a day they bombarded him with copies of every book in the world.” This description amuses Pantalone, who bluntly retorts, “That’ll be your destiny, Doctor: being bombarded like that, ignoramus that you are.” The Doctor, oblivious to Pantalone’s harsh jab at his character, continues his description of Hell: I saw surgeons, the ones who cut people up unnecessarily, being stoned to death with glowing embers...pathologists pierced all over with nails, knives, swords, and chopped into little bits like fine parsley to be put into soup....bankrupt apothecaries, who put hot water in enemas whilst swearing it’s oil. They have to empty their bowels every fifteen minutes and, afterwards, they have to eat it all up again.

Again, Pantalone calls the Doctor out for hypocrisy, asking, “And whilst you were passing, Doctor, did you try a spoonful?” It is evident from the discourse that the Doctor’s description of

a Hell for distrustful charlatans, insidious apothecaries, and sadistic surgeons would have injected a great deal of highly discernible dramatic irony to a Renaissance audience. This ironic portrayal could be attributed to the fact that, while in the midst of these physician-scholars who claimed to know the secrets of the human body and the cures to many illnesses, the common people still found themselves surrounded by rampant disease that characterized the pre-modern era. It is hence not surprising that an intelligent contemporary audience would see these black-robed academics through cynical eyes.

Through primary and secondary source analyses of Commedia dell’Arte scenarios, and through interpretation of the scenarios within a historical context, it is evident that the rapid rise of the scholarly medical paradigm during the Renaissance was met with a great deal of cynicism. In the two Commedia scenarios compiled originally by Flaminio Scala discussed herein, the first analyzed by Pierre-Louis Duchartre (1996) and the second by John Rudlin (1994), one is able to discern some common stereotypes that are satirically portrayed by the character of Il Dottore. Among such stereotypes discussed in this paper are gluttony, pedantry, social-ineptitude, aloofness, self-centeredness, and hypocrisy—all qualities that were associated with the committed academic.

Given that Commedia had a tendency to find vulnerabilities and hypocrisies in traditionally “prestigious” figures such as military men (“Il Capitano”) and academics such as Il Dottore, it may appear uncertain to the modern critic whether such caricatures were intended to affirm or shock the contemporary audience.

However it is a fair assumption that

21 the stereotype of Il Dottore was largely based on truth given that the medical theories and remedies employed by Renaissance physicians are now deemed obsolete as they are known to be inaccurate, often uncomfortable, and useless. Regardless, the rise of academic medicine, as exhibited by the portrayal of Il Dottore, greatly increased the existing knowledge gap between Renaissance physicians and their patients, inciting cynicism in the patients who no longer understood the explanations of their own bodily processes provided by the doctor.

REFERENCES Duchartre, P. L. (1966). The Italian Comedy.

Trans. Randolph T. Weaver. Toronto, Canada: Dover Publications.

Lindemann, M. (1999). Medicine and Society in Early Modern Europe. Cambridge, U.K.: Cambridge University Press.

Lines, D. A. (2004). Natural Philosophy in Renaissance Italy: The University of Bologna and the Beginnings of Specialization. Early Science and Medicine, 6, 267-320.

Pilcher, L. S. (1906). The Mondino Myth.

Medical Library and Historical Journal, 4, 311-28.

Rudlin, J. (1994). Commedia dell’Arte: An Actor’s Handbook. London: Routledge.

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&

When one thinks of Africa the first thing that often comes to mind is a statistic. Maybe it’s that a child dies every 45 seconds from malaria or maybe that half of the population lives on less than one dollar a day. Despite being bombarded with these numbers, we invariably push them to the back of our minds. Why? Because they imply a problem so vast, so overwhelming, that we feel utterly powerless to do anything that could have any impact.

This past summer I spent a month and a half in East Africa. For three of those weeks, I lived in a remote Tanzanian village where I helped build a school. I worked as a volunteer with the English NGO Volunteer Africa, in cooperation with a local organization, HAPA. Living there was unlike anything I had experienced before. My fellow volunteer and I lived without running water or electricity – most meals involved gathering twigs to start a fire and life meant being on constant alert for ants, rats, snakes and mosquitoes.

Maintaining basic hygiene was a complicated affair and we quickly grew to cherish every drop of water.

It was also the first time I had the experience of living as a racial minority. The fact that I am white clearly indicated my status as an outsider.

We were quite the novelty in our village – I think of the many times that the school children would run up to us hoping to have their picture taken and, afterwards, would yell and mob us as they each tried to point to themselves in the photo. When walking alone down a street in a larger town near

Summer Journal our village, I invariably felt as if I was the centre of attention. When I later took a local bus up to the north of the country I could hear people’s whispers, I sensed their glances.

Our work back in the village was, at times, quite demanding. We had to carry and lay hundreds of 35-pound bricks, shovel and level mounds of dirt, fill and load dozens of jugs of water, and push sand-laden wheelbarrows.

Progress was slow, but steady. When I arrived, all I saw were rows and rows of bricks. When I left, the school’s foundation was nearly complete. It was enormously satisfying.

The poverty of the village was impossible to ignore. One day, I had the opportunity to visit a small two-room house in which six people lived - it was not tall enough for me to stand up in. The roof was charred with ash, open windows were stuffed with clothing, and the beds were made of sticks covered with sheep skin. I thought of the kids whom I saw every day, so full of energy and enthusiasm, but whose families had to devote all of their income to basic needs. They wore the same clothes throughout my whole time there.

The work done by the villagers was extraordinary. Fathers pulled and pushed wheelbarrows for hours on end to help build the school so that their sons and daughters could gain a better education. Mothers carried babies on their backs while shovelling dirt for the foundation. One grandmother came to the work site and laboured hard and

Y &

long every day. Her work ethic put us volunteers to shame. And the amazing children who, after a full day of school, were always so eager to help out in any way possible.

I quickly realised what a privilege it was to work there: to help men, women, and children who, despite their poverty, maintained a sense of optimism as they worked hard to improve their lives. Living among them, I never felt a sense of despair that one would think would be pervasive in a community where living standards are so low. Instead, I was struck by their devotion, persistence, and strong sense of self-reliance.

Was coming to Tanzania, to this tiny remote village, really worthwhile?

After all, if I had given the significant amount of money it cost to fly half way across the world directly to the villagers, they could have used it to make immeasurable improvements in their lives. What I accomplished, however, was to establish a human connection. Now, when I read of the mass of people who live in Africa on less than a dollar a day, I think about Salim, Rama, and Salvatore, young men whom I met and befriended. Now, when I hear about how a child dies from malaria every 45 seconds, I think about Francis and Veronika’s older brother, who lived steps away from me and who died from that disease because his family lacked access to basic medical care.

Never again will I be able to separate the numbing statistics from the real people they represent. My experience made me utterly unable to sit down and accept the situation as it is – it has pushed me to do whatever I can to help.

And as for solving overwhelming problems, I am convinced that small, seemingly futile actions can eventually lead to profound change. A journey of a thousand miles begins with a single step.

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Summer Journal The radiance of youth so warmly glows Beside dead ashes of a former time; With but four notes, let symphonies compose The seasons and their one cyclical crime.

Fair faces decay, bold passions shall sway Beneath the throne of imperial Life; From sweet budding May ‘till Death’s dying day, We plough His fields unaware of our strife.

But in one moment, one moment serene – As summer’s heat is chilled by autumn’s breeze – The Veil is torn: observe the pastures green.

The field is your own, both hardship & ease.

Moments are the bricks by which lives are built – Awareness their cement: both joy and guilt.

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Yesterday I went to Remba, a tiny but densely populated island in the middle of lake Victoria. The island’s few thousand inhabitants have relatively high incomes from fishing, but don’t benefit from basic services such as electricity, running water or sewage. Most of it’s male residents spend the early hours fishing for Nile Perch, then come home and trade in their catch for disposable income to spend on drink and the company of fancy women.

Upon my arrival I opted to go for a stroll around the place. There were fishing boats all along the shore. All of the houses on the island were semipermanent; made of iron sheet metal walls and roofs. They were crammed everywhere and, their resident’s incomes notwithstanding, looked very slumlike. As I strolled along, a mass of people started running off to one side of the island and calling out crazy war cries. Against my better judgment, I followed the mob to see what was going on.

More and more people were marching off angrily and you could feel the mob-mentality in the air. I stopped to ask an old man what was going on.

He muttered something about a man getting stabbed in the neck. Despite the screaming and my feeling rather auspiciously pale-skinned, I told him I was going to get a closer look at the action. He didn’t stop me, so I thought it’d be ok. By now, several hundred people had gathered just below a ridge that lay beyond my view. Suddenly, gunshots were fired and a few people started sprinting away, some of whom ran right past me. As I proceeded further I began scanning people’s hands to check if any of those passing near me were brandishing machetes. Another shot rang out, but I still couldn’t see who was shooting and why. I made my way to about 10 meters from the ridgetop

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Summer Journal

where a group of people was looking down at the action. A shot was fired and dust spattered into the air just next to them. They bolted back and I finally came to my senses and did likewise.

After making my way back through the slum with my adrenalin pumping, I rejoined my colleagues who were very unimpressed by the gunplay.

Upon hearing the story their smiles distinctly smacked of indifference. Oh Kenya. .

Before leaving the island a few hours later, I learned that a Somali resident had prepared a place to park his boat, but another guy had taken the spot before he could. They argued and the Somali ended up stabbing him in the neck. The police arrested the Somali and then took them both in to the police station. They arranged for the stabbed one to get treated and were proceeding to take them to the mainland for further medical treatment and prosecution.

The mob had other ideas. Rather than leaving things to the police and the courts, its angry members had wanted to assert their own brand of justice and had marched on the police station to deliver it. The cops had to fire shots out in order to disperse the crowd and re-assert their authority. If the mob had gotten to the Somali, he would unquestionably have been beaten to death‌

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I was supposed to take organic chemistry this summer. The night before my first class I logged onto Minerva and withdrew from the course.

Call it procrastination, or whatever you want, but something came up. I am referring to a particular something in the form of an email I had received a few weeks previously from a high school friend, Cate, with the idea to bike down the coast of California. It was one of those emails I responded to with a “That sounds amazing!” but I meant “That sounds like a cool idea, but you and I both know we’ll never make it happen, so let’s just pretending we’re going to do it until it’s too late.” Sound familiar? Think about all of our plans to go to the Rally to Restore Sanity in Washington, DC this fall. Props to anyone that actually made it! But I diverge…

I am proud to say that in this instance, I did follow through. I called Cate the next morning and committed to the trip. Beginning on June 21, 2010, three friends and I biked 450 miles of California and raised over $2000.00 for the Mercy Corps Haiti Relief Effort in the process.

Our trip began in Lake Tahoe, continued through Napa and Point Reyes, over the rolling hills of Petaluma, across the Golden Gate Bridge and through San Francisco, past Half Moon Bay, and finished in Santa Cruz. We camped along the way and rotated driving duty to transport our gear in a large red van named Vivian. The trip marks the longest period of time I have ever been essentially homeless for. If I had to choose one place that was our home (besides Vivian) it would have to be various locations of McDonald’s. Unfortunately, that is not a joke. Not only are they found within five miles of

Summer Journal any point in the US, they have free internet and running water. Whenever our homemade Google Maps bike route failed us, we needed only to scan the horizon for the golden arches to find a place to remap our route. The malleability of the trip proved thrilling rather than unsettling, and the diverse and beautiful scenes of California balanced any obstacles we encountered nicely.

Obstacles were plentiful as was expected from our late and almost nonexistent planning, but with a positive attitude they were easily dealt with.

A surprise snowstorm awaited us in Tahoe the first day. Though the storm was no match for a Montreal blizzard, our optimism about so-called ‘Sunny California’ left us with nothing but bike shorts and tee shirts. We scrounged up all the layers we could find and at the instruction of a local bike shop we stuffed newspaper inside our jackets for extra insulation. It works, in case you were wondering. We also managed to acquire nine flat tires for four people in one week; after flat #7 it just seemed laughable. A generous man named Gary, grandfather of 12, rescued us when a broken axel left us stranded at Carson Pass. He drove us to the nearest bike shop over an hour away. We ate more oatmeal than you can fathom (about three Quaker oats cylindrical tubs to be precise.) I learned to appreciate the variety of ingredients you can add to oatmeal to make it less boring. From raisins, to brown sugar, to peanut butter, bananas, and jelly, we tried them all!

So, yes, I may have nudged organic chemistry a few inches to the right on my life timeline, but it was well worth it, and I did not even start explaining the drive across the country to get back to New Hampshire. Take opportunities when they present themselves, no matter how difficult. Make it happen!

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33 Tobacco use is widely known to be a leading contributor to premature death in the United States and Canada, and is individually accountable for nearly five million deaths per year worldwide (Nichols & Harlow, 2004). Despite the negative health outcomes attributable to cigarette use and the major public health concern it presents, there is little sociological research on the structural factors that are associated with the acquisition of the habit. Although sociologists do acknowledge the fact that smoking initiation is a socially motivated behavior, most research, including that which inspired the majority of existing schoolbased preventative programs, focuses on micro rather than macro level analyses of the risk factors involved (Chassin et al., 1984). This approach is rooted in the typically American appreciation for individualism. Researchers all too often ignore the discipline’s elemental belief that social factors can promote illness and contribute to health inequalities and choose instead to focus on the pervading cultural attitude which emphasizes personal choice and merit (Tepperman et al., 32007). Addiction is an individual behavior, but it is necessary to discern and understand that it occurs in a social context and can be influenced on a macro-level (Adrian, 2003).

ness and desire to smoke or refrain from smoking, which ultimately determines whether they become smokers. This approach fails to take into account the fact that an adolescent’s social environment may have a substantial effect on his/her attitude towards smoking. A second set of approaches, ‘social learning theories’, on the other hand, claim that observational learning is the fundamental cause of smoking. Proponents of these theories believe that if an adolescent has high self-efficacy, then he/she is more likely to imitate the smoking behavior that their parents model. This argument fails to explain why there are variations in regional smoking rates as it is unlikely that such variations can be explained by geographic differences in self-efficacy ratings. The third type, ‘social attachment theories’ focus on a person’s attachments to conventional institutions, commitment to conventional behavior, and belief in the legitimacy of social order as the keys to preventing deviant behavior like smoking. The last type, ‘problem behavior theory’, views smoking as a part of a system of psychosocial variables that reciprocally influence one another; the other parts of the system being the objective social environment and one’s perceived environment and personality.

here are currently four general theories in the literature that attempt to explain why certain adolescents start smoking and yet none incorporate macro level structures; a perfect example of the existing overemphasis on the psychosocial in lieu of the sociological (Collins & Elickson, 2004). The first of these theories is the ‘theory of planned behavior’, which states that it is adolescents’ intentions, that is, their willing-

Addiction is an individual behavior, but it is necessary to discern and understand that it occurs in a social context and can be influenced on a macro-level.

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The results of the study led to establish that there is a threefold risk of smoking among women who experienced both physical and sexual abuse and a twofold risk among women sexually abused during childhood.

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hough they are few in number, there are several studies which confirm that structural components can help identify the portion of the adolescent population at an increased risk of smoking. This is not to disregard the aforementioned hypotheses, as individual characteristics do play a role in smoking behavior, however, individual traits are a more important consideration in explaining why some adults continue to use cigarettes in light of the health risks, whereas contextual factors appear to be more relevant in explaining variances in the initial acquisition of the habit (Chassin, Presson and Sherman, 1990).

Structural factors such as race, gender, parental attitude and expectations, socioeconomic status, education, and child abuse, among others, play an important role in causing some adolescents to be more vulnerable than others in terms of smoking acquisition, and will be discussed in further detail in this paper.

hood abuse. The results of the study led to establish that there is a threefold risk of smoking among women who experienced both physical and sexual abuse and a twofold risk among women sexually abused during childhood. Similar results were found for men, though the risk was slightly less high. This is consistent with findings which show that boys may be more resilient and less susceptible to stressors (Simantov et al.,

hildhood abuse is a social problem strongly correlated with cigarette use, especially among women, and thus must be considered a contextual variable. Nichols and Harlow (2004) evaluated the relation between childhood victimization and cigarette smoking using a retrospective cohort study, and noted an increased risk for adults who had either experienced or feared child-

2000). Whether smoking was a direct or indirect consequence of the abuse is irrelevant, since the correlation existed regardless. As the method or resources a person uses to cope may be learnt and internalized through observation of their in-group, it is unnecessary to comment on the value of smoking as a coping mechanism- if it is indeed one.

The increased risk of smoking that is due to the experience of child abuse is

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Being currently employed is also positively associated with never having smoked, suggesting that unemployed parents are more likely to model smoking behavior in front of their children

   35 sufficient evidence of the importance to consider abuse a macro level factor, especially considering that the severity of the outcome is somewhat gendered.

Child abuse is but one of the many stress experiences that arise, at least partially, from patterned differences in life circumstances that can later have very real effects on health (Turner, Wheaton & Lloyd, 1995).

Although blacks were most likely to start smoking at fourteen years of age, whites often start several years earlier, at the approximate age of twelve.

An additional reason why childhood abuse can be deemed a contextual factor is its inherent relation to poverty and unemployment. Gillham et al. (1998) confirmed that male unemployment rates can be used to predict rates of child physical abuse, and, to some extent, neglect. This relation clearly sets some adolescents at a greater risk of smoking acquisition than others, as unemployment, and hence abuse, is an outcome that is not as equally likely across all social strata. Being currently employed is also positively associated with never having smoked, suggesting that unemployed parents are more likely to model smoking behavior in front of their children (Binkley, 2009). Simantov et al.

(2000) suggest that this implication confirms the importance of screening for abuse during adolescent health care visits, as recommended by the Amer-

ican Medical Association, especially for those patients who are from a lower socioeconomic background. Professionals providing health care need to elicit information from adolescents about stressful life events and find productive ways, such as outreach and counseling, to help adolescents cope. The medicalization of smoking risks may be necessary in this way.

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indings from research studying smoking acquisition have been applied to both races, but this practice may have lead to erroneous conclusions about the behaviors of blacks who are often subjected to different life experiences (Headen et al., 1991).

Headen’s work refuted the assumption that all smokers, regardless of their race, start the habit for similar reasons. Although blacks were most likely to start smoking at fourteen years of age, whites often start several years earlier, at the approximate age of twelve. Peer behavior was found to be correlated with smoking

Though black adolescents are less likely to initiate smoking than whites, they are also less likely to quit once they smoke. initiation only among white adolescents, where the odds of smoking if a friend smoked were 2.44 times greater, but no such association existed for the sample of black adolescent smokers (Headen et al., 1991). Especially noteworthy is the fact that all adolescents, regardless of race, were reported to be more likely

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to initiate smoking if they had a close relationship with their mother who also smoked; however, black adolescents considered parents to be more important influences than did white adolescents, hereby increasing their chances of being negatively affected by maternal smoking (Headen et al., 1991). Though race is often considered a macro factor due to the differential effects it can impose on a person’s life through discrimination, in this case, racial differences appear to be the result of cultural upbringing.

These findings are significant in terms of policy application. White adolescents ought to be targeted starting in elementary school, appreciably earlier than the intervention that black adolescents require. In addition, smoking prevention programs that focus on the attitudes and behaviors of peers –which are currently widespread– may not be effective with black adolescents (Headen et al., 1991).

Though black adolescents are less likely to initiate smoking than whites, they are also less likely to quit once they smoke (Binkley, 2009). Overall, this suggests that there is a need to test models of adolescent smoking which consider the distinctive cultural and environmental factors that shape the behavior of black adolescents (Headen et al., 1991). Race is a structural feature that can have a significant impact on which risk factors the adolescent is most susceptible to.

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dolescents with divorced parents are less likely to feel embedded in the parental relationship, which in turn heightens their risk of nicotine use (Kirby, 2002). The relationship between divorce and smoking is such that an adolescent being raised by a single nonsmoking parent is more likely to initiate

The relationship between divorce and smoking is such that an adolescent being raised by a single non-smoking parent is more likely to initiate smoking than is an adolescent in a two-parent smoking household smoking than is an adolescent in a twoparent smoking household (Goddard, 1992). Socioeconomic status, household income and educational attainment are all negatively correlated with divorce.

Therefore, these basic structural factors can, even prior to a divorce occurring, increase a specific segment of the adolescent population’s risk of exhibiting smoking behavior. Divorce often leads to downward residential mobility, causing poverty to become a cumulative risk factor that has an increasingly negative effect on adolescents’ smoking habits (Kirby, 2002). After experiencing the effects of divorce-induced poverty, adolescents are more likely to become friends with other adolescent smokers (Kirby, 2002). Bearing in mind that parental expectations may protect against smoking even in the context of favorable attitudes and friends who smoke, parental involvement becomes an important protective factor after the occurrence of a divorce (Simons-Morton, 2004). Adolescents’ perception of their social environment is partially dependent on the parental expectations to which they are

37 accustomed to, and it is this perceived social environment that influences conduct]by defining the consequences of behavior and by differential reinforcement (McAlister, Krosnick and Milburn, 1984). Although it may be far-reaching to consider carrying out interventions at the parental level, parents do need to be aware of the impact they have on their adolescents’ health habits, including in terms of smoking behavior.

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dolescents’ educational aspirations, which are unsurprisingly correlated with their own parents’ educational attainment, can influence their likelihood of smoking. Adolescents with low academic expectations are more likely to become frequent smokers by grade ten in

Deviant behavior arises when there is a discrepancy between socially encouraged and approved achievements and the means -or lack thereof- that a certain segment of the population has available to them in trying to achieve these goals (Kitsuse & Cicourel, 1963). This theory can be related to the observation that students who do not succeed academically -education being a socially valued achievement- are more likely to initiate smoking and to be judged as deviant in the process. Concurrently, it has been determined that for adolescents with a lower self-image, smoking can be a way to close the gap between their actual and ideal self-image; those with the greatest disparity between their actual and ideal self-image are most likely to intend to smoke (Elders et al., 1994).

The benefits of education are apparent even when comparing relatively minute differences in attainment; college graduates are less likely to smoke than those who attended college but did not complete their degree. comparison to those who plan to attend college (Collins & Ellickson, 2004). In fact, one’s academic performance and trajectory, especially absenteeism, appear to be very significant indicators in predicting future smoking behavior (Gruber & Zinman, 2000). The benefits of education are apparent even when comparing relatively minute differences in attainment; college graduates are less likely to smoke than those who attended college but did not complete their degree. The difference is even more noticeable when comparing college graduates and high school dropouts, the former being less than half as likely to become smokers (Binkley, 2009).

Implementing policies to help adolescents and younger children achieve and maintain a certain standard of academic success would not only minimize the risk of smoking behaviors for adolescents across all social strata, but could also reduce the future prevalence of poverty and unemployment; two factors associated with education and with future rates of cigarette use. The Quebec provincial government has recently unveiled a plan to boost the province’s high school graduation rate from fifty-five percent to eighty percent by 2020. One component of the plan, which has a strong focus on social support, is entitled The 13 Paths.

These paths encompass measures like

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extracurricular activities, smaller class sizes and after-school homework programs as part of an overall approach to target at-risk students (Branwell, 2010).

Though this strategy is primarily aimed at increasing provincial academic success, this is exactly the kind of policy that can affect adolescent smoking rates.

This program, by having a beneficial impact on the adolescent’s self-concept can have far-reaching positive consequences (Vasta et al., 2009).

Nonetheless, education is more than a mediating factor between low socioeconomic status and smoking. School culture is also an independent risk factor associated with smoking acquisition. Aveyard et al. (2004) noted that, irrespective of the students in attendance’s backgrounds, schools providing value-added education provide effective social support and control, have a relatively strong influence on pupils’ lives and are associated with lower than average smoking prevalence; on the other hand, schools providing value-denuded

bodies (Aveyard et al., 2004). This notably demonstrates that schools with an authoritative structure can decrease smoking rates, even for students from lower income families who are typically at higher risk. Bruvold (1993), among others, has claimed that an adolescent’s’ intention to smoke is based on his/her individual attitude and interpretation of the surrounding social norms, and is, for this reason, a personal choice. However, Avenyard (2004) provides evidence that school-based interventions do not necessarily have to assess the personal behavioral, normative and control beliefs held by the target group in order to successfully modify adolescent smoking behaviors. Macro level interventions can overlook these individual factors and still have the capacity to enact change.

When educational institutions stringently impose a non-smoking policy for students, teachers, and staff, [it] not only reduces the visibility of smoking models, but also reinforces a nonsmoking norm as standard behavior for adults and youth (Alexander et al., 2001).

When educational institutions stringently impose a non-smoking policy for students, teachers, and staff, [it] not only reduces the visibility of smoking models, but also reinforces a nonsmoking norm as standard behavior for adults and youth education have a relatively weak influence on pupils’ lives and are associated with higher than average smoking prevalence. The difference in smoking rates found between the two categories of schools is potentially due to the fact that adolescents in value-added schools are more likely to adopt the values and identities that the school explicitly espouses and implicitly em-

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ocioeconomic status is also an important contextual factor to keep in mind, as economic influences can affect not only the likelihood of initiating smoking as an adolescent, but as mentioned, it affects the likelihood of quitting as an adult.

Increased income increases the value of longevity,[and smoking can lead to a potentially larger cost in loss of ex-

39 pected utility due to reduced longevity (Binkley, 2009). Thus, those with higher income tend to have more to gain from abstaining from cigarette use. Stated quite simply, the poor just have less to look forward to (Binkley, 2009). It is this disheartening social context which causes those of low socioeconomic status to make, what appears on their part, to be the rational decision to indulge in smoking, which is perceived as more rewarding than the increase in life expectancy that would come as a result of quitting cigarette consumption. Any policy that can target the at-risk adolescents who fall within this group should be supported.

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he refusal to acknowledge the influence that structural factors have on smoking acquisition, may be inadvertently affecting the success adolescents have in quitting or in simply generally abstaining from cigarette use. When the locus of control for smoking habits is placed firmly within the individual, any person who exhibits the habit is consequently labeled a deviant. This occurs without consideration for the social institutions or practices that may have contributed to the development of the nicotine addiction to begin with. When assigned the title of ‘deviant’, smokers are less likely to attempt to rid themselves of their addiction- it essentially becomes a part of their flawed self-identity. Once a label is internalized, it can become a part of not only that person’s self-identity but of their culture and lifestyle, thereby increasing the likelihood that the behavior may be passed down to future generations. While it may be difficult to establish causality in studies that specifically look at smoking acquisition, several longitudinal studies

have shown that social conditions often clearly predate health outcomes, and that social conditions predict morbidity and mortality even when competing risk factors are held constant (Link & Phelan, 1995).

Medical sociologists have the difficult task of trying to determine the relative contributions that people’s mind, body and social environments make to their health so as to tailor interventions –medical as well as social– accordingly (Tepperman, Curtis and Kwan, 2007).

It is important to remember that though we humans are rational creatures, we are rational within our social context.

The sociological imagination requires sociologists to uncover the patterns and regularities shared by people whose social characteristics and circumstances are similar (Pearlin, 1989). By identifying the fundamental causes of the disadvantages that certain adolescents systemically encounter, sociologists have the best chance of determining the contextual risk factors that lead to adolescent smoking.

REFERENCES Adrian, M. (2003). How Can Sociological Theory Help Our Understanding of Addictions?

Substance Use & Misuse, 38, 1385-1423.

Alexander, C. et al. (2001). Peers, Schools and Adolescent Cigarette Smoking. Journal of Adolescent Health, 29, 22-30.

Aveyard, et al. (2004). The Influence of School Culture on Smoking Among Pupils. Social Science and Medicine, 58, 1767-1780.

Binkley, J. (2009). Low Income and Poor Health Choices: The Example of Smoking. American Journal of Agr. Economics, 92, 972–984.

Branwell, B. (2010, December 4) Where do ’13 Paths’ Lead? The Gazette.

Bricker, J. et al. (2007).The Role of Schoolmates’ Smoking and Non-Smoking in Adolescents’ Smoking Transitions: A Longitudinal Study.

Addiction, 102, 1665-1675.

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Bruvold, W. (1993). A Meta-Analysis of Adolescent Smoking Prevention Programs.

American Journal of Public Health, 83, 872-880.

Chassin, L. et al. (1984). Predicting the Onset of Cigarette Smoking in Adolescents: A Longitudinal Study. Journal of Applied Social Psychology, 14, 224-243.

Chassin, L., Presson C. and Sherman S. (1990).

Social Psychological Contributions to the Understanding and Prevention of Adolescent Cigarette Smoking. Personality and Social Psychology Bulletin, 16, 133-151.

Collins, R. and Ellickson P. (2004). Integrating Four Theories of Adolescent Smoking.

Substance Use & Misuse, 39, 179-209.

Elders, J., Perry C., Eriksen M. and Giovino G. (1994). The Report of the Surgeon General: Preventing Tobacco Use Among Young People. American Journal of Public Health, 84, 543-547.

Gillham, B., Tanner G. and Cheyne B. (1998).

Unemployment Rates, Single Parents Density, and Indices of Child Poverty: Their Relationship to Different Categories of Child Abuse and Neglect. Child Abuse and Neglect, 22, 79-90.

Goddard, E. (1992). Why Children Start Smoking. British Journal of Addiction, 87, 17-18.

Gruber, J. and Zinman J. (2000). Youth Smoking in the U.S.: Evidence and Implications. NBER Working Paper, 7780, 1-74.

Headen, et al. (1991). Are the Correlates of Cigarette Smoking Initiation Different for Black and White Adolescents? American Journal of Public Health, 82, 854-858.

Kirby, J. B. (2002). The Influence of Parental Separation on Smoking Initiation in Adolescents. Journal of Health and Social Behavior, 43, 56-71.

Kitsuse, J. and Cicourel A. (1963). A Note on the Uses of Official Statistics. Social Problem, 11, 131-139.

Link B. and Phelan J. (1995). Social Conditions as Fundamental Causes of Disease. Journal of Health and Social Behavior, Extra Issue 1995, 80-94.

McAlister, A., Krosnick J. and Milburn M. (1984). Causes of Adolescent Cigarette Smoking: Tests of a Structural Equation Model. Social Psychology Quarterly, 47, 24-36.

Nichols and Harlow. (2004). Childhood Abuse and Risk of Smoking Onset. Journal of Epidemiology and Community Health, 58, 402-406.

Pearlin, L. (1989). The Sociological Study of Stress. Journal of Health and Social Behavior, 30, 241-56.

Simantov, E., Schoen C. and Klein J. (2000).

Health-Comprising Behaviors: Why Do Adolescents Smoke or Drink? Arch Pediatric Adolescent Medicine, 154, 1025-1033.

Simons-Morton, B. (2004). The Protective Effect of Parental Expectations Against Early Adolescent Smoking Initiation. Health and Education Research, 19, 561-569.

Tepperman, L., Curtis J. and Kwan A. (2007).

Social Problems: A Canadian Perspective.

Toronto, Canada: Oxford University Press.

Turner, R., Wheaton B., and Lloyd D. (1995).

The Epidemiology of Social Stress. American Sociological Review, 60, 104-125.

Vasta, et al. (2009). Child Psychology. Toronto, Canada: John Wiley & Sons.

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The health care system of Taiwan is an exemplary model of how modern health care reform and major policy changes can bring about high quality universal health coverage to a country in a relatively short period of time.

After years of analyzing in-depth studies of health care systems from other nations, Taiwan instituted its universal National Health Insurance (NHI) program in 1995. The program extends a comprehensive benefits package ranging from doctor’s visits and prescription drugs to traditional Chinese medicine to ninety-nine percent of the Taiwanese population. The Taiwanese receive quality health care services in a timely manner with minimal wait times. As a result, the overall population remains both healthy and happy with its nation’s health care system.

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he expansion of health care in Taiwan mirrors its rapid economic development. In the 1980s, after more than twenty years of strong economic growth, the Taiwanese public demanded better health insurance coverage. In 1995, reform led to a new national health insur-

ance program, the NHI, which is now a government-run and single-payer system with universal coverage similar to that of Canada’s. Prior to the establishment of the NHI, forty-one percent of the Taiwanese population was uninsured.

The majority of the uninsured were young children and seniors, whose need for health care is often greatest. Due to mandatory enrolment, the reform has brought insurance to ninety-nine percent of citizens and legal residents in Taiwan, and has increased the health care utilization rates of the uninsured up to par with those of previously insured populations (Cheng, 2003).

Despite several similarities with the Canadian health care system as a whole, there are several notable differences between the two systems. First, Taiwan’s health care coverage is more comprehensive than that of Canada. The NHI covers services that Canadians must pay out-of-pocket for or through supple-

In 1995, reform led to a new national health insurance program, the NHI, which is now a governmentrun and single-payer system with universal coverage similar to that of Canada’s. mental health insurance. These services include prescription drugs, dental care, vision care, and traditional Chinese medicine (Cheng, 2003). Second, patients are free to see doctors of any specialty without going through a referral

43 or ‘gatekeeper’ system. In other words, there is no need to see one’s primary health care provider prior to receiving a referral to see a specialist. Consequently, there is virtually no waiting list for a visit to a doctor’s office. Additionally, the Taiwanese have the freedom to choose amongst different health care facilities, ranging from small public health clinics to large private hospitals that offer comfort with luxurious décor.

With high health indicators comparable to any developed nation, including an infant mortality rate of 5.26 per thousand births and life expectancy at birth of seventy-five years for men and eighty-one years for women (Central Intelligence Agency, 2010), it is clear that Taiwan provides health care that

insurance rates (Cheng, 2003). However, it remains unclear how Taiwan plans to sustain a health care system that will achieve similar, if not better, results than that of Canada and the United States.

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he NHI is a publicly funded program and is financed using income-based premiums as opposed to general tax revenues. The premiums are based on payroll taxes paid by the employer, the employee, and the government in varying amounts depending on population groups. Most people who are employed pay thirty percent of the premium, while the employer pays sixty percent and the government subsidizes the remaining ten percent. The self-em-

[A] closer look at Taiwan’s national health expenditure rates indicate that this is being achieved at a fraction of the cost for other nations: only six percent of Taiwan’s GDP is spent on health care, compared to ten percent for Canada and sixteen percent for the United States. successfully sustains a healthy general population. Furthermore, a closer look at Taiwan’s national health expenditure rates indicate that this is being achieved at a fraction of the cost for other nations: only six percent of Taiwan’s GDP is spent on health care, compared to ten percent for Canada and sixteen percent for the United States (Organization for Economic Cooperation and Development, 2010). Since its implementation, NHI has had a public satisfaction rating ranging from seventy to eighty percent, decreasing only in the years during which new policies introduced higher

ployed pay one-hundred percent of the premium, while individuals from lowincome households are fully subsidized by the government. For the employed, the total insurance premium typically amounts to 4.6 percent of their wages (Underwood, 2009). Taxes from tobacco and the national lottery revenues are also injected into the system (Bureau of National Health Insurance, 2010).

The cost of the services from providers is covered mainly through reimbursements from the NHI, but it is also partially covered by co-payments from

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users (Cheng, 2003). The NHI is also supplemented by a co-insurance system in which the user pays a nominal co-payment to the health care provider upon the use of its services; its purpose is to discourage overuse. The co-payment is usually a few dollars, or a fraction of the true cost of the service provided. The amount is capped by the NHI to eliminate any concerns of bankruptcy resulting from an accumulation of the fees. It is also waived for catastrophic diseases, individuals from low-income households or remote areas, infants, and veterans.

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ne problematic area of health care that the NHI has been progressively tackling is the implementation of universal coverage and assuring similar health statuses between indigenous marginalized populations and the rest of Taiwan. To eliminate disparities regarding access to health care, NHI has focused on both the demand and supply side of health care. On the demand side, it has ensured that the population at risk is provided with insurance and exempted them from co-payment. On the supply side, it has implemented an Integrated Delivery System (IDS) and guar-

anteed income for physicians practicing in remote areas (Bureau of National Health Insurance, 2010). Although certain disparities still exist, policy tools such as IDS and rural payment bonuses contribute to continuous improvements (Chou, Huang et al., 2004).

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noteworthy innovation of the Taiwanese system is the integration of traditional methods in a modern system.

In Taiwan, traditional Chinese medical practice is considered mainstream medical care. Thus, Chinese medicine is covered under the NHI. Traditional Chinese Medical (TCM) services range from acupuncture and fire cupping massages to medicinal herbs. It is believed to be effective in alleviating many illnesses and diseases, managing pain, and promoting well-being. Traditional Chinese medicine is often used in conjunction with Western biomedicine (Chen, Chen et al. 2007) and accounts for six percent of health expenditure on outpatient services in Taiwan (Bureau of National Health Insurance, 2010). However, not all TCM clinics are registered under the NHI and standardization regarding the quality is fully transparent.

Due to the competitive nature of the Fee-ForService system, physicians were called upon to see an overwhelmingly large volume of patients per day, leading to rushed visits and insufficient time to obtain a complete patient history or conduct a thorough exam, which in turn could lead to a misdiagnosis, improper treatment or delays in proper treatment.

I

n the late 1990s, the NHI began facing deficits and relying on bank loans to pay health care providers. Between 1996 and 2009, NHI expenditures have grown at an average of five percent per year, exceeding NHI revenues with an average growth rate of four percent per year (Bureau of National Health Insurance, 2010).

The high expenditures are a fault of the open-ended health insurance system relying on a Fee-For-Service (FFS) payment of providers. Health care providers perform unnecessary procedures and prescribe unnecessarily expensive drugs at the expense of the NHI. Submission of false reimbursement claims is another example of misuse of the system (Cheng 2003).

Due to the competitive nature of the Fee-For-Service system, physicians were called upon to see an overwhelmingly large volume of patients per day, leading to rushed visits and insufficient time to obtain a complete patient history or conduct a thorough exam, which in turn could lead to a misdiagnosis, improper treatment or delays in proper treatment.

This has given rise to a vicious cycle of doctors ordering frequent follow-ups, which contributes to higher patient volumes and shorter visits. Moreover, many patients feel that their problems are not adequately addressed, resulting in repeat visits and ‘doctor shopping’ – visiting numerous practitioners and seeking unnecessary care or care that does not require specialists, all further impinging on the system (Gunde, 2004).

T

o address some of these issues, the NHI has made a number of changes to how health care providers are reimbursed. From 1998 to 2002, a global

45 budget policy was imposed on different sectors, replacing the Fee-for-Service system. The global policy set an expenditure cap for each sector, such that services provided beyond the cap would be reimbursed at lower rates. The new policy gave health care providers an incentive to stay within their set budgets.

Global budgeting has proved to be effective and overall growth rates of per capita medical spending declined in nearly all of the health sectors in the early 2000s. However, it is an incomplete solution, as the NHI continues to face ever increasing expenditures. In 2004, the NHI implemented a ResourceBased-Relative-Value Scale (RBRVS) into the physician fee system. Physicians were to be paid according to the ‘relative value’ of services provided and the resources they consumed. The fee is based on the amount of physician-involving work that goes into the service, the practice expense associated with the service and the professional liability expense for the provision of that service.

The fee is also adjusted according to the geographic region (American Association of Pediatrics, 2005). The NHI continues to experiment with different methods of payment for provider services. In 2010, Diagnosis-Related-Group reimbursement (DRG) was introduced.

Under this scheme, physicians are reimbursed at a certain rate for different types of patients according to their primary diagnoses (Bureau of National Health Insurance, 2010).

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urther efforts to improve the quality of the NHI system have lead to the introduction of the Integrated Circuit Smart Card: a mandatory health card of sorts, integrating innovative information technology. The Smart Card

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The Smart Card contains electronic data about the cardholder’s personal identity, medical record, prescription history, remarks on catastrophic diseases, number of visits, and administrative and expenditure data among other pieces of information. contains electronic data about the cardholder’s personal identity, medical record, prescription history, remarks on catastrophic diseases, number of visits, and administrative and expenditure data among other pieces of information (Smart Card Alliance, 2005). The introduction of the Smart Card in 2002 allowed Taiwanese hospitals and clinics to send electronic records on a daily basis to the Bureau of NHI, where data can be analyzed and audited on an on-going basis. The Smart Card makes it possible to monitor high-utilization cases through patient profile analysis, prevent fraud from aberrant medical claims, and helps with surveillance of public hazards and tracking down suspects of communicable diseases (Bureau of National Health Insurance, 2009). The tracking of symptoms of communicable diseases is becoming increasingly important with the rise of pandemic diseases. Infected persons need to be identified and isolated as soon as possible to prevent the spreading of the infection.

Although it is a relatively new system, preliminary results have indicated that the Smart Card has enormous potential to be a key tool in reducing infectious outbreaks, such as severe acute respiratory syndrome (SARS), through implementation of an on-line real-time mechanism for disease control, tracking and surveillance (Huang and Hou, 2007).

Another major benefit from the use of

Smart Card technology is the reduction in administrative costs due to improved administrative, billing and provider ef-

In hopes of easing its growing deficit and financial burden, the Taiwanese government’s Department of Health began planning distribution channels and marketing campaigns on medical tourism. Now, Taiwan brands itself as a home for first-rate medical care services. ficiencies. The technology has allowed for automatic operation of electronic transfer of medical records and bills, resulting in expedited reimbursements to providers. As Smart Cards last for several years, it has also eliminated costs involved with frequent replacement of older health cards, which were previously made of non-durable material.

As a result, Taiwan’s health care sys-

47 tem has the lowest administrative costs in the world, accounting for only two percent of its total health expenditure.

Comparatively, Canada spends sixteen percent of total health expenditures on administration and the United States spends thirty-one percent (Woolhandler, 2003). The low administrative cost significantly contributes to Taiwan’s low health expenditures.

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n spite of such efforts of technological innovations and policy implementation, health care costs are rising in Taiwan. The NHI’s deficit is expected to reach $3.2 billion US dollars by the end of 2010. The government could increase spending from its GDP by raising the premiums, although this may cause public unrest in the process.

Nevertheless, the extra income generated from increased premiums will only be a temporary measure in keeping the balance and offsetting the existing deficit of $1.84 billion US dollars (Taiwan Today, 2010).

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aiwan is now looking overseas for potential solutions.

Medical tourism is a new and growing area in the world economy (Morgan, 2009) and it has come to the attention of the Taiwanese health care industry. In hopes of easing its growing deficit and financial burden, the Taiwanese government’s Department of Health began planning distribution channels and marketing campaigns on medical tourism. Now, Taiwan brands itself as a home for firstrate medical care services (International Medical Travel Journal, 2009). Taiwan has long been popular with its expatriate population as a medical-travel destination (Tung, 2010). However, the market is expected to expand by several

folds as Taiwan further opens its door to mainland China. With the recent lift of travel restrictions, 2009 alone brought forty thousand visitors from China to Taiwan to undergo health checkups and cosmetic surgery (Kastner, 2010).

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reating a system that is both financially sustainable and adequately prepared to meet the needs of an evolving population is a fine balancing act that relies on many factors. Taiwan will face health care challenges common to many other countries in the near future: an aging population, rising cost of the workforce in the medical health industry, and increasing costs of new technology, drug research, and development.

As it stands, the Taiwanese government is currently working on a ‘second generation’ NHI reformation by implementing new policies and strategies to

Taiwan and the NHI stand as a successful case of how a nation has been able to successfully establish universal health care coverage for the entire nation – almost from the ground up. make the health care system more sustainable (Bureau of National Health Insurance, 2010). Collaborating with other nations by sharing information on policy implications, research data, consultations and other innovations has led to the development and establishment

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of what the NHI is today. Further innovation and collaboration among nations can ensure that future steps taken to develop and to implement health care policies are more effective.

For now, Taiwan and the NHI stand as a successful case of how a nation has been able to successfully establish universal health care coverage for the entire nation – almost from the ground up. The system offers, at an affordable cost to the users, easy access to comprehensive and high quality health care. Despite some of the financial weaknesses it has shown and the downfalls it has faced in the last fifteen years, it is an example of how a government can strategically manage its resources to serve its people effectively by providing access to health care to those who need it most.

REFERENCES American Academy of Pediatrics. (2008).

Application of the Resource-Based Relative Value Scale System to Pediatrics. Pediatrics, 122, 1395-1400.

Bureau of National Health Insurance. (2010).

National Health Insurance in Taiwan.

Retrieved Feb. 7, 2011, from NHI . The Official Web Site: http://www.nhi.gov.tw Central Intelligence Agency. (2010, Nov). Taiwan.

Retrieved Nov. 7, 2010, from CIA Library. The Official Web Site: http://www.cia.gov/library Chen, F., Chen J., et al. (2007). Use frequency of traditional Chinese medicine in Taiwan. BMC Health Services Research, 7, 26.

Cheng, Tsung-Mei. (2003). Taiwan’s new national health insurance program: genesis and experience so far. Health Affairs, 22, 61-76.

Chou YJ, Huang N, Chang HJ, Yip W. (2004 ) National Health Insurance and Disparities in Access to Care in Rural Areas: A populationbased study in Taiwan. Abstract Academy Health Meeting, 21, abstract # 1049.

Gunde, R. ( 2004). Health care in Taiwan: Opportunities and Success. Retrieved Feb. 7, 2011, from UCLA International Institute. edu . The Official Web Site: http://www. international.ucla.edu.

Health Canada. (2004). First Ministers’ Meeting on the Future of Health Care 2004: A 10-year plan to strengthen health care. Retrieved Feb 7, 2011, from HealthCanada.org, The Official Web Site: http://www.hc-sc.gc.ca/ Health Canada (2008). Healthy Canadians: Federal Report on Comparable Health Indicators 2008. Retrieved Feb 7, 2011, from HealthCanada.org, The Official Web Site: http://www.hc-sc.gc.ca/ Huang, J. & Hou T. (2007). Design and prototype of a mechanism for active on-line emerging/ notifiable infectious diseases control, tracking and surveillance, based on a national health care card system. Computer Methods and Programs in Biomedicine, 86, 161-170.

IHS Global Insight. (2010). NHI to See over US $3—bil. Deficit in Taiwan, Health Minister Announces Resignation. Retrieved Feb 7, 2011, from IHS Global Insight.org, The Official Web Site: http://www.ihsglobalinsight.com International Medical Travel Journal (2009).

TAIWAN: Taiwan government to promote inbound medical tourism. Retrieved Feb 7, 2011, from IMTJ.org, The Official Web Site: http://www.imtj.com Kastner, J. (2010, October 5) Taiwan’s Medical Tourism Boom. Asia Sentinel.

Lu, R. & Hsiao, C. (2003). Does universal health insurance make health care unaffordable?

Lessons from Taiwan. Heatlh Affairs, 22, 77-86.

Morgan, D. (October 2009) “Tracking the growth in Medical Tourism: OECD helps Ministers shape the debate.” Organization for Economic Cooperation and Development. Health division.

Nelson, C. (2007). Taking the Cure: Medical Tourism. Taiwan Panorama, 3, 34.

Organization for Economic Co-operation and Development. (2010) OECD Health Data 2010. Retrieved Feb 7, 2011, from OECD.org, The Official Web Site: http://www.oecd.org/ Smart Card Alliance. (2005). The Taiwan Health Care Smart Card Project. Retrieved Feb 7, 2011, from SmartCardAlliance. org, The Official Web Site: http://www. smartcardalliance.org Statistics Canada (2008) Healthy Canadians: A Federal Report on Comparable Health Indicators 2008. Retrieved Feb 7, 2011, from Statistics Canada.org, The Official Web Site: http:// www.statcan.gc.ca Health minister resigns over health premium increase http://www.taiwanheadlines.gov. tw/ct.asp?xItem=182000&CtNode=39 (2010, March 9). Taiwan Today.

49 Tsang, I. (2007) Establishing the efficacy of traditional Chinese medicine. National Clinical Practical Rheumatology, 3, 60–1.

Tung, S. (2010, July 16) Is Taiwan Asia’s Next One-Stop Plastic-Surgery Shop? Time.

Underwood, Anne. (2009, November 3) Health Care Abroad: Taiwan. The New York Times.

Zuellig, P. (2006). The expansion of medical tourism in Asia is proving a healthy boost for a growing number of the region’s economies.

The Market Partners, 33, 8-9.

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